Revenue Cycle Exchange: Sharing Solutions to Collections Challenges

Revenue cycle leaders attending this week's HealthLeaders Media conference say clinical documentation and high-deductible health plans are among their top worries. Here's an advance look at solutions.

Later this week I will be at HealthLeaders Media's first Revenue Cycle Exchange in Austin, TX, where I will have access to 25 hospital revenue cycle executives for two days of discussions on their organizations' top strategies for improving billing and collections practices.

As the moderator of one of the three roundtable tracks that are the cornerstone of the event, I will have a front-row seat to hear what's working, what isn't, and what challenges are on the horizon as the healthcare industry continues to evolve towards value-based care. And if my past experience as a moderator holds true, I'll come away with a laundry list of ideas for future columns as our Exchange members share ideas for solutions to some of the biggest problems they face when it comes to getting and retaining payment for services provided.

Identifying the major issues

Before HealthLeaders convenes a group like this—which we do several times throughout the year for our Exchange program, including our CFO Exchange, CEO Exchange, Population Health Exchange, and CNO Exchange—we survey attendees to get a sense of the topics they would most like to discuss during the roundtables.

In the Revenue Cycle Exchange pre-event survey, it was pretty clear what issues are top-of-mind for our attendees. When asked to identify the three biggest threats to their organization's revenue cycle, 79% cited incomplete clinical documentation, 71% cited high-deductible health plans, and 64% said RAC audits and the two-midnight rule, which ultimately are documentation issues as well.

Revenue Cycle Exchange: 3 Big Ideas

Improving clinical documentation

Wade Wright, director of hospital billing at West Tennessee Healthcare in Jackson, TN, told me in a recent telephone conversation that his organization has been working to improve its clinical documentation for years and has found that increasing communication between coders and physicians is one key to success, especially while the patient is still in the hospital.

"One thing that has been a big initiative for us relates to improving our mid-cycle analytic platform and really tying it to our clinical and financial operations. Previously, coders weren't reviewing the documentation until everything was said and done. Now we are making a push to do concurrent coding so that the coders can go back and ask for more specificity immediately while the patient is still there and the physician is still actively working with them," Wright says.

"Now that we have our electronic medical record, coders can also look at changes in DRGs, like a surgery or something that results from test results. We have complex rules built into the ERM system to have another opportunity for coders to look at that and go back and get more complete documentation. It's a whole lot better to do that while the patient is still in the hospital."

By capturing more accurate clinical documentation, West Tennessee has improved metrics such as its case mix index and length of stay, which helps to strengthen its revenue cycle, Wright says.

"We are looking for those documentation opportunities and are really pushing toward making improvements," he says.

Jackie Powers, director of patient financial services at Anne Arundel Medical Center in Annapolis, MD, tells me her organization is also placing a big emphasis on better clinical documentation.

"Like everyone else, we're focused on what documentation is in the patient record to support the charges because it's that medical record that determines whether or not there was medical necessity for the treatment," Powers says.

"Within our organization we have a reimbursement and compliance department, and we have a compliance and audit specialist that keeps abreast of changes in coverage and sends that information to our clinical directors. In addition to that, we are proactive with doing audit work and looking at the documentation and the medical record to make sure we documented appropriately and charged appropriately. A formal report is created and that information is shared with our clinical directors in a proactive way."

Powers notes that as the walls that have traditionally separated the finance and clinical teams come down to create a more integrated culture, physicians are generally on board with the changes. She says physicians and clinicians want the assistance in improving their documentation because they know it improves the fiscal health of the organization and can also positively impact the quality of patient care.

"I think, at least at our organization, that our clinical directors and physician leadership are grateful for the support," she says.

The increase in high-deductible health plans

It's not surprising that high-deductible health plans are of major concern for the finance leaders who are attending the Revenue Cycle Exchange. These plans have been a growing trouble spot for healthcare providers for years and are expected to become more widespread.

"We've been seeing more high-deductible health plans for a while now, and we think that they will continue to grow in number," Wright says.

To mitigate the effect on revenue, West Tennessee Healthcare is educating patients more intensively on what coverage their plan really provides—something Wright says is particularly necessary because employers are not doing a good enough job of providing information as they move employees into high-deductible plans.

"The human resources departments at many employers are not medical benefits specialists, so they do the best they can, but they are not always doing a good job of explaining these benefits and how they work. As much as possible, we are trying to do a whole lot of education on people's benefit plans," he says, adding that finance representatives from his group visit area employers to provide on-site education whenever possible.

Helping patients access coverage

In addition to the three major revenue cycle threats identified in the pre-event survey, Powers considers Anne Arundel's self-pay patient population to be a big challenge. The system is working to help patients gain healthcare coverage, she says.

"We are actually doing an entire financial screening and attempting to enroll patients into Medicaid if they are eligible, or if not, to refer them to the exchanges. If an individual doesn't qualify for Medicaid but hasn't reached out to the exchange, we'll help facilitate that process. We are taking a different perspective of being there as a patient advocate and helping to guide them through it." Although coverage purchased on the exchanges is not retroactive, it may cover future medical visits.

Another piece of the financial counseling, Powers says, is to help patients understand that they may be eligible for coverage now even if they have been denied before.

"Some people didn't take steps to enroll in the first wave of the exchanges because they had been declined for coverage in the past, and they assume they don't qualify. But now it is purely based on income, not on whether you have assets that may have disqualified you before."

Watch the pages of HealthLeadersMedia.com for more on revenue cycle and healthcare finance issues, including follow-up coverage of our Revenue Cycle Exchange.