Workforces United Hospital Revenue Assessment example

Hospital Revenue Assessment Proposal

Introduction

Background:Health information managementWorkflow re-engineeringBusiness gap analysisRevenue cycle management Cost allocationsVendor managementContract Negotiations

Workforces United LLC

Information Save$

Measurement and Reporting, Information Systems

Scheduling,Admitting,

Registration

Pre-Certification

Authorization

ChargeEntry

CaseManagement

MedicalRecords

Billing ContractManagement

CollectionsFollow-up

CashPosting

CustomerService

Pricing, Managed Care Contracting, Reimbursement

Assess and quantify opportunities for improvement in revenue cycle performance that can result in additional cash

and net revenue. Areas addressed included:

• Process Effectiveness & Accuracy

• Metrics & Reporting

• Organization & Governance

• Cash Acceleration Opportunities

• Patient Access

• Self Pay & Bad Debt Management

• Uncompensated Care

• Avoidable Write-Offs

• Denial & Adjustment Management

• Charge Capture & CDM Maintenance

• Strategic Pricing

• Managed Care Contracting


Project Tasks 1 2 3 4 5 6 7 8 9 10 11 12

Project Management and RCLC

I.T. Optimization

Denial Mgmt, POS, Patient Access and Self Pay Strategies

CDM /Charge Capture

Managed Care

Cash Acceleration

Transition to Customer

MonthMonth

Revenue Cycle


5

Activities• Perform qualitative

interviews• Review all information and

data elements• Evaluate financial and

operating information• Review managed care

contracts and pricing• Benchmark performance

indicators• Review organizational

structure

Deliverables• Estimate potential financial

improvement opportunities

Typical Implementation

Develop Initiatives

Implement Initiatives

Monitor Results

AssessmentAssessment

8 weeks

Revenue Cycle EnhancementRevenue Cycle Enhancement

TodayToday

Activities• Restructure revenue cycle operations to streamline workflows • Implement reporting tools• Align departmental revenue goals, targets and accountability• Train and coach front-end and back-end employees on new

methods, techniques and tools

Deliverables/Outcomes• Enhance recurring cash flow • Enhance operational and customer performance• Support an accountable revenue cycle culture • Cohesive and consistent approach to managing the revenue cycle• Enhanced efficiency, productivity and job satisfaction

8 to 10 months

Revenue Cycle


Net Revenue Leakage can be reduced through: Integrating and standardizing workflow throughout the revenue cycle

process Decreasing avoidable write-offs through improved root cause identification,

denial follow-up, and resolution Decreasing bad debt write-offs through improved financial clearance

activities, securing additional coverage for the uninsured, and improving patient liability collections

Improving cash collections through reduced payment variances and effective pursuit of expected reimbursement

Improving collectability of A/R across all aging categories through increased rigor and process effectiveness

Net Revenue Enhancements can be maximized by: Improving charge capture of services rendered Improving managed care rates and strategy

Revenue Cycle


40

45

50

55

60

Current Target

Billing: Streamlining billing throughput and

improving follow-up enabled by workflow integration and collaboration across all revenue cycle functions

Pro-active follow-up and increased focus on critical activities within 0-90 days from discharge and improved follow-up effectiveness on accounts aged over 90 days

Timely and effective resolution of denials

Projected Gross A/R Days Performance

54 5- 8 day A/R reduction

46

Revenue Cycle


Denials and avoidable write-offs are a significant source of net revenue leakage. Additionally, net revenue losses associated with denials are occurring at a higher rate than write-off transaction data indicates. Sample findings indicate a high volume of denied claims are being adjusted to contractual allowances. Findings at a recent hospital include:

Avoidable write-offs tracked appropriately were $4M (gross) in FY08 Of the 50 accounts reviewed for high percentage write-offs adjusted to

contractual allowance, 44% were deemed avoidable or potentially avoidable

Revenue Cycle


There is significant opportunity to minimize bad debt losses through POS or Point of Service collections:

POS collections have not been performed throughout the organization. A POS program was to be implemented in the ED as of 3/23 and was delayed until 4/8/09

The POS ED collection strategy will be challenged due to lack of infrastructure (e.g. limited documented policies and procedures, limited training, lack of communication and goals)

There is significant opportunity to deploy an effective POS collection program organization-wide

The current financial counseling process is fragmented and not optimal Customer has recognized the need to change the current strategy and reduce

dependence on an external vendor. The plan is to bring financial counseling in-house and minimize the use of the vendor. This strategy is supported in conjunction appropriate training, outcomes management and rigorous vendor management

The current Financial Advocates spend a significant amount of time interacting with walk-in patients versus focusing on seeing uninsured or underinsured patients in-house

Revenue Cycle similar findings:


Within the Business Office there is significant opportunity to improve workflow which will result in improved A/R performance and decrease net revenue losses

Optimizing workflow management tools and staff prioritization to promote proactive collections

Implementing comprehensive denial management reporting Implementing I.T. contract management has not been successful There is an opportunity to develop an overall A/R management strategy

utilizing vendor relationships in the area of small balance follow-up and Self Pay early out program

There are significant charge capture opportunity areas across the organization. Opportunities include:

Surgical supply and ancillary surgical services ED procedural charging Observation procedure and supply charging CDM maintenance integrity

Revenue Cycle


Significant managed care opportunity exists: Outpatient and ED rates appear to below market There is a lot of rate variability across payers, particularly for outpatient

services Inpatient yields vary across service lines and present an opportunity Some opportunity exists through improved steerage of workers

compensation and managed government programs

There is not a net revenue enhancement opportunity to be gained through a strategic pricing initiative at this time. Customer’s prices were compared to MHA’s 2008 data and are at or above market

Revenue Cycle


Supporting Analyses Avoidable Adjustments Avoidable Write-off Sampling Contractual Allowances Sampling Bad Debt Placements Patient Access Charge Capture Strategic Pricing Managed Care Contracting Business Office A/R Agings Overview A/R Dollar Stratification Active A/R Activity I.T. Optimization

Revenue Cycle


Denials and avoidable write-offs are a significant issue across the organization

Opportunities exist across the organization to reduce denials and avoidable write-offs through:

Improved patient access eligibility and insurance verification screening

Medicare medical necessity screening

Proactive, timely and effective Business Office follow-up

Current processes and infrastructure do not support proactive or effective resolution of these net revenue losses

Revenue Cycle

Customer’s Denials Noted By Root Cause Reason

FY 2008


Avoidable Write-off Sampling: Objective: Determine appropriate administrative, bad debt, and other uncompensated

care write-off reduction opportunity

Performance Standard: Documentation of all write-offs to show timely, appropriate steps (due diligence, linkage) were taken and that the write-offs were unavoidable

Main Areas of Front End Process Breakdown: 44% of accounts scored as avoidable or potentially avoidable contained

front end process breakdowns, including: Insurance verification / coordination of benefits Authorization / pre-certification Securing sponsorship / eligibility linkage

Main Areas of Back End Process Breakdown: 67% of accounts scored as avoidable or potentially

avoidable contained back end process breakdowns, including:

Billing and appeal timeliness Lack of proactive and timely follow-up Delays in coding review

Review Population: 100 accounts with transactions within the last 6 months


Unavoidable 57%

Avoidable21%

PotentiallyAvoidable

22%

Customer Write-off Summary

Revenue Cycle

Contractual Allowance Sampling: Objective: Determine opportunity to reduce avoidable contractual allowances

Identify avoidable administrative write-offs misclassified as contractual allowances Performance Standard: Contractual allowances represent only appropriate discounts

on insurance payments Opportunity Exists for Improvement:

Accounts are being written off to contractual

allowances that should have been categorized

as avoidable or bad debt Many of these, based on the documentation

available, appear to have been avoidable

(44% of reviewed population) Inaccurate transaction code usage was witnessed

in the account reviews Review Population

50 accounts with transactions within the last 6 months


Eligibility and Authorization

23%

No Documentation

36%

Non-Covered14%

Unclassified Denials

18%

Customer Summary of Misclassified Allowances

Payment Variances 9%

Revenue Cycle

Customer’s Percent of Patient Dollars Transferred to Bad Debt

45.5% of expected SPAI dollars were transferred to bad debt in 2008. This SPAI bad debt transfer rate presents a good opportunity to improve POS collections and avoid negative P&L impact

45.5% of expected SPAI dollars were transferred to bad debt in 2008. This SPAI bad debt transfer rate presents a good opportunity to improve POS collections and avoid negative P&L impact

Revenue Cycle


Customer’s 2008 Bad Debt Placements By Dollar

Customer’s 2008 Bad Debt Placements By Volume

SPAI dollars represent a significant portion of Customer’s bad debt. Even more significant is the volume of bad debt placements SPAI represents

SPAI dollars represent a significant portion of Customer’s bad debt. Even more significant is the volume of bad debt placements SPAI represents

Revenue Cycle


Customer’s top contracted payers represent 69% of the total SPAI dollars in bad debt

Customer’s top contracted payers represent 69% of the total SPAI dollars in bad debt

15.6% of Customer’s 2008 Bad Debt Placements were OP services, which are routinely elective and/or non-emergent

15.6% of Customer’s 2008 Bad Debt Placements were OP services, which are routinely elective and/or non-emergent

Point of Service Collection Opportunity by Payer and Patient TypePoint of Service Collection Opportunity by Payer and Patient Type

Revenue Cycle


Patient Access Findings: Organizational Structure & Registration Services

Patient Access leadership consists of a Registration Manager, two Registration Supervisors and one Lead position

Registration reports to Patient Financial Services; however, there is minimal communication between these two departments

There are five registration sites on campus, including the Atrium, Patient Care Center, Imaging, Breast Imaging and the Emergency Department (ED)

Rehab Services schedules and registers their own patients All registration staff are members of the union; employees are encourage to take

FMLA, creating challenges with staffing/scheduling Bed placement and Information Desk services report to Registration

Revenue Cycle


Patient Access Findings: Pre-Service Processes

Scheduling is decentralized, with three non-integrated I.T. scheduling modules, as well as manual scheduling in some areas

Pre-registration is centralized and comprised of 4.5 FTEs that pre-register patients via I.T. work queues

Insurance is pre-verified for payers that are available online Scheduled add-ons are not processed by the pre-registration team and do not

have insurance verified prior to service Authorization/pre-certification functions are decentralized and not coordinated

with insurance verification Responsibility for medical necessity is not well defined, and there is no

accountability to ensure compliance prior to service There are no pre-service financial assessment or collection activities

Revenue Cycle


Patient Access Findings: Insurance Verification/Authorization

Insurance is verified on line via McKesson/Relay, Healthia, and payer websites. Insurance is not verified for payers not online

Ownership for authorization/pre-certification is not clearly defined Insurance verification is also performed by a back-end team for accounts not

verified at time of service Denials related to front-end processing are not shared with the registration

leadership team

Revenue Cycle


Patient Access Findings: Point-of-Service (POS) Collections

Training and preparation for POS collections implementation has been occurring over the past several months

POS collections in the ED was targeted for March 23; however, this has now been postponed until the second week in April, occurring 4/8/09

There has been minimal communication to key stakeholders regarding the POS collections initiative

There are no system-wide policies/procedures in place to govern POS collections or cashiering protocols

POS collection goals have not been established for all potential collection sites There are no plans for automated monitoring or tracking of future POS collections Automated tools are not available to assist with calculating patient liabilities on the

front end There are no prompt pay discount policies in place for front-end processing Outstanding balances/bad debt are not discussed with patients during pre-

registration or at point of service

Revenue Cycle


Patient Access Findings: Emergency Department

Non-urgent patients are referred to Fast Track; however, patients are never denied service based upon inability to pay

ED nurses “arrive” (quick-register) patients in I.T., often resulting in errors/additional work associated with incorrect patient information and duplicate medical record numbers

Mobile computers are available for bedside registration, however, registrars have reverted back to manual procedures

There is no financial discharge process in place for ED patients POS collections management and petty cash handling will be decentralized and

handled by registrars in each pod

Financial Assistance Program Two Financial Advocates (FAs) currently focus on inpatient accounts There are no designated FAs for key intake areas/procedures such as the ED, pre-

service and high dollar outpatients

Revenue Cycle


Patient Access Findings: Financial Assistance Program (Continued)

FAs handle all walk-in patient billing inquiries, which often hinders their ability to visit and assess self-pay patients at the bedside

FAs provide patients with information on state/federal programs and charity care, but do not provide assistance with completing applications or follow through on all uncompensated care accounts

Financial assessment functions (i.e., Medicaid eligibility screening) are currently outsourced to Outreach Services of Minnesota

A proposal has been submitted to bring financial assessment functions in-house by adding 7-9 FTEs and minimizing outsourcing activities

Plans for in-house financial assessment implementation include shadowing staff at Regents Hospital, hiring staff with financial counseling skills/knowledge, and internal training and development

There are no county caseworkers on site to assist with expediting Medicaid eligibility processing

Revenue Cycle


Patient Access Findings: Training and Quality

I.T. training is handled by Information Technologies, but there are no dedicated trainers/program for front-end services

Insurance processing/training is not managed or coordinated across the system There are no productivity standards, quality reviews or competency requirements in

place for front-end staff I.T. reports have not been developed to assist with managing front-end functions Staff performance reviews are very subjective; only attendance and dress code are

addressed objectively

Revenue Cycle


Charge Capture Findings: The current CDM process is fragmented and lacking the structure to

ensure coding and data integrity The Finance Revenue Coordinator is responsible for the CDM but has no

access, including view access, into the I.T. system housing the CDM Information services has a dedicated person responsible for the CDM. Their

responsibilities includes updating the system based on the Excel worksheet submitted by the Finance Revenue Coordinator and e-mails by other individuals such as Lab, Radiology, and the Billing Office

CDM validation occurs retrospectively typically by notification from the billing department of a claim edit or denial

Revenue Cycle


Charge Capture Findings: The charge capture process, particularly, in respect to supplies and

implants lacks automation and is cumbersome and labor intensive. This is an inefficient process and is difficult to maintain

Pre-op surgery has evolved into the Patient Care Center Unit Both pre-op and outpatient procedures are performed in the PCC unit. Pre-op

nursing staff are responsible for pre-op and outpatient procedures including procedure charge tickets leading to incomplete charge tickets and procedure charging. The process creates bottlenecks in the OR

The Surgical Department staff and leadership feel removed from the revenue management function and lack clear direction on where to find charging and coding guidance

Revenue Cycle


Charge Capture Findings: A review of the Emergency Department CDM, revenue and usage

report, sample patient accounts, including their medical records, and interviews with the ED Coding Supervisor found the following: Emergency department has certified coding staff dedicated to ED CPT coding and

charge capture. The current process includes chart and coding audits to assist with identifying areas clinical documentation and charge capture improvement

A coding supervisor performs routine chart audits and implements corrective action plans including clinical education when findings occur

Significant opportunity exists to improved clinical documentation and capture separately billable procedures

• 30% of ED Level 3 and Level 4 records reviewed had documentation errors resulting in lost charges

A review of the Observation (OBS) sample patient accounts, including their medical records, found opportunities for improved charge capture

There is an opportunity to improve nuclear medicine procedure charging

Revenue Cycle


Strategic Pricing Findings: Overall, Customer appears to be above market in terms of CDM

prices For the procedures where competitive market data was available, 60% were

above the 75th percentile of the market

Therefore, it is recommended that Customer not perform a comprehensive pricing study that aligns its prices with those of its peer group

Generally, organizations are unable to perform a price decrease with a zero net revenue impact. Given the financial status of the organization, this likely should not be pursued at this time

Revenue Cycle


Managed Care Findings: Senior Management understands most local market dynamics,

including the area’s unique political pressures Managed Care management is new and eager to improve financial

yields Customer’s “Integrated Delivery” strategy has accumulated the

necessary components to negotiate as a true “System” Inpatient Yields generated from ED admissions appropriately exceed

“non-ED” inpatient admissions The Top 4 Payers’ Managed Care’s Inpatient yields exceed 2008

market benchmarks by 1-14%, but financial opportunities still exist

Revenue Cycle


Managed Care Findings: Managed Care revenues are fairly well disbursed across multiple payers,

but should be a higher portion of total revenues (preferably >50%) Growing Workers Comp. revenues would improve margins

Revenue Cycle


Managed Care Findings: Inpatient Yields Overall, CMI-Adjusted IP yields meet or exceed 2008 market benchmark

($2,525). However, Customer should leverage its strengths to achieve higher rates

$EPDs are fairly consistent, but CMI-adjusted $EPDs vary across payers

2008 CMI-Adjusted Benchmark= $2,525

2008 CMI-Adjusted Benchmark= $2,525

*Top 4 Payors account for 86%of Total Contracted Revenues*Top 4 Payors account for 86%of Total Contracted Revenues

Revenue Cycle


Financial ClassNet Rev ($M) IP Days

CMI-Adjusted

$EPD

% of Medicare

EPDER $ Per

Visit

IP/ OP Total % of Chg

Medicare $88 36,114 $1,478 $383 26%Managed Medicare $33 13,242 $1,503 102% $443 25%Medicaid $17 8,967 $1,233 83% $281 21%Mgd Medicaid $23 8,483 $2,077 141% $340 29%Workers Comp. $7 683 $4,746 321% $1,423 73%

Contracted Managed Care $139 32,771 $2,730 185% $671 39% BCBS $44 10,980 $2,549 172% $741 37% Medica $27 6,512 $2,866 194% $552 39% HealthPartners $35 8,472 $2,544 172% $675 36%

Preferred One $13 3,044 $2,773 188% $455 37%

Select Care $14 2,031 $4,946 335% $915 62%

Other Contracted $6 1,732 $2,053 139% $733 34%

NonContracted Managed Care $9 1,384 $2,351 159% $1,732 53%

Improvement Opportunity Growth Opportunity

Managed Care Findings:Financial Classes’ Relative Volumes & Financial Performance

Overall yields among the top 4 payers are fairly consistent

Overall yields among the top 4 payers are fairly consistent

Converting Medicare& Medicaid to “Managed” productswould improve IP yields

Converting Medicare& Medicaid to “Managed” productswould improve IP yields

Workers Comp. is quite lucrative, but low volume

Workers Comp. is quite lucrative, but low volume

EPD = Effective Per DiemEPD = Effective Per Diem

Revenue Cycle


Service-line IP yields also vary significantly across payers-especially OB, Orthopedics, and Neurology

Managed Care Findings: Inpatient Service-Line Revenue Yields

Revenue Cycle


Outpatient & ER yields are 6 to 40% below market averages

Outpatient & ER yields are 6 to 40% below market averages

Total % of Charge, and some Outpatient Yields vary too much across payers

Total % of Charge, and some Outpatient Yields vary too much across payers

Managed Care Findings:Outpatient & Total Yields

Revenue Cycle


Business Office Findings: Workflow Management

Key information and data necessary for optimal management of the revenue cycle is difficult to obtain and often unavailable

The current staffing alignment compared to accounts volumes does not allow for proactive, timely and effective follow-up activity. Opportunity exists to outsource certain account populations, enabling staff to focus on accounts that will provide maximum returns

Job aids and response guidelines do not exist A generally reactive approach to account follow-up leads to significant gaps

in work, delaying reimbursement Processes and tools to support a focused payment review function do not

exist to ensure appropriate reimbursement is secured While high level goals exist, individual quality and productivity standards are

not consistently defined

Revenue Cycle


Business Office Findings: Denials Management

Work-in-process levels are high, frequently resulting in denials, delayed reimbursement and in some cases unnecessary write-offs

Identification and resolution of root causes is limited and as a result, necessary process improvements are delayed

Avoidable write-offs consist primarily of timely filing and no authorization denials

Additional avoidable write-offs are misclassified as contractual allowances, which by sampling findings is a high volume

Revenue Cycle


Business Office Findings: Interdepartmental Communication

Process breakdowns exist interdepartmentally and with detailed line staff Management exhibits candor and honesty in describing areas which they

feel require improvements Front end to back end communication lacks consistency, standard

measures and comprehensive reporting Controls over certain key processes are insufficient and essential tasks are

not consistently performed While current workflow management tools can support the flow of accounts

through the system, process gaps exist due to the lack of accountability across the revenue cycle

Upgrades and modifications to the I.T. work drivers are needed to effectively manage and consolidate tasks, establish priority and allow staff to work proactively throughout the revenue cycle

Revenue Cycle


Overall Aging of A/RPayer Specific Aging

% of Account Dollars over 90 Days

Overall A/R Agings are slightly higher than the benchmark. However, Self Pay After Insurance (SPAI) is high at 83% greater than 90 days

Bill holds in I.T. and unposted cash are contributing to higher than expected A/R totals

There is no vendor management strategy, compromising the overall A/R strategy and key success factors to achieve A/R goals

% of Account Dollars

Includes all discharged AR

(both billed and unbilled)

A/R Aging Customer Benchmark

A/R > 90 Days 22% 20%

A/R > 120 Days 18% 10%

A/R > 180 Days 12% 5%

A/R > 365 Days 3% 2%

Revenue Cycle

0% 20% 40% 60% 80% 100%

SPAI

Work Comp

Self Pay

Medicaid

Other

Medicare

Commercial

BC

Total


A/R Findings:

High dollar and low dollar accounts provide opportunities for different strategies to maximize the overall return

Accounts >$5K+ represent 15% of total account volume but 84% of the total account dollars

Conversely, accounts under $2K represent 73% of total account volume and only 8% of total account dollars

Stratification by Account Balance

Stratification by Account Volume

Discharged AR (includes billed and unbilled):

Account and $ Stratification

Actuals % of Total

Account $s Account Volume Account $sAccount Volume

(1) 0-100 $ 329,802 5,987 0.17% 13.84%(2) 100-500 $ 3,878,645 13,577 1.95% 31.38%(3) 500-2K $ 12,685,946 12,142 6.37% 28.07%(4) 2K-5K $ 15,591,468 4,976 7.83% 11.50%(5) 5K-10K $ 16,444,340 2,293 8.26% 5.30%(6) 10K+ $ 150,271,138 4,287 75.44% 9.91%Total $ 199,201,339 43,262 100.00% 100.00%

Revenue Cycle


Accounts Receivable Sampling: Objective:

Determine opportunity for cash flow improvement by reviewing the frequency, quality and effectiveness of account processing activity (e.g., billing, follow-up, appeals)

Performance Standard: More than 90% of accounts have timely, proactive and effective processing Proactive processing occurs at least every 30 days for accounts over $1,000 and

more frequently for accounts over $10,000 All processing activity is thoroughly documented

Main Areas of Process Breakdown: Large gaps in follow-up Interdepartmental hand-offs Coordination of benefits Billing and appeal timeliness

Review Population: 50 accounts $1K+, 90+ DFD


No Documentation

8%

Not Timely, Proactive or Effective

86%

Timely, Proactive and Effective 6%

Revenue Cycle

I.T. Optimization Findings: Existing revenue cycle workflows are not leveraging “best practice” standards

resulting in the sub-optimization of the I.T. integrated platform Although work queues exist, there are concerns that various work queue

structures are not capturing all the appropriate accounts Management of existing work queues is lacking resulting in many unresolved

accounts across the revenue cycle continuum There is a lack of understanding of I.T.’s standard reporting capabilities and

other dynamic reporting tools I.T. system’s training has not been adequate and the end-users’ knowledge of

I.T. functionality does not go beyond basic navigation Limited designated resources to address both I.T. workflow and system

modification requests, which is evident by the outstanding issue log

© 2009 Huron Consulting Group Inc. All rights reserved. Confidential & Proprietary.

Not Timely, Proactive or Effective

86%

Revenue Cycle


Revenue Cycle Leadership Recommendations: Implement an interdisciplinary Revenue Cycle Leadership Committee

(RCLC) charged with duties that include oversight of revenue cycle performance, standardization, accountability, training and monitoring: Recurring project management meetings with all revenue cycle key

stakeholders Integration of hospital operations leadership into Revenue Cycle

improvement Standardized revenue cycle reporting tools with established baselines,

goals and monitoring of trends for net revenue dollars Collaboratively develop specific up front cash collections,

denials/adjustment, bad debt and accounts receivable initiative targets

Revenue Cycle


I.T. Optimization Recommendations: Deploy Workforces United I.T. resources to optimize revenue cycle

workflow that is enabled by I.T. over the course of the engagement to accomplish the following: Maximize Customer’s IT investment by designing best-practice workflow with

Customer specific design considerations and enabled by I.T. system capabilities Optimize I.T.’s reporting tools that feature a wide variety of reports, queries, graphs,

and charts to manage revenue cycle performance

Deploy contract IT resources to support the I.T. workflow optimization efforts: Contract IT resources will address the technical build changes required in the I.T.

system Resources estimates are approximately 2 dedicated resources for 4 – 6 months.

The cost to Customer would be approximately $200K - $400K in addition to consulting professional services

Revenue Cycle


Patient Access Recommendations: Organizational Structure & Registration Services

Reassess strength, skills and responsibilities of registration leadership team to ensure sustained improvement for front-end operations

Develop a constructive and unified approach for communicating and sharing information between all revenue cycle divisions

Ensure that all intake areas either report to registration services or are trained and monitored according to revenue cycle standards

Realign intake staff/services in the Patient Care Center to accurately reflect registration versus clinical responsibilities

Reassign bed placement and information desk responsibilities to nursing and volunteer services, respectively

Develop a centralized registration area for inpatient/outpatient services, excluding Breast Imaging and the Emergency Department once processes are standardized and stabilized

Revenue Cycle


Patient Access Recommendations: Pre-Service Processes

Develop new workflows to include all scheduled encounters, including add-on procedures and high-ticket stat orders

Realign pre-registration responsibilities to ensure that all automated work queues are completed daily and that insurance verification, including benefit and eligibility checks, are performed for all payers

Redesign financial counseling processes to perform patient liability assessments prior to service

Centralize pre-encounter activities in a comprehensive Pre-Service Unit, including scheduling, pre-registration, insurance verification, authorization/precertification, medical necessity processing, and pre-service collections post process standardization and stabilization

Develop a centralized and fully automated scheduling approach for ancillary services post process standardization and stabilization

Revenue Cycle


Patient Access Recommendations:

Insurance Verification/Authorization Develop streamlined workflows to ensure that insurance verification occurs for all

payers, both during pre-service and point-of-service encounters Reallocate insurance verification resources from the back end to the front end to

support real-time eligibility and benefit checks Define clear responsibility and accountability for obtaining authorization/pre-cert

and coordinate with insurance verification processes Develop and distribute routine denial reports related to front-end processing, and

hold leadership accountable for performance improvement relative to avoidable write-offs

Revenue Cycle


Patient Access Recommendations: Point-of-Service Collections

Develop a comprehensive strategy for rolling out POS collections including: Project plan with definitive go-live dates and timeline accountability Communication plan to all key stakeholders (executive team, department heads,

Customer staff, physicians/office staff, patients, etc.) Identification of all potential intake/cashiering sites, including clinical areas Development of system-wide policies/procedures to govern both POS collections and

cashiering protocols Training and quality assurance program for all front-end staff, including the collection of

outstanding patient balances/bad debt Goals and accountability measures for all intake areas Tools for calculating patient liabilities due at time of service Equipment for processing and receiving patient payments (credit card terminals, petty

cash funds, safes, etc.) Automated tracking and monitoring of POS collections Development of prompt pay discounts and other incentives to increase up-front cash

collections

Revenue Cycle


Patient Access Recommendations: Emergency Department

Reassign quick-registration responsibilities to registration staff to ensure accuracy of medical record assignment and mitigation of risk associated with electronic patient record

Explore options for screening and referring non-urgent self-pay patients to alternative treatment settings

Reinstitute bedside registration using mobile computers Develop a discharge process to ensure that patients are financially assessed prior

to leaving the ED Develop more stringent controls for managing cash collections in the ED to ensure

optimal performance

Revenue Cycle


Patient Access Recommendations: Financial Assistance Program

Develop a comprehensive strategy for managing financial counseling: Expand in-house program and add three (3) FTEs that are strategically located in the

Emergency Department, Pre-Service Unit and proposed Centralized Registration Center

Seek extensive training/education and management of financial assessment processes, including state/federal program assistance and charity care processing; redesign workflows to incorporate real-time assistance with application processing and follow through on all uncompensated accounts

Continue to utilize Outreach Services of Minnesota to assist with complex cases and overflow from in-house program

Contract with county office to station caseworker on site to assist with expediting Medicaid eligibility screening

Provide coverage for walk-in patient billing inquiries by reallocating back-end staff to support customer service at the hospital

Develop key performance indicators to measure and monitor financial assessment activities performed both in-house and by outside vendor

Revenue Cycle


Patient Access Recommendations:

Training and Quality Develop a comprehensive training program for all front-end services Develop productivity standards, key performance indicators (KPIs) and I.T.

management reports to improve and sustain operational performance on the front end; Align KPIs with performance evaluations to provide fair and objective staff reviews

Develop a systematic quality assurance program to ensure front-end accuracy, reduce bad debt and accelerate cash flow

Revenue Cycle


Charge Capture Recommendations: Redesign and redeploy charge capture process for surgical support

services Design and implement clinical department training for increased

performance expectations as related to OP documentation and missed charges Emergency Department Observation areas PCC Unit

Review performance expectations, job training and reporting relationship for all for all OP charge entry staff

Redesign and redeploy CDM position responsibilities, authority, system access, and expectations

Design and implement charge reconciliation process across all outpatient departments

Revenue Cycle


Managed Care Recommendations: Customer needs to develop a comprehensive Managed Care strategy

that: Applies a “healthcare system” approach for leverage, including

Hospital Employed and contracted physicians JVs & Ancillaries Maple Grove’s geographic leverage

Incorporates payers’ need for Customer to remain independent & viable Addresses emerging market trends, including:

Payment trends (e.g.,103-105% of Medicare for Managed Medicare products) More equitable provider rights Benefit changes & increasing patient liability Payers’ and Employers’ tumbling financial results

Revenue Cycle


Managed Care Recommendations: Customer’s strategy also needs to:

Close market gaps and equalize payer yields for ED & Outpatient services

Reduce discounts for non-steered business (e.g., Trauma, ED, Air Ambulance)

Add carve-outs similar to market/national trends (e.g., implants, high cost drugs, Trauma Activation, etc.)

Further equalize IP & Service-line Yields across payers Consider leveraging Customer employees’ benefits for both improved

revenue & benefit administration savings Leverage high CMIs for higher reimbursement rates Pursue lucrative “psuedo-managed” lines of business (e.g., Workers

Comp, Managed Medicare, Managed Medicaid)

Revenue Cycle


Managed Care Recommendations: Develop more sophisticated:

Contract modeling tools Contract management tools to monitor financial performance:

Year over Year Actual versus Negotiated Year over Year changes in, and payer variances in, Patient Liabilities

Collecting patients’ increasing liability will be critical to maximizing contractual revenues

Revenue Cycle


Business Office Recommendations: Initiate a cash acceleration project to increase cash collections and

reduce A/R days Optimize I.T. work drivers, staff training, and supervisory expectations Implement a comprehensive A/R management strategy and staffing plan to

enable timely and effective A/R follow-up at all balance levels Implement a low-balance strategy to maximize benefits of stratification Develop clear goals and metrics to guide process. Create and maintain a

comprehensive staff training program including a working quality follow-up measurement program

Create job aids and response guidelines to direct specific tasks in a consistent and effective manner. Presence of these job aids will allow for consistent follow-up and timely accounts resolution, as well as, enable objective feedback to staff

Implement an issues database to capture and prioritize issues across the revenue cycle that will drive specific task-oriented action plans

Revenue Cycle


Business Office Recommendations: Enhance and implement changes to the current denials management

program, and the tracking of avoidable write-offs Enhance existing reporting tools to provide additional detail and merry

denial reporting with denial net revenue losses Formalize and enhance processes for Revenue Cycle stakeholders across

the organization to review, discuss and resolve denial management issues, and reduce avoidable write-offs

Provide targeted feedback and process improvement implementation to responsibility areas (patient access, case management, and medical records) for denial management initiatives

Redefine denial management workflow

Revenue Cycle


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Workforces United Hospital Revenue Assessment example

Documents

revenue cycle process

revenue cycle performance

revenue cycle operations

net revenue losses

departmental revenue

outcomes management

cash collections

pos collections