REVENUE CYCLE EXHANGE ROUNDTABLE:

What should Start, Stop, or Stay in the Revenue Cycle?At the recent HealthLeaders Revenue Cycle Exchange retreat in Ponte Vedra, Florida, representatives from Professional Credit had the pleasure to facilitate a roundtable discussion with an insightful group of health system leaders.

Panelists: Facilitators:

After an introductory discussion on patient demographics of their respective health systems, panelists shared theirthoughts on the challenges they are facing and the best practices to address those issues in the following areas of the revenue cycle:

1) Pre-Service/Time of Service Patient Financial Engagement 2) Denial Management 3) Accounts Receivable Management

They also identified practices in each area that should start, stop, or continue

Roundtable HighlightsIntroductions/Demographics

Jeff: What’s unique about the community you serve?

Terri: We are a former GM town. We had multiple GM plants that have closed. We went from four high schools to one and are dealing with issues associated with poverty and drug abuse. Our biggest challenge is discerning the difference between people who can pay their bills and choose not to and those who truly cannot afford to pay their bills.

Gerilynn: Being from San Diego, we’re right on the border and have a lot of transient traffic and we’re a vacation area. We’re trying to deal with how to recover from someone who potentially isn’tgoing to be in our community for very long. There are also a lot of high tech companies, so we have the full spectrum fromundocumented immigrants to people who have no problem paying their bills.

Bill: We have a large Amish and Mennonite population that we serve. They will literally drive three hours away to save $100 so it’s very competitive. We also work with the local churches and they will help get bills paid if need be. They are also looking at starting their own micro-hospital for imaging, lab work, and other services so we’re watching that and want to support it but they represent a hugeportion of our patient revenue.

Judy: One our biggest challenges was getting the buy-in from the smaller communities. Our CBO came to life five years ago and we started incorporating 19 regional and critical access facilities. People were used to going to the facility and discussing any challenges they had in person and now those discussions are over the phone with the business office. The other issue is with charity care in going through all the documentation to determine who should and who shouldn’t get it and which information is correct or incorrect.

Laurie: La Crosse has a lot of good paying jobs for people in our community. We also serve a large Amish population. I’m dealing directly with the churches to agree on pricing but it is challenging because you can’t contact the patients over the phone and they don’t come to our portal. But since we still have a lot of people with good paying jobs I’m not facing the challeges that others are. However, we still have high deductibles and a lot of the responsibility is being pushed to the patients who get frustrated and angry about it.

Round table disscussions at the HealthLeaders Revenue Cycle Echange. Gerilynn Sevenikar provides feedback while engaging with other healthcare leaders and facilitators on challenging topics in revenue cycle. From left to right, Jeff Johnson, Scott Purcell, and Laurie Hurwitz.

“Our biggest challenge is discerning the difference between people who can pay their bills and choose not to and those who truly cannot afford to pay their bill.”Terri Rinker, Director of Revenue Cycle,Community Hospital Anderson

• Judy A. Beiswanger, Director of Patient Account Services, Avera Health, Mitchell, SD

• Bill Franquet, Associate Vice President, Revenue Cycle, Evangelical Community Hospital, Lewisburg, PA

• Laurie Hurwitz, Executive Director, Revenue Cycle, Gunderson Health System, La Crosse, WI

• Terri Rinker, Director, Revenue Cycle, Community Hospital Anderson, Anderson, IN

• Gerilynn Sevenikar, Vice President, Hospital Revenue Cycle, Sharp HealthCare, San Diego, CA

• Scott Purcell, President, Professional Credit • Jeff Johnson, Chief Marketing Officer, Hawes Group• Lisa Kirk, Vice President of Sales, Professional Credit

Pre-Service and Time of ServiceJeff: What are you doing to engage patients more effectively early on in the process?

Gerilynn: They have a right to know, they’re entitled to know but we emphasize that it is only an estimate. If it were easy, everyone would be doing it.

Terri: Because Medicare is the largest payer in our community, we don’t get very many shoppers, but we’re piloting a program where we offer to follow up with patients who need to know their estimated out-of-pocket costs.

Judy: We don’t have many shoppers either, but we’re really focused on getting estimates out in advance and working on staffcommunication and how they’re asking for payments.

Laurie: We are centralizing pre-registration so we can standardize the process, including verification of benefits and cost estimation. With multiple registration options it’s extrememly difficult to train and ensure patients receive the same pre-serviceexperience.

Another area in need of improvement is ensuring clinical staff can help address financial questions and concerns. Oftentimes, a provider will recommend treatment that may have a negative financial impact such as a denied claim. The key is communciation with physicians about these potential impacts.

Bill: We have made rounds with all departments and are fortunate to have a physician advisor who creates collaboration between clinicians and the revenue cycle. For example, she will call the physician to let them know that the patient’s insurance provider requires pre-authorization for a specific treatment. Engaging the physician at that level has been very beneficial and it’s greatly reduced our denials.

Scott: We’re currently studing the research on how people talk about money. We have a behavioral scientist on staff and his very first experiment was successful. The new language in our talk-offs actually had a 10% increase that month and then we started rolling it out more widely. Most rational people want to be in control of their lives. So when you turn the conversation into how many payments it will ltake or the interest involved if applicable, the consumer is asking the collector, “Well what if I did nine payments, what if I did twelve payments,” and they’re actually building trust. In many cases, consumers ended up picking

Scott: There are two court cases dealing with this issue that are important to discuss. First in the Reyes case out of the 2nd Circuit Court of Appeals, the judge found that consent agreed for calling on a mobile phone, texting, emailing… all of that is actu-ally bargained for in that intake contract. And regardless of what the TCPA or other regulations say, the consumer cannot revoke consent because you actually bargained for it in the original contract. So that’s really good news. Also, the DC Court of Appeals just came out with a favorable ruling that’s going to undo, how the FCC has said that using anything other than the rotary phone to contact con-sumers without prior consent is in violation of the law. So many of our laws are anti-quated and didn’t even take into account the technologies that we have today.

But training staff in how to have these financial discussions upfront is even more important than having the estimation tools. The fact that estimates are only estimates, must be emphasized. And staff not accustomed to asking forpayment in advance need scripting.

Providing better price transparency to patients before treatment was cited as a challenge for most of the panelists. To address this issue, they are using estimators but sometimes experience inaccuracies that can frustrate patients when they get their bill and find that they’re having to pay more than planned. However, the consensus is that it is still a best practice to provide the estimates.

It was also pointed out that communicat-ing with patients based on their evolving communication preferences is important. However, there are regulatory hurdles such as the Telephone Consumer Pro-tection Act (TCPA) which restricts certain types of contact to cell phones including texting or using an auto dialerwithout prior consent.

Continue

Pre-Service

Start

Stop

• FAP on home page of website• Centralize and standardize

registration• Pre-registration benefit

verification• Move current registration staff to

pre-registration• Physician champions - know the

cost and educate clinical staff• Ask better questions

• Manual charity care paperwork

• Physician advisor in revenue cycle• Co-pay estimation letters• Scripting on how to ask for

payment• Adapting to consumer communication preferences

payment plans that were higher even than what we would have accepted as a minimum because they wanted to be in control of their lives and take care of the bill in a particular timeframe.

“We are centralizing pre-registration..With multiple registration options it’s extremely difficult to train and ensure patients receive the same pre-service experience.”Laurie Hurwitz, Executive Director of Revenue Cycle, Gunderson Health System

“In many cases consumers ended up picking payment plans that were higher... because they wanted to be in control of their lives and take care of the bill in a particular timeframe.”

Scott Purcell, President, Professional Credit

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Denial Management

Most of the panelists reported that they depend on their internal systems to help manage denials and are also using outside vendors to conduct more in-depth analysis of claims that should be paid.

Laurie: We’re having Epic come in and analyze if we’re using their tools for denial management and prevention as well as we should be. The answer is probably not, so we’re going to implementeverything they come up with that brings in new dollars. We’re also going to bring in vendors who can help us with the things that Epic can’t do but we expect them to have some skin in the game.

Gerilynn: We have a similar thought process. I think the takeaway here is that when you’re working with revenue integrity to see what’s going on with denials, you first go to your internal controls, then after you pass your internal controls, you go to your safety net to make sure you haven’t left anything on the table which is where the outside vendors come in. And it should always be contingency based.

Jeff: But what happens when the appeals process has been exhausted?

Scott: Something that we started doing recently is providing the services of our in-house attorneys on a full contingency basis to sue the payer. Typically, you’re going to go to settlement because they’re actually not interested in going to court, but you don’t want to let the claim just be zero if you feel so strongly that it should be paid.

Gerilynn: Well, it needs to be a part of everybody’s excalation process, so when you are escalating a denial, you need to know where you’re going to go next.

Laurie: We have also filed complaints with the state insurance commissioner.

Scott: Does that get attention?

Laurie: Immediate. Yes, it does.Continue

Denial Management

Start

Stop

• Fully utilize available Epic tools• Bring in vendors where Epic can’t

help - contingency-only contracts• Track user adjustments that staff is

making• Review small balance adjustment

policy

• Compare what should have been paid and what was actually paid

• Report card and analytics around denials

• Continue to file complaints with state

“When you’re working with revenue integrity to see what’s going on with denials, you first go to your internal controls...so when you are escalating a denial, you need to know where you’re going to go next.”

Gerilynn Seveniker, Vice President of Hospital Revenue Cycle, Sharp HealthCare

Lisa Kirk

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AR Management

Most of the discussion about AR management centered around addressing rising self-pay by adapting to patients’ changing communication preferences. Online portals as well as the prospect of being able to have financial discussions through texting present opportunities. Several panel-ists are also using analytics to measure effectiveness of patient interactions and to improve those interactions.

Jeff: Are you using analytics on every call?

Laurie: We are. We’re looking for key words. For example, did they say “thank you” on every call. We’re trying to find calls that are good examples of what went really well that everyone can learn from and also look for examples of calls where it was extraordinarily challenging. We don’t want anybody feeling like they’re being singled out and disciplined, but we’re trying to see at a collector level how they’re collecting and compare.

Gerilynn: I just have the share the most exciting thing for me. First, I think everybody has to do call reviews. Unless you actually hear it, it’s really hard to judge the quality of a call. Then there’s the productivity side of the call, who’s taking the calls, how long are the calls, what’s the abandonment rate, all of those things you are monitoring in the call center. And we use these metrics with real time gamification through analytics software which displays the numbers on a leader board for everybody to see. If you want to see something improve let them see metrics in real time.

Judy: Has that been healthy for the staff?

Gerilynn: Oh, they love it!

Judy: We have a board that displays metrics for inbound calls, how long you’ve been on a call, how long you’ve been at your desk, but we haven’t added how many calls each person is doing per day. We’ve talked about if it would encourage staff.

Gerilynn: This next generation of employees are used to seeing data in real time. They’re used to knowing instantaneously what you think of them, so you’re just delivering to them what their world is today. They don’t want to wait until the end of the week.

“We have a board that displays metrics for inbound calls...we haven’t added how many calls each person is doingper day. We’ve talked about if it would encourage staff”

Judy Beiswanger, Director of Patient Account Services, Avera Health

“This next generation of employees are used to seeing data in real time...you’re just delivering to them what their world is today”

Gerilynn Sevenikar, Vice President of Hospital Revenue Cycle, Sharp HealthCare

Continue

AR Management

Start

Stop

• Drop-calls/Voicemails• Give consumers control of paying

how they want to pay• Create competition among staff

• Emails• Taking too long to share feedback

with staff

• Show real-time call stats• Call gamification

HFMA staff and volunteers determined that these healthcare business solutions have met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of these healthcare business solutions or that any results will be obtained.

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