Importance of Revenue Cycle Management in Value-Based Care

Episode Overview

• When aiming to increase revenue and create efficiencies, leaders must educate and properly train front-end staff so that they understand the entire revenue cycle and how to avoid costly denials.

• Key performance indicators support operational effectiveness as they drive outcomes and improve the overall financial performance of the group.

• Centralized pre-certification processes can reduce inefficiencies as staff members become subject matter experts who are focused on the requirements of the payers to ensure timely and proper payment for services.

Transcript:

Daniel J. Marino: Welcome to another episode of Value-Based Care Insights. I'm your host Daniel Marino. In today's episode, we're going to spend a little bit of time discussing revenue cycle and revenue cycle performance. This remains a pretty hot topic. As we see organizations across the country rebound from COVID. Many of them are facing their ability to increase revenues, or at least create efficiencies that help them to ensure that they're collecting everything that should be collecting from payers, and particularly on the physician side or the medical group side, because of the complexity related to the revenue cycle. When you think about the front end, and all of the activity that occurs with registering patients, checking eligibility, or getting a pre-certification for a surgical case, all of those elements taken together does lend itself to certain complexity impacting the revenue cycle. And when it comes down to it, as we've talked about many times, these three things: people and your ability to really train the staff and help them be successful in the process of revenue cycle, second, the process in and of itself has to be efficient and it has to be streamline. So everybody's kind of doing the same thing. And then the technology, so if technology is set up appropriately, that aligns the process and helps support the staff, there's your opportunity to maximize your collections. Well, I'm really excited today to have two fabulous guests. Cecilia Gonzalez, who's director of revenue cycle of Community Care Network, which is part of community hospital in Munster, Indiana. And Rachel Greenspan, Director of Medical Group revenue cycle operations for NorthShore University Health System, which is in the north suburbs of Chicago, these two ladies did a great presentation with HFMA at their revenue cycle conference that they had a couple of months ago. Extremely well received. a lot of great information. Cecilia. Rachel, welcome to the program.

Cecilia Gonzalez: Thank you.

Rachel Greenspan: Thank you. Good morning.

Daniel J. Marino: So maybe we could start with you, Cecilia, as I mentioned I've been doing the revenue cycle for a long time. And as we think about this, I always focus on what is the biggest issue that we need to solve as we want to enhance revenue cycle performance. And the front end always comes to mind, because it is complicated. There are many different impact factors that influence your ability to collect. What are some of the things that you've focused on, as you think about some of the front end processes? In particular, where do we go to identify if you have a problem?

Cecilia Gonzalez: Some of our challenges in this day and age have been just a lot of trying to find the right candidate to sit at the front desk, but then cumbersome with all the different Medicare plans, all these different quality contracts that we're getting, ensuring that they're done right at the beginning. It's a story of we were going down the path that this is a value based care patient. That we think it is, because it's a great product line and system, and we get to the end and realize, oh, the patient had this instead of this. So it's very important for that training at the front end, we developed a Medicare grid with every potential type of Medicare and value based contracts that aligns to make sure our front end users are looking at their card, putting in the system right. It is the front end process of it, but it really is huge when it comes to the value based contract and moving the downstream line for the physicians to make sure they're hitting the metrics.

Daniel J. Marino: You are absolutely right. As as we start to expand the amount of contracts, so if it's just fee for service, there's a set of requirements that complement that, but then when you layer on top of that some value based care elements such as HCCs (Hierarchical Condition Categories), or ensuring that you're tracking where patients are coming from, and all of those things that help sort of support the value based care components. I can't help but wonder that the system setup has to really be structured appropriately to complement that process, right? Otherwise, you're having staff really work through a very cumbersome type of approach. Rachel, what are you seeing in terms of maybe system setup and some of the things that you've been able to do, or maybe some of the criteria, that's really important to set up the system right to complement the process?

Rachel Greenspan: In thinking about HCC, you really need to get the physician to buy in. For some organizations, it's going to look very different from others. For example, one organization may want to create a habit. When they build their best practice alerts to let the physician know that a patient has HCCs, they're going to want to do that for every patient, regardless of their plan. Because the thought is, we need people to remember to do this every time because more and more people are going to move to these value based plans. So on the other side of that another organization may want to focus on just their MA plans, or MA and MFSP, because their physician has already talked about BPA, (best practice alert), fatigue. And so for that organization, it may not make sense to fire for everybody.

Daniel J. Marino: When you think about the system set up, and your comment about buy-in from all the providers in capturing a CCS, the system has to be set up to complement it. I think alerts are great. But I talked to numerous physicians about their EMR (Electronic Medical Record), and alert fatigue is probably the number one issue that resonates to the top very quickly with managing their inbox. There's a lot that goes into it. But I think as we start to streamline that you're gonna see your revenue cycle performance really expand. When we think about denials, and managing denials, obviously is a big part of improving the revenue cycle performance. Cecilia, what are some of the things that you've been focused on, as you've been managing denials and reducing denials, and sort of solving that at the point of where the challenge of denials may take place?

Cecilia Gonzalez: We have dashboards that we've been implementing in several different areas. We definitely are looking at denials in general, but we also are focusing on some of our ACC contracts, just making sure we're hitting the core elements requirements for all of our value based care contracts as well. It is quite challenging. We've had to do regular dashboards, or we're having to now do an additional dashboard just for the quality metrics and things that we want to make sure we're touching for some of these additional quality based contracts that we're hoping to hit. And our challenge has been trying to kind of level set and look at a little bit at a time, because it can be quite overwhelming with multiple things going on in the denial forefront.

Daniel J. Marino: Oh, you're absolutely right. When you think about either working through the denials, or looking at the impact of the denials, or the opportunity related to reducing denials, it touches the number of stakeholders in an organization. If you're focusing on the Vice President of Managed Care who’s negotiating these contracts, they want to know what the denials are so hopefully you can incorporate that into some of your future contract negotiations and either create a carve out or put some protections into the contract. The same holds true for the CFO, they want to understand what that denial rate is, because that impacts their net collection rate. When you were presenting, what were some of the things that you worked through, or discussed with the audience around some of the stakeholder impacts related to denials?

Cecilia Gonzalez: We focused on, obviously, the high dollar impact. What are our highest challenges? Where were our easiest wins with the denials? Where can we put the team to really focus on making an impact and moving things around? As Rachel said, we acknowledge a lack of infrastructure and a system that needs a lot of build, and also a lot of room for education. And that's probably been one of our areas that we would put a lot of focus on. As we learn about denial, we understand what we might have done, could have done differently, getting out there and sharing it with the physicians that are the stakeholders of helping reduce that. Education has been one of our biggest focuses for the last six months and we do see movement in our denials based on some of that. Sharing is caring, and the denials tend to be quite stressful. I think it takes a team to really move it forward and make a change when it comes to revenue cycle in general with value base, with regular, with the whole gamut of it.

Daniel J. Marino: I absolutely agree. Rachel, what are you seeing in your organization related to some of the denial management? Or what are some of the things that you've been able to put in place?

Rachel Greenspan: I agree completely with what Cecilia had to say and highlighting that educational piece, I think a lot of organizations struggle with just an overall understanding which crosses through the patients, our frontline staff, and our physicians. Your annual wellness visit (AWV) is going to be your biggest opportunity to capture that HCC, and our front desk staff don't necessarily know what that is because they don't go to annual wellness visits. Our patients, their entire lives they've been going in for annual physicals, they don't know what an annual wellness visit is. And our providers don't always understand the benefit of it either. And their patients are looking to come in for a physical, they want a physical and AWB, and a physical aren't the same thing. So for us, I really think that education is the foundation that has to happen before anything else. Because when things get scheduled wrong, then you get the denial.

Cecilia Gonzalez: Disheartening when you do that I mean, I think we've had multiple scenarios where the physicians are like, pat on the back, we got it right, we send the claim, then it comes back to be a completely different carrier. And those are the heartbreaks of registration not doing it right at the beginning.

Daniel J. Marino: It sounds like you ladies really put in place very focused education programs that's geared towards the receptionist, or the registration staff, definitely the physicians, and even some of the other areas within the business office, to really educate folks and to raise the competency level or the understanding of where denials are occurring.

Cecilia Gonzalez: It's an ongoing education. I think it's very interesting when you use the dashboard, people tend to want to move the number down. So I think Rachel and I both have talked about this, where it becomes very competitive. When you start showing this is where we'd like to be and this is where we're at, and look at what they're doing. It's always wonderful to put metrics and dashboard away and show improvement as it occurs.

Daniel J. Marino: Let's talk a little bit about that. Maybe some of the key performance indicators and some of the things that you've created within your dashboard reports, or at least some of the information that you share. Rachel, maybe we can start with you. What are some of the things that you look for, as you begin to generate your KPIs and share this information with providers are with staff.

Rachel Greenspan: So we look at our annual wellness visit rates, we look at our HCC capture rate, and we look at the trajectory of our score. And we do use a number of different dashboards and reports, and we will look at it from an organizational level for maybe our senior level administration. For our physicians, we will do one for just primary care, and we'll do another one for our specialty team. Sometimes we get down to the practice level, and really graph it out so that they can say, I'm here but my peer is here. And it does work to get that competitive spirit going because doctors are competitive, and they want to be the best.

Daniel J. Marino: I mean, to share this information with them to help them understand how they're doing compared to others you're kind of building off that internal competition, right?

Rachel Greenspan: So you have the argument because sometimes the specialists will say, well, that that's the primary care physician's job. And so this is hard data to show. Well, your peers are doing it. So you can do it too.

Daniel J. Marino: You're absolutely right. So Cecilia, how are you using this information? What are some of the things that you begin to share with your teams?

Cecilia Gonzalez: We'll look at the RAF scores as well. We do a lot more of quality metrics. We're just kind of dabbling in the HCC and we've kind of taken the HCC with let's focus on these five or 10 little areas from the HCC. RAF scores have been a really big thing for us, it seems to be kind of the target. We do measurements of comparison looking at where they were last year and where they're at today. And then just kind of looking at the bell curve of what we see on the Medicare website. But, again, pretty standard with what Rachel is doing a lot of dashboarding data, we've not taken it to the practice level quite yet. And we're at a physician scale. But that's just because we have physicians that are doing lots of movement within our organization. And we just haven't gotten to that level. But, again, the RAF scores are huge for us. Just kind of monitoring, as Rachel said, we want to look at how many annual wellness visits we're dealing with. Did we capture them all? Making sure our system is set up so that we're not getting somebody to come in too soon for that annual wellness exam, because that's a denial right there. So it's got a lot of moving parts happening. As related to all this wonderful value based stuff. That, I'm with you, is not going away. It's the way of the future. And so we're always looking for more opportunities to bell curve, benchmark something else and improve it.

Daniel J. Marino: I liked the way that you're presenting this because coordinating the KPIs around where the outcome is, and the outcome not only, in some instances, reducing your denials, but it's increasing your revenue and your revenue opportunities. It leads me to think about a recent conversation that I had with one of my other clients who was heavily involved in a risk based Medicare Advantage product, and everything was built around the RAF score. And to improve the RAF score, they needed to make sure they were capturing all of their HCCs. In order to capture their HCCs, they needed to have the annual wellness exams, and it needed to be at a high rate and done appropriately. Then also ensuring that the denials for your services were as low as possible, because all of that feeds off one another. And so what it really did is it connected the dots in terms of how these indicators can drive a certain outcome, and then improve the overall performance. It sounds like a lot of what you ladies are doing within your organizations as well.

Rachel Greenspan: I would just add that I think it's really important to mention that with all that, you have to look at the documentation to make sure that it's compliant. It's one thing to talk about wanting to build your RAF. But it's another thing to do it compliantly. So I just want to put that plug in.

Daniel J. Marino: I agree with you. It all has to be done in compliance. There is a revenue piece to it, but that's really not why you do it. You make sure that you're actually accurately capturing what you need to capture on the patient visits, and really tracking appropriately, the complexity and the risks associated with a particular physician panel. That's really why you do it. Cecilia, anything you might add?

Cecilia Gonzalez: I think you said it best. The annual wellness, HCC, RAF, they have to kind of link together to make this all success. Again, it all has to be physician buy-in because it really is, unfortunately on them. But if you got a lot of education, great coders, and great office staff supporting the initiative I think it can be done. It can be successful. It just takes a while to get there.

Daniel J. Marino: Absolutely. One area of denials I'd like to spend a couple minutes talking about is around pre-certifications and pre-authorizations of surgical cases. We've been doing quite a bit of work with organizations lately improving a lot of their surgical processes. And we've seen in most cases, as we've started to work with these organizations, a real breakdown in terms of being able to catch the pre-certification or the pre-authorization and how that information needs to flow from the front-end, to the claim, to the back-end, and so forth. What are you all seeing in your organization? Are there certain things that you've put in place checks and balances, if you will, to ensure that you're getting that right information on the claim, and the claim is going out clean. Cecilia, does anything come to mind?

Cecilia Gonzalez: We use Epic as our system and they do have a great authorization module, but it does lack some of the luster that some of our payers are challenging us with. So we have developed what I would call a smart phrase for our team to like, ask all the questions. We're getting down to who am I speaking with? Authorization? How long is this good for? Here are the exact CPT codes. Here are the exact diagnosis codes. We see a lot of authorizations coming back saying that these three diagnoses were not added on and we are just stunned with the level of weight. But the procedure is accurate. We are trying to get down to that. Authorizations are getting very down to specificity of exactly what are you doing, and what are you getting permission to do? We just implemented that about a month ago, and we are hoping to track and monitor the outcome of it. It's been challenging. We have a lot of challenging players that want to push the button with authorization.

Daniel J. Marino: It's really challenging. Some of these things are no-brainers. You should be able to get the authorization from the insurance plan, the patient absolutely needs it. It sort of just puts delays in the process. It sounds like for what you put in place it'll be interesting to see how that works. Rachel, what do you see it in your organization related to some of these pre-service, pre-auths for surgical cases,

Rachel Greenspan: At Northshore, what we ended up doing is moving to a more centralized pre-cert process. We just found that having experts who are doing this all day every day worked better for us than having the practices do it. That's what's been successful for us.

Daniel J. Marino: I think that's a great idea. Many organizations have started to move to more centralized pre-cert pre-authorization processing, because it just adds to that efficiency. And the other thing that it did, and it sort of builds on what you ladies have talked about before, is because some of the pre-cert pre-auth is a little complicated based on what the requirements are from the plan. If you centralize it, you're only educating a small number of folks who really become the subject matter experts for the organization, as opposed to creating education for all of the front-end staff, which could be 100 people. Is that some of what you've seen, Rachel?

Rachel Greenspan: Exactly. Spot on. It's definitely a lot easier to train 20 people than to go out to all the different practices. When we have a centralized 313, that's what they're doing and what they're concentrating on. The folks in the practice are juggling hundreds of things every day. And so I think just being able to focus and give it your full attention really makes a difference too.

Daniel J. Marino: I absolutely agree. And like you said, they become those subject matter experts that really understand what the payers want and how to move it through. Let's move to the KPIs perspective here. When you're looking at your pre-cert, pre-authorization, and denials, how do you know if you have a problem? What are some of the KPIs that you're looking for that help identify if there is an issue that you could bring back to the group? And maybe specifically a specialty, if you will, anything come to mind there, Rachel?

Rachel Greenspan: To be honest, the research falls under another team, and so I am not as adept in knowing the ins and outs of what they're looking at and the trending.

Daniel J. Marino: Did you see anything on the back-end that you provide to that team? Like maybe I don't know, eligibility denials or something of that nature?

Rachel Greenspan: For us it's really more about just the documentation that needs to be there, but isn't.

Cecilia Gonzalez: We do a little bit of dashboards on what we would call the front end denials, which are the authorizations. We will usually take our authorization denials, roll them out into where they occurred, and do some kind of monthly level sets. Again, we're finding that even best practices putting an authorization in a system, sending it over, we still see insurance companies reject a claim for an authorization and we'll call and they say okay we are re- processing it now. There is a little bit of that which we see occur, but we monitor our authorization denials, and we try to keep up. We'd like to see them closer to 5% of our total denials, but obviously, there's some challenges every month with different payers moving their systems around as well.

Daniel J. Marino: Cecilia, have you seen a centralized approach work well? Or are you still decentralized and just providing a number of education, and like you said some good reporting, just to provide that level of feedback?

Cecilia Gonzalez: I would prefer centralized work. We are a smaller organization. We do have a very big separation. We have three hospitals that we feed into. We would hope to move to that model at some point. And we're still kind of in a growth mode. We do have core areas that we focus on. Those members in the offices that are doing authorizations are usually nurses and the surgery scheduling type of person. Long term, we would love to go into a centralized place because I have seen it be successful, as Rachel said, it's nicer. We're just not an organization that has it at this point.

Daniel J. Marino: I think you have to evolve into it. I think as you start to move forward with the level of complexity around these different surgical cases you can make the decision to create a subject matter expert in each of the individual practices, or you can centralize it. I think it sort of works both ways. But it does come down to the process, it does come down to the technology. One area, though, that I do want to spend a couple minutes on is the information that you provide to your physicians on denials. Rachel, you had mentioned that, obviously, the documentation is important. Providing the right level of feedback is important. What are some of the things that you've shared with the physicians to make them aware of some of the denial activity that's occurring, and in particular, what collectively or collaboratively we need to do to reduce our denials?

Rachel Greenspan: We spend a lot of time talking about the AWV. And again, part of that as a reg issue, but part of it is also the physician making sure that they have all the elements that they need. With the AWV, that's not something that you can try to reduce it with a modifier. You have to have all of the key elements. If the HRA is not in there, or the visual acuity is not there when it is when it needs to be, then we can't even send them out the door. Really trying to focus on that education to get it right from the beginning to avoid the denial. I'm all about avoiding the denial.

Daniel J. Marino: Going right down to the root cause and solving for that. That's the best way to reduce your denials. Otherwise, it's a churn and burn. So the physicians are pretty receptive to this information.

Rachel Greenspan: I think the primary care physicians seem to understand it more. They have more contact with the patient, they have built that relationship, and patients expect to see them on a regular basis. It's definitely more challenging with the specialists, because there is a fear that if they're putting down an HCC that's unrelated to their specialty that means all of a sudden, they're responsible for that condition. And that's absolutely not true.

Daniel J. Marino: I definitely can see that. Cecilia, what are you sharing with your physicians?

Cecilia Gonzalez: We focus on the annual wellness, and we focus a lot on medical necessity, because that seems to be the trend. We want to focus on medical necessity usually related to the diagnosis. It leads us into the HCC. What did we miss? Is the documentation supporting that? Was your intent to write this but you picked this code? We get a lot of those kinds of scenarios, and working closely with the physicians and making sure they're comfortable with the diagnosis they're selecting. I'm with Rachel, I think that's one of the number one things we hear from our physicians is they know they've assessed a diagnosis, but they don't feel that they are managing it 100%, so why should they code it? But I'm like you documented it, though. So it's a lot of that type of relationship, getting them comfortable with that whole thought process. It's been challenging, but we share a lot of those types of denials, and that's all part of our education with our providers as well.

Daniel J. Marino: It's sharing the information and it's educating around the why, and if you’re doing that you're able to improve your performance. Well, ladies, I want to thank you both for joining me today in this discussion. Revenue Cycle always has a strong place in my heart and obviously managing your denials, educating, it really helps answer three things. How do we know if we have a problem? How do we get started in solving that problem? And then how do we measure improvement or measure our success? You all did a great job. Appreciate all the insight that you bring from your organizations. We'd love to have you back sometime down the road. But thank you again for your time today. Thank you again, to our listeners. I'm Daniel Marino. Thank you for listening to Value-Based Care Insights. And until next time, have a wonderful day.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners.