Top Performing PFS Sustaining Revenue Cycle Excellence

Greg West COO, Healthcare Resource Group

• Competition – target

• Free agents – “turnover”

• Rule changes – laws and regs and industry shifts

• Complacency

Why so few super bowl repeats

Why this topic

• Revenue Cycle is the life blood of your organization

• Patient care begins and ends with the rev cycle

• Sustaining success is the hardest thing to do

• Generate ideas to push innovation and improvement

• Learning and building from other’s success is the

easiest innovation

Best practices David Hammer and HFMA Members collaboration as published by HIMSS • People • Process • Technology

• Sustained 1. To keep in existence; maintain. 2. To supply with necessities or nourishment; provide for. 3. To support the spirits, vitality, or resolution of; encourage. 4. To keep up, competently

• Excellence 1. The state, quality, or condition of excelling; superiority. 2. Something in which one excels.

What is sustained excellence?

• AR days at 50 or better • Cash as a % of net revenue at 100% • Aging at 90 days below 20% • Credit balance = 1 day or less • Turnover rate of less than 10% • No poor scores on patient surveys re: billing • 5 years minimum of this performance • No “significant” unexplainable performance decrease

Qualifying organizations

• Hospital Size 2 CAH (25 bed) 4 under 100 beds 4 over 200 beds 2 Large CBO organizations

• Location 6 West Coast 2 Mountain 2 Midwest 2 East Coast

• Hospital Type 3 For Profit 9 Non-profit 4 Religious affiliation 4 are HRG clients

• Not included (yet) Case Management Charge Capture/CDI CDM HIM

Breaking it Down *study size is 32 and excellence list is 12

This report is about the differences between great versus marginal and long lasting versus short lived success

The Process and Technology

• Always confirm patient Identity and financial information • Use financial counseling in patient access • Check patient’s other account balances • All have eligibility tool – strong insurance verification • Many have implemented patient out of pocket estimators (more

recent) • Process to copy and store cards (Ins/ID) and other financial

documents • Strong up front payment processes (policies, training, tracking)

Process at patient access

• Manage billing edits constantly

• Dedicated team or individual for billing

• Bill daily – don’t tolerate backlogs

• Measure billers performance

• Track clean claim rate

• Focus on automation

Process at billing

• Focus on automation

• All used lockbox service

• Dedicated cashiering team or person

• Refunds are never put aside for other priorities

• Process to find underpayments

• All payments are reconciled daily

• All partial payments and zero pays are posted and set to work

Process at cash posting

• Stratified account follow-up (dedicated high balance team)

• Priority work queue process

• Denials are tracked and appeals are tracked – done timely

• Some type of reminder system is used for follow-up

• Teams are empowered for adjustments to dollar thresholds

• Closely monitored for accounts nearing untimely – reported and watched

• Outsourcing “ugly accounts” is norm

Processes at follow-up

• Dedicated team or individual

• Outsourced or have predictive dialer phone system with tracking

• Call monitoring system or manual tracking

• Placement of early-out and bad debt with separate vendors

• 120 day collection period standard – projection of bad debt was accurate

• Web based payment system and after hour phone payments

• Voicemail and email capabilities

• Self-pay policies on payment plans and discounts and steadfast in policy

Processes at patient service

• Days in revenue outstanding • Gross to net revenue ratio • Discharged not final billed • Days in credit balances • Denial % • Accounts receivable % over 90 days • Bad debt • Top performers tracked and knew them

• What’s wrong with these measures?

Standards – everyone measures

• More detailed in the standards • Point of service collections • Added registration error reporting - details • Timelines between stages – both self and payer management

Discharge to billed Billed to adjudicated Paid to posted Work the gaps

• Measure of exceptions – the 80/20 rule • Cash projections – timely look into cash shortfalls

Common measures in top group

• Scorecards – Organization, department, leaders, staff – All scorecards supported each other – Measured weekly/monthly/YTD

• Accountable – Reported to team by team – Gaps in performance at each level was immediately

handled – Action items were reported on

How the best used KPI’s

Billing Monthly Scorecard

Name

Month Key Performance Indicators (KPI)

Quality Month Yes/No YTD Yes/No Effective Time Management Month Yes/No YTD Yes/No

% claims paid due to clean billing (2pts) 76% N 81% Y Unexcused Absences.…..…………..(2pts) 0 Y 0 Y

Clean claims rates……………………..(2pts) 14% N 9% Y Time Card Accuracy…………………....(1pt)

Client Satisfaction…………………………...(1pt)

Productivity Month Yes/No YTD Yes/No Divisional Maturity Month Yes/No YTD Yes/No

# of claims billed…………………......(2 pts) 4014 Y 9001 Y Training Hours Completed…….…….(1pt) 2 Y 4 Y

Billing queue cleared daily…….…….(1pt) Y Y Y Y Monthly client cash goal……...……(2pts) 110% y 104% y Standards of Performance Goals and Objectives Quality Meets Individual/Team Comments % claims paid due to clean billing …………………. > 80% Team

Working to move "% claims paid due to clean billing" & "# of claims billed" into an individual score, but can currently only get the data by client

% claim edits hitting due to HRG……………………… < 10% Team

Client Satisfaction- No Material Issues Reported from Client ………………………………………

Productivity # of claims billed……………………………...………………… > 2000 Team Billing queue cleared daily…………………….……………. Yes Individual Monthly Cash Goal……………………………………………….. Effective Time Management Yes No Unexcused absences …………………………………………… < 6 a year Individual Monthly Score Time Card Accuracy………………………...……………….. Yes Individual YTD Score Divisional Maturity Training Hours Completed ……………………...……….. > 2 hrs a month Individual

• Quality process was documented

• Individual accountable for QA commitment

• QA corresponded to training program

• QA celebrated success as well as located gaps

• Employees viewed QA as a positive program

• QA was calibrated for consistency

Robust QA process

The People Part

• Patient service is focus of entire organization

• Focused training on the patient experience

• Administration has made revenue cycle departments part of the patient experience

• Setting of standards for service was the norm

• High accountability for service

Culture

• Strong hiring process – Team interviews/trained interviewing to leaders – Background and reference checks

• Strong training program from first day (dedicated area and training accounts)

• Sense of purpose – mission

• Feedback loop on performance

• Turnover was low

• Rewards were often/recognition was evident

Culture and employees

• Employees were engaged – the huddle was a standard

• Teams met and helped create plan

• Employees were encouraged to stretch

• Interpersonal skills and maturity was evident

• Several had social committees/others not but friendships were evident – staff turnover and sick time were not issues

• All did employee surveys and acted on them

Culture and employees

• Partnered with payers – Collaborative approach – Shared innovation – Open sharing of data

• Vendors were treated as partners

• Community partners – Revenue cycle team had sense of community

Culture and partners

• Revenue cycle was lead by one person

• Weekly leadership meetings was norm

• No one type of leader evident

• Average tenure of the leader was 7 years

• No standard education level

Leadership

• Passion for the job - “She loves the organization and she loves the staff and she love AR”

• Walk the walk – “She works hard and expects the same from us”

• Care for the people – “I’ve never had a boss so caring about me

as an individual”

• Fair – “We are all held to the same standards”

• Communicate – “He let’s us know what’s going on and more importantly how I am doing.”

Common comments about the Leaders

Leader remarks were good reminders

• Training and QA – Peer review of accounts as a team – Accountability is paramount

• Stay in touch with industry – Be involved in associations – Network with peers

• Stay in touch with staff – Sit with your team – Invite and reward innovation – Empowerment is consistent culture

• Calm process – Schedules of tasks – Consistent expectations

• Never stop learning -HFMA

• Network with peers – HFMA

• Allow yourself time for strategy (Hippie Tree Time)

• Take time for your priorities besides work

• Build process to sustain success – watch our for the flash fix

• Acknowledge your and your team’s accomplishments

• Have fun

• Be passionate about you work

Personal lessons from my time with the 12 Leaders

• Added areas – charge capture/coding/CDM • 15 more “top performers” • Deeper dive into culture and leadership of

organizations • Some top crashes and why • Region 10 in August

Coming Soon – Part II

What do I do with this??