From using blanket advance beneficiary notices to keeping credit card receipts in a shoe box, revenue cycles are filled with bad habits and employees who don't fully understand their jobs.
"Please do not have blanket ABNs," Shawntea (Taya) Moheiser, CMPE, CMOM, owner of Omaha-based ITS Healthcare, LLC, warned during her presentation at the MGMA Financial Conference in Nashville last week.
But looking around at the audience after giving this advice about advance beneficiary notices (ABN), Moheiser saw knowing smirks and smiles from those in the audience.
Apparently, many people in the room were guilty as charged.
Later, one of those audience members who listened to the presentation caught up with Moheiser and her co-presenter, Kem Tolliver, CMPE, CPC, CMOM, president of Medical Revenue Cycle Specialists in Maryland, to whisper a confession.
"That was us for a long time. We know better, now we don't do that now. But yeah, we did that." he said.
"They don't know what they don't know," Moheiser told HealthLeaders later. "And we are in an industry where you are at risk for what you should have known."
Moheiser and Tolliver, who have coauthored the forthcoming MGMA book, Revenue Cycle Management: Don't Get Lost in The Financial Maze, spend their days helping revenue cycles get on track with laws, regulations, and best practices.
And because of this work, they've seen a lot of questionable habits, from using blanket ABNs to one physician practice that kept all of its credit card receipts in a shoe box under someone's desk.
Most of the time, these revenue cycles aren't filled with unscrupulous people. Instead, their employees don't fully understand their work responsibilities or the rules required for doing their jobs.
But, as Tolliver says, "abuse is not an excuse."
"Fraud is intentional. Abuse is unintentionally making a mistake. But that's no excuse to CMS; they're still coming after you," Tolliver says. "That's why my slogan is, 'Abuse is no excuse.'"
"And mine," Moheiser chimes in, "Is, 'Please tell me the whole story,' because I know you are embarrassed about some stuff you guys are not telling me."
Here are four of Moheiser and Tolliver's most recent revenue cycle horror stories.
1. The appointment colors mean what? Moheiser and Tolliver worked with one organization that was stumped by its "gigantic issues with patient demographic data being accurate," despite its batch eligibility process, which it was very proud of.
If all of these eligibility checks generated responses, why were there so many issues?
It turned out there was just one problem: The front desk staff thought a blue highlight on an appointment within the practice management software meant a patient was eligible to be seen by a provider.
However, they learned that wasn't the case.
"The blue highlight meant we got a response back from EVS [Eligibility Verification Service] and you should click into that further to see if the patient is eligible," Moheiser says.
Teaching the front desk staff to actually click in and review the responses resulted in the organization seeing a double-digit increase in patient demographic accuracy.
2. Write-off happy: One practice would write off in full anything that wasn't paid by insurance.
And if a payer requested documentation for a service? Forget about it.
"It was astonishing. 'Guess we're not getting paid,'" was how Moheiser described their response.
"When I explained that these things were collectable they were astonished. It was brand new information. Think of how basic that is, submitting documentation. The person posting payments never had any training in rev cycle," she says. "We went back and captured as much with timely filing but the depth of the total loss across several years is still painful to think about."
3. Coding audits take a turn: Tolliver and her team were about to engage a really large organization in initiating medical record documentation reviews and coding audits.
Although the contracts were signed, and the work was about to start, during a kick-off meeting, Tolliver discovered that the organization was under a Medicare audit.
Tolliver was forced to tell the client that the audit would change the "entire scope" of their work.
Now, they needed a new conversation—with the client's attorney—about whether the attorney should hire Tolliver instead of the organization itself so the coding audit results would be privileged.
4. No cost-sharing here!: In her work on a clinic's chronic care management program, Moheiser asked the client what their approach to cost sharing would be.
The reply? "We don't do cost sharing here."
They didn't collect co-pays or deductibles either because, the clinic reasoned, "that's the government's way of trying to keep this community down."
Moheiser asked how they felt about federal law in general.
"Because that's illegal. We actually can't do that," she said. "You'd be surprised how many times I tell that story and instead of laughter people say, 'Wait we can't do that?'".
All of these examples might seem far-fetched, but they're actually not that uncommon, Moheiser and Tolliver say. And although ignorance isn't an excuse, they also note that organizations are usually embarrassed by their gaffes and eager to fix their mistakes.
"When they expose us to the truth of what's actually happening in their organizations we are better prepared to educate them and give them resources to be successful and compliant. Healthcare providers and executives are in medicine because they want to serve. When they realize the error of their ways it's very rare that we've encountered practices that continue on that same path," Tolliver says.
People want to do what's right; they want to follow the law and they want their practice to succeed. They just don't know what they are doing that may be getting them in trouble, Moheiser and Tolliver say.
"Inadvertent risk and damage," Moheiser says. "Isn't that the real horror story?"
Alexandra Wilson Pecci is an editor for HealthLeaders.