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Analysis

3 Boots-on-the-Ground Revenue Cycle Strategies for a Second COVID-19 Surge

By Alexandra Wilson Pecci  
   June 09, 2020

Northwell Health executives share practical, in-depth strategies to help revenue cycle leaders prepare for additional COVID-19 surges and other emergencies.

Health system leaders around the country can look to systems like Northwell Health in New York for guidance about how to best prepare their own revenue cycles for a possible second wave of COVID-19 cases as states ease restrictions and mass protests flood the streets.

During the months of March and April, Northwell Health was at the pandemic's epicenter.

"When we say we were in the hotspot," said Rich Miller, Northwell Health's EVP and chief business strategy officer, during a webinar last month. "We [have] either tested or treated over 40,000 COVID-positive patients across our health system, including over 14,000 inpatients."

That was as of mid-May. Its peak was around April 12, with more than 3,400 in-house COVID-positive patients across its hospitals.

During the webinar, Miller and Gerard Brogan, MD, Northwell Health's SVP and chief revenue officer, spoke broadly about some of the financial lessons the system learned during its COVID-19 work, such as redeploying staff, shifting to remote work, and revamping workflows.

A few weeks later, Miller and Brogan spoke with HealthLeaders to share practical, in-depth information to help other revenue cycle leaders prepare for additional COVID-19 surges and other emergencies.

In this first of a two-part series, Miller and Brogan share details of Northwell Health's strategies for three specific elements of their revenue cycle work during the COVID-19 crisis: Queries, redeploying revenue cycle employees with clinical credentials, and field hospital registration.

1. Fielding physician queries from the revenue cycle

Physicians often receive queries from CDI staff who need clarification or additional information for appropriate documentation. COVID-19 presented a unique challenge to that process.

"You've got doctors that are all day long in personal protective equipment. They're really not in a position to sit down and answer a couple of query emails they got from the CDI staff," Brogan notes. "So, how do you get a new workflow for answering queries? You need to be ready to come up with an alternative."

It's always crucial for clinicians to properly document clinical care to ensure proper reimbursement, but that work took on new urgency during the pandemic. COVID and non-COVID cases were billed and reimbursed differently in many cases. In addition, the system needed to report its COVID-19 cases to CMS to ensure FEMA funding, Brogan says.

Instead of sending a query to the attending of record as usual, Northwell Health leaders knew it needed a team-based approach. By convening revenue cycle leaders with CDI experts, the IT team, clinicians, and the system's directors of hospitalist medicine, Northwell Health was able to use the query system it had built within its EMR to direct queries to the appropriate hospitalist team for each case. Then, the hospitalist team could route the questions to an appropriate physician. 

2. Redeploying revenue cycle staff who had clinical credentials

Northwell Health's denials prevention unit and clinical denials offices are staffed with nurses who help secure payer authorizations and write clinical appeal letters to payers when a claim is denied.

Because there were fewer non-COVID patients in the hospitals during the pandemic's peak—and therefore less denial work—the system redeployed those nurses out of the revenue cycle and back into clinical settings.

In general, emergency preparedness plans should not only include reserve staff to deal with increased volume, but the plans should also identify those staff members before the crisis strikes, which is important in terms of getting them credentialed, Miller says.

But it's also important to redeploy them strategically. For instance, Brogan says many of those revenue cycle nurses were redeployed into case management and discharge planning roles.

Because many patients who were ready for discharge were still sick and requiring oxygen, they were "more complicated to place than your average medical patient during non-COVID times," he says. The redeployed nurses were able to get complex COVID-19 patients discharged to the appropriate facilities.

3. Setting up remote registration for a field hospital

COVID-19 patients take up more space for more time because they have long lengths of stay and double rooms must be used for one patient at a time for infection control, so during Northwell Health's surge, it had to add a 1,000-bed tented field hospital.

Not only is it helpful to have tents in storage and electricity, heating, and cooling systems ready to deploy, but revenue cycle leaders also must think about a registration process that appropriately identifies and tracks patients while keeping registration staff safe.

"You're going to be registering patients in tents. So, how do you set up remote registration processes" that allow you to print things like wristbands, name tags, and consent forms? Brogan asks.

The solution was a tele-registration process.

"The patient would be in the tent and, through tele-registration, a registrar inside the main [emergency department] (ED) was registering that patient, as well as the patients that were coming into the ED," Brogan says. The registrar's computers were networked to the printers inside the tents.

Such measures were crucial for mitigating risk for employees whose tasks prevented them from working remotely the way other revenue cycle employees, like coders, call center staffers, and financial counselors, could.

"Of note, we had 95 of our registrars test positive for COVID and we had two deaths within revenue cycle from COVID," Brogan says. "People talk about revenue cycle as a back-office group of folks … that's clearly not true. We have over 1,000 staff members—registrars specifically—who are among the first to meet, talk to, and help these COVID-positive patients as they're seeking care."

"These folks—just like the doctors and nurses—are really risking their lives taking care of their community," he adds. "It's no exaggeration."

Stay tuned for part two when Miller and Brogan discuss Northwell Health's progress and plans moving forward, including plans for extended work-from-home arrangements.  

Alexandra Wilson Pecci is an editor for HealthLeaders.


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