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Five Actions to Bolster Payment

News  |  By Julie Auton  
   February 01, 2018

Forget shortcuts. Focus on relationships and education.

This article first appeared in the January/February 2018 issue of HealthLeaders magazine.

Revenue cycle leadership often boils down to hitting the right number.

And each decimal point on that number means a new tool or strategy to drive more efficient and involved operations.

Heightened tactics include establishing greater rapport with payers, intensifying ways to reduce denials, shaping a dynamic team, and making it easy for patients to pay their bill.

Two roundtable events in 2017—the 45-executive HealthLeaders Media Revenue Cycle Exchange in Tucson, Arizona, last March, and the smaller-group HealthLeaders Media Revenue Cycle Leadership Exchange in October in Nashville—invited qualified revenue cycle leaders to share tested approaches and gain applicable ideas from their peers.

Successful strategies that materialized from the discussions include the following:

1. Build relationships with payers.

It's painstaking. It takes time. But there is no getting around the need for establishing closer and more regular contact with payers.

The MetroHealth System in Cleveland, Ohio, a 926-bed hospital with 600 physicians, a Level I adult trauma center, a life flight trauma burn unit, and two freestanding emergency departments, focuses on persistent communication and having the right people on the line for meaningful conversation.

"We meet with each of our payers monthly, and include a physician chair or anyone else involved with the appeals process," says Donna Graham, senior director of revenue cycle. "Having clinical-to-clinical has expedited resolving issues that revenue people and managed care people go back and forth about.

"We've also added our utilization review (UR) team, since payers have a UR clinician, so everyone is talking the same language and determines an action plan."

"We hire good customer service people with experience at department stores, restaurants, and other places involving aggravating situations with consumers."

—Donna Graham, senior director of revenue cycle at MetroHealth System in Cleveland, Ohio

UnityPoint Health, an integrated health system in Iowa, Illinois, and Wisconsin with $4 billion in net revenues, is taking a more assertive approach with payer terms.

"We're working to get shared savings," says Renee Rasmussen, vice president of revenue cycle. "We're also issuing termination notices to third parties for things that aren't right such as denials, and holding insurance companies more accountable."

2. Minimize denials through staff performance, improved documentation, and involving clinicians.

"The major source of waste is first-pass denials," says Patrick McDermott, vice president of revenue cycle at Sutter Health, a not-for-profit healthcare system based in Sacramento, California, with 24 hospitals, 5,500 physicians, and an ambulatory network.

"If you submit 1 million claims a year, 8% to 15% of them will get an immediate denial. And if it's not a key performance indicator, then it's a blind spot for someone running the revenue cycle," he says.

McDermott's strategy was to assign his entire team the responsibility of reducing denials and tying it to performance evaluations. His approach brought positive outcomes.

MetroHealth has minimized denials by attaching a summary of key indicators to the top of the medical record chart. Graham says a concise write-up makes it easier for insurers to review the claim. "It also puts the onus on payers to justify why they're denying it," she says.

Critical to refining claims submissions is engaging physicians and case managers.

"We've implemented meetings three days a week with case management, our front-end staff, our finance folks, and our health information management (HIM) team to discuss concurrent denials, which are mostly status change issues," says Donna Ellenburg, director of revenue cycle at Community Health Systems Grandview Medical Center, a 372-bed hospital in Birmingham, Alabama.

3. Make it easy for patients to interact with you about their bill.

Educating patients about their coverage and payment options is key to getting paid.

South Nassau Communities Hospital, a 455-bed, acute care, not-for-profit teaching hospital with multiple ambulatory facilities in Oceanside, New York, deploys financial counselors to meet with patients during their hospital stay.

Their role can be particularly important when a patient's change in status alters payment responsibilities.

"Our counselors are not just bill collectors; they are focused on education," says John Stryska, senior director, access services. "If there are other people in the room, our counselor explains who she is, that her purpose is to talk about their insurance coverage, and if the patient is comfortable having that conversation with others present. If they're not, then she'll return at another time."

"Our counselors are not just bill collectors; they are focused on education."

—John Stryska, senior director, access services at South Nassau Communities Hospital in Oceanside, New York

Providing easy-to-understand statements and online service is another approach to securing payment. More organizations are offering self-service portals and a chat line for questions about estimates, as well as the ability to pay.

"We used to have separate bills for our hospital side versus our physician side, and recently we put everything on My Health Online, which is our online system," says Alex Collins, director of revenue integrity at Piedmont Athens (Georgia) Regional, a 360-bed nonprofit hospital in the Piedmont Healthcare system that includes a Level II trauma center and a Level III neonatal intensive care unit. "Combining it makes it easier for patients."

4. Develop a high-performing team built on customer service skills.

Nothing beats a top-notch business office staff, who are adept at operations, possess content knowledge, and offer excellent people skills.

Building a high-functioning workforce starts with hiring people who are proficient in dealing with others.

MetroHealth observes applicants before offering them a position. "We hire good customer service people with experience at department stores, restaurants, and other places involving aggravating situations with consumers," says Graham.

Establishing a service-focused team also requires ongoing training and staff development.

"We have a revenue cycle education team dedicated to training," says Collins. "The trainers have a learning portal covering all kinds of courses, including customer service. We provide education about the entire revenue cycle, no matter where an employee fits in."

To spark creative thinking among his team, Josh Welch, executive director of revenue cycle at John Muir Health in Walnut Creek, California, which has two acute care hospitals, an inpatient behavioral health center, and 350 employed primary care and specialty physicians, initiated a program called "Revination" in which staff are rewarded for contributing process improvement ideas.

"Employees need to feel like they can suggest an idea and know that it's going to be carried forth and at least vetted, and then involve them in the process," says Welch. "With our Revination initiative, it's constant communication, sharing success stories, and celebrating people's [input], and even hopefully recognizing employees monetarily."

5. Know when to outsource expertise to minimize service and technology gaps.

Many health systems have learned that it's easier and more effective to outsource portions of their revenue cycle services to outside entities who can address specific limitations.

South Nassau Communities Hospital uses an outside vendor for online payment. "Our vendor has set up a portal in which a patient can go online and make their payment, because our IT department doesn't have the staff or technology to achieve that," says Abdool Razack, senior director of revenue cycle. "It's definitely cheaper to do it outside than internally."

"Employees need to feel like they can suggest an idea and know that it's going to be carried forth and at least vetted, and then involve them in the process."

—Josh Welch, executive director of revenue cycle at John Muir Health in Walnut Creek, California

John Muir Health saves on statements using a vendor. "Our statements are better and their call center is more efficient," says Doug Robison, performance improvement leader. "We collaborated on the scripts to provide a cohesive message."

John Muir is also working with a company to do patient advocacy to help patients—such as those with neurological issues or cancer—figure out highly complex bills, says Welch. "For specific populations who have recurring bills, our vendor advises them about what to pay and when, so we hope that will lead to a positive experience for folks who really need it."

Hospital and health system revenue cycle vice presidents and directors will once again meet to review these strategies and new ones at the 2018 HealthLeaders Media Revenue Cycle Exchange, March 21–23 at Ponte Vedra Beach, Florida.

To learn if you qualify for the invitation-only event, please contact


Julie Auton is the leadership programs editor for HealthLeaders.

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