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Central Scheduling, CDI Solutions Boost Revenue Cycle

 |  By Rene Letourneau  
   April 06, 2015

Executives attending the HealthLeaders Media Revenue Cycle Exchange shared how they solved two of the function's biggest problems.

At HealthLeaders Media's recent Revenue Cycle Exchange, held in Austin, TX, finance leaders from more than 20 hospitals and health systems came together for two and a half days to share with each other solutions to some of the biggest billing and collections challenges their organizations are facing.


Kathleen Bourgault

Two of the many success stories I heard were presented at the Idea Breakfast on the last morning of the event.

Agreeing on three priorities at a time

When Kathleen Bourgault, vice president of revenue cycle, joined Mary Washington Healthcare in October 2011, she arrived in the middle of what she calls "the perfect storm" for the Fredericksburg, VA-based health system.

"Mary Washington for years had been designated a sole community provider. In 2010, a 100-bed, for-profit hospital was built a few miles from Mary Washington Hospital. The loss of sole community provider status was estimated to be worth over $30 million in Medicare and Tricare reimbursements," Bourgault says.

"In the same period of time Mary Washington Healthcare had already started building a smaller facility to the north, towards the Washington, D.C., area in a growing but underserved market. Almost overnight we had competition, a significant reduction in reimbursement dollars, a major system conversion, and a still sluggish economy."

Bourgault says her first priority was cultural rather technical. She had to inspire the changes that were necessary for the organization to succeed within its new economic reality.

"Mary Washington had not experienced these kinds of financial situations in their recent history. I first needed to create a sense of urgency in the revenue cycle. I convened an executive steering committee, including the vendor of our HIS system because they were key partners," she says.

The next critical steps were to define priorities and get everyone agreed on the actions that needed to be taken.

"We created a meeting structure and prioritized items, because what I found was people weren't tying their efforts together. IT had their own list and revenue cycle had their own list. There were a huge number of consultants in there, and they had their own list," she says.

"Everybody had their own list of priorities, and they were working very hard with their individual lists, but nothing was happening. So the first thing we did was to create one list and identify three priorities per week. No more than that. Everybody was focused on those top three priorities. ... We developed cross-functional teams and then we developed process and action owners to make sure people were being held accountable."

One area of focus was central scheduling, which at that time was not integrated into the billing software. The result was a duplicate registration process where patient data was entered into two systems, resulting in long call wait times, patient and physician dissatisfaction, and a high percentage of denials for no authorization.

After hiring a manager, Bourgault says she began to reorganize the department to streamline processes and provide a better patient experience.


Jill Barber
Director of Managed Care
and Payer Strategy,
Southwest General Health Center

"In our high-volume practices, we actually placed a 'concierge.' The concierge can do it all, including scheduling, insurance verification, and pre-registration. Then we have a centralized team for those smaller offices, and they do the same functions," she says.

A crucial aspect for success was placing the right people in those important jobs. "We talked about the job competencies and the skill set that was needed. What did we really need for these people who are so key to our front door to gather the correct data and to provide great customer service and to be able to do both quickly? When we did a staffing analysis, we realized we didn't have the right skill set in all areas and we didn't have the right mix, so we had to focus on hiring and retraining the right people."

The improvements from all these changes were substantial for patients and the healthcare system alike. In less than a year, the average call wait time decreased from three minutes and seven seconds to 28 seconds, and no-authorization denials dropped from 2.6% to 0.5%.

"It was a big win," Bourgault says.

Engaging physicians in clinical documentation improvement

While most hospitals and health systems are working hard to improve the precision of their clinical documentation, these efforts can be futile unless physicians are invested in the process and understand the value to the patient, the organization, and themselves.

Jill Barber, director of managed care and payer strategy at Southwest General Health Center in Middleburg Heights, OH, says that although the hospital has had a CDI program in place for years, its case mix index was in decline while length of stay and complications were on the rise.

"CDI and the idea of case mix index erosion really started becoming front and center as an issue for us" in 2012, Barber says, noting that Southwest General added clinical documentation specialists to its finance team to help deal with the concern.

"They were all seasoned CDI nurses, but our physicians were very easily able to ignore them. … We had physicians who would take the stairs to go around the CDI nurses. It really was not a good relationship."

As a result of the lack of cooperation from physicians, the query response rate for clinical documentation-related questions was less than 20% for the hospital, and a lot of money was being left on the table, Barber says.

In the fourth quarter of 2012, Southwest General piloted a query process program with the 13 physicians who are part of its cardiovascular service line's co-management company. Queries were sent via email through the electronic medical record's message center. For the first time, physicians were able to respond easily, and the impact was clear. For these 13 physicians, the query response rate rose from 23% to 75%, and there was a significant decline in duplication of queries.

"The physicians were really getting it, and also, we noticed we weren't querying them for the stupid stuff anymore. … We really hardwired the process, and basically what happened was we were seeing such significant results we said this was no longer a pilot, and we began to hardwire the whole process across all physicians."

The impact on revenue was substantial, Barber adds. "For us, in one short year, it was $1.4 million in additional revenue for our cardiovascular service line. To put that into perspective, that is over 3% of that service line."

Additionally, the organization-wide case mix index has increased by 7.6% because physicians are now capturing a more complete and accurate picture of their patients' severity of illness. Along with benefitting the hospital's revenue cycle, the higher CMI means patients' medical records are more precise—which can help improve quality—and physicians receive acknowledgment for treating sicker patients.

A key to the program was engaging physicians in a way that matters to them, Barber says. "I think this speaks to them on a more real level than just the idea that the hospital wants more money. You are telling them to get credit for the sick patient that they are really taking care of. I am saying, 'Let me tell your story through the codes you put on the bill about the high-quality doc that you really are.'

"The main takeaway is pretty evident. We were not able to really be successful in a CDI program until we engaged the physicians," Barber says.

Southwest General is now focusing on engaging physicians outside of the cardiovascular service line to expand the positive impact of the CDI program, she says. "The query response rate for all physicians is still only 46%, and our goal is to get over 80% for the organization."

Rene Letourneau is a contributing writer at HealthLeaders Media.

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