We spoke with the organization about how they selected their automated solution, the key players involved, and results they've seen.
Pennsylvania based Allegheny Health Network (AHN) brings in $4.5 billion in annual revenues. Like many healthcare businesses, it has recently invested in the digitization of its revenue cycle, specifically the automation of patient billing.
To tackle the network's growing issue of uncoordinated bills and fragmented communications between patients, payers, and providers, they looked for a solution that would benefit providers and payers while also helping patients understand healthcare costs.
James Rohrbaugh, CFO and treasurer for AHN, explained to HealthLeaders that now that patients are shouldering more of the cost of their healthcare, not trusting the billing process and not understanding their benefits makes for a frustrating and stressful experience.
It can also cause the patient to disengage from the healthcare system, he added.
"It was clear to us that the patient billing process is broken, and that providers and payers alone can't solve the systemic challenges," Rohrbaugh said.
Technology selection
When brainstorming options for streamlining billing and insurance process, leaders from Highmark Health were involved in the decision-making process along with AHN staff from the communications, information technology, revenue cycle, and finance departments.
Previous strategies and technologies AHN implemented weren't curated for customer preference and, Rohrbaugh added, customer preference should be the main driver in patient-facing technology.
That's when Highmark Health and AHN partnered to implement a financial engagement platform from Cedar that improves the end-to-end journey for its patients. Patients now have a connected financial experience that integrates their payer, provider, and financial institution.
A unique element of the solution AHN chose is that they're able to integrate patient's claims data with explanation of benefits data seamlessly between Highmark and AHN.
Customer preference regarding how patients can choose how they communicate with the AHN network had previously been an area that AHN had been behind the curve on, Rohrbaugh said. The network's new tool assists with this and includes a portal where patients can choose a payment plan and access different self-service tools to meet other healthcare needs.
Once decision-makers found the patient billing solution that aligned with the AHN's goals, during the implementation process, they identified specific priority areas for the network to focus its efforts on collectively.
Testing the tool with a pilot group of patients, they measured the results to see what was and wasn't working, making the necessary adjustments to meet their objectives.
Investing
When considering an investment like this, financial leaders must consider cost and return on investment. According to Rohrbaugh, building a contract with your vendor partner where both parties share in the success, and failures, is also important.
"Ongoing tracking of the KPIs that will drive value and financial [growth] is a critical part of return on investment," he added. "I would also say having operational metrics as well, because we need to balance the financial metrics with making sure that the patient engagement and patient satisfaction is equally important."
Absence of this, he said, creates situations where people don't want to access care.
Outcomes
Since implementing the tool into the network's operations, AHN has seen a $17 million increase in patient payments, a 33% lift in the utilization of HSA/FSA accounts, and an 11% reduction in call center inquiries. Patients have also been satisfied with the new payment process.
The healthcare landscape is ever evolving, and revenue cycle leaders need to be creative when bolstering the patient financial experience.
As more organizations are looking to improve patient experience, revenue cycle and finance leaders are getting creative with new payment options.
Complex billing processes can translate into a disjointed patient payment experience. In fact, a recent report by US Bank found that common complaint amongst patients is that their bills are “confusing and unclear,” leading 55% of finance leaders to reevaluate their vender and customer payment experience altogether.
The accessibility and ease of use of an organization’s payment method makes a difference in the speed of an organization’s payment reconciliation process, and in turn is a crucial part of the revenue cycle.
In an effort to keep up with the ever-changing landscape, more organizations are looking to be more creative with their payment options.
According to the report, 54% of providers have already begun utilizing cash sharing applications like Zelle and Venmo for patient payments, and those who haven’t are planning to do so in the future.
Not ready to make the leap to Venmo? That’s OK but streamlining the patient payment process in any way is a must for the revenue cycle.
HealthLeaders previously spoke with Drew Smith, director of revenue cycle at Main Street Family Care, on its decision to implement a text-based bill pay process with its patients. Smith said the goal wasn’t to just increase payment speed but reduce cost to collect as well.
“Paper statements cost $6 per statement for our organization based on paper and postage costs, the time it takes to post physical checks and respond to returned mail and the need for a lockbox,” he explained.
Smith added that Main Street Family Care isn’t charged for having the wrong number for a patient or if the text wasn’t delivered successfully. Since starting their mobile pay option in 2019, 14% of their patients use it to pay their bills. Within that group, 80% pay before a paper statement is ever printed.
Revenue cycle technology is everywhere, but it’s not without financial risk.
While many organizations are implementing technology to save money or streamline processes, assessing the risks of new technology is the first place revenue cycle and finance leaders need to start.
Revenue cycle leaders know there’s zero room for error with a costly investment, luckily there are three factors that can help ensure technology success.
In a new report by US Bank, healthcare finance teams ranked the pace of technological innovation and digital disruption as their third-most important business risk.
According to Shawishi Haynes, EdD, MS, FACHE, director of revenue cycle operations for Valley Presbyterian Hospital, there are numerous tasks within the revenue cycle that can benefit from technological solutions but, the state of an organization’s finances and current utilization of technology will determine whether the investment is worth the risk.
“It will take time to see every organization using technology in the same way due to the differences in organizational philosophy, financial position, and technological growth,” Haynes told HealthLeaders.
So how can revenue cycle leaders best asses the risks of new technology and ensure success? According to the report, there are three factors that can slow organizations down and hinder success:
Unclear strategy
Revenue cycle leaders should work with their chief financial officer and other C-suite leaders to ensure that the potential investment will be in alignment with future tech-focused plans for organization.
Failure to get employees onboard
Reluctant employees were considered the second biggest obstacle to successfully integrating new technology into operations. To encourage usage, employees whose responsibility it will be to use the new technology should be included in the decision-making process.
Lack of expertise
There needs to be employees or a group of individuals within the organization with extensive knowledge about the technology being used. Another way to continue to get employees onboard would be to get the organization’s technology and digital teams to access the needed expertise.
Other factors that can slow down an organization’s technical advancement include lack of budget, fear of business disruption, and figuring out what the return on their investment will be.
The latest code sets include Spanish-language descriptors and streamlines SDOH data capture.
Documentation and coding are a crucial element to the revenue cycle, making it even more important for leaders to stay up to date with changes and new additions to the code sets.
Here are some of the most recent HealthLeaders stories on coding, including updates for 2024.
The American Medical Association released the 2024 code set in early September, with over 300 updates including 230 additions. Over 50 codes related to COVID-19 vaccination were consolidated, and rev cycle leaders should be sure to review the clarifications made regarding the reporting of evaluation and management services.
Spanish language descriptors were also incorporated into the code set in an effort to improve accessibility for Spanish-speaking patients.
Another code update includes the 2024 diagnosis code set. These changes affect the way certain diseases, accidents and injuries, and social determinants of health (SDOH) are reported.
To better address patient’s social need and broader social determinants of health, 30 new diagnosis codes were added for factors influencing health status and contact with health services. There are also special guidelines for reporting these codes.
In early October, CMS published an infographic illustrating ways organizations can improve upon the ways they collect SDOH data.
SDOH data enables revenue cycle leaders to better predict healthcare utilization patterns and allocate resources more efficiently to ultimately lower healthcare costs. CMS’ recent attention to SDOH data suggests there may be focus on future reimbursement for these services.
Patient access errors are a top reason for denials, which could be costing revenue cycles a lot of cash.
Mistakes during patient access or registration are the main cause of initial claims denials by payers, a new survey found.
This doubles down on the idea that revenue cycle leaders need to address denials management and embrace tech solutions, and they should have done so a long time ago as the financial implications of denials is huge.
Over 350 chief financial officers and financial leaders at health systems and hospitals across the nation ranked the common reasons for initial payer denials and the top five reasons, in order, were as follows:
Errors in patient access/registration
Lack of documentation to support medical necessity
Missing or incorrect patient information
Physician documentation issues
Utilization management
Other reasons mentioned included coding errors, duplicate claims, and untimely filing of claims.
Its obvious that issues with eligibility and registration occurring at the front end of the revenue cycle are affecting the reimbursement process, so what can revenue cycle leaders do?
The key to avoiding these denials may lay in automation.
Patient access plays a tremendously important role within the revenue cycle, Alicia Auman, former director of patient access at KSB Hospital in Dixon, Illinois, previously told HealthLeaders.
"If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials," Auman said.
KSB Hospital implemented front-end technology that included automated claim verification, front-end claim scrubbers that catch errors immediately, and tools to collect copays and payments at the point-of-service.
KSB now has real-time edits that prompt the registrar to talk to the patient at the point of service, as well as eligibility verification, which automatically checks eligibility.
“Access related denials were around 21%, now they're around 7% of total denials,” Auman said.
And since implementation, KSB’s technology has prevented an average of $800,000 per month in denied charges, with more than $20 million in total savings that would have been denied, Auman explained.
Patient access errors are a top reason for denials, which could be costing revenue cycles a lot of cash.
Mistakes during patient access or registration are the main cause of initial claims denials by payers, a new survey found.
This doubles down on the idea that revenue cycle leaders need to address denials management and embrace tech solutions, and they should have done so a long time ago as the financial implications of denials is huge.
Over 350 chief financial officers and financial leaders at health systems and hospitals across the nation ranked the common reasons for initial payer denials and the top five reasons, in order, were as follows:
Errors in patient access/registration
Lack of documentation to support medical necessity
Missing or incorrect patient information
Physician documentation issues
Utilization management
Other reasons mentioned included coding errors, duplicate claims, and untimely filing of claims.
Its obvious that issues with eligibility and registration occurring at the front end of the revenue cycle are affecting the reimbursement process, so what can revenue cycle leaders do?
The key to avoiding these denials may lay in automation.
Patient access plays a tremendously important role within the revenue cycle, Alicia Auman, former director of patient access at KSB Hospital in Dixon, Illinois, previously told HealthLeaders.
"If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials," Auman said.
KSB Hospital implemented front-end technology that included automated claim verification, front-end claim scrubbers that catch errors immediately, and tools to collect copays and payments at the point-of-service.
KSB now has real-time edits that prompt the registrar to talk to the patient at the point of service, as well as eligibility verification, which automatically checks eligibility.
“Access related denials were around 21%, now they're around 7% of total denials,” Auman said.
And since implementation, KSB’s technology has prevented an average of $800,000 per month in denied charges, with more than $20 million in total savings that would have been denied, Auman explained.
In a survey commissioned by AKASA, 78.7% of financial and revenue leaders said denials management required the most subject matter expertise. The same survey found that only 38% of hospitals and health systems are currently automating denials management.
With the risk of inefficiencies and mistakes, investing in artificial intelligence or other technological solutions could potentially save organizations time and money, enabling them to utilize physical staff more efficiently.
According to the 2023 Plutus Health Revenue Cycle Management Challenges Index, 40% of providers are losing over half a million dollars each year due to claim denials and 18% losing over a million.
Claim denials remain a significant issue for providers, making denials management the top priority for many revenue cycle leaders. Some organizations have embraced technological solutions, but the index also reports that others are hesitant to do so; despite benefits like improved efficiency, fewer errors, and accelerating cash flow.
Two Cigna members filed a class action lawsuit against the insurer for failing improperly denying their claims due to its PXDX algorithm. The algorithm allegedly allows doctors to automatically reject payments in large groups at a time, without opening or reviewing patient files.
This isn’t the first time PXDX has been scrutinized. In March it was reported that 300,000 requests for payment were denied over two months, with the algorithm spending 1.2 seconds reviewing each case.
A report by the Office of Inspector General found that Medicare managed care organizations (MCOs) denied one out of every eight prior authorization requests in 2019. The report illustrates a lack of denial oversight in most states.
Of the 115 MCOs reviewed in the report, 12 had a prior authorization denial rate over 25%. It was also found that state Medicaid agencies didn’t review the rates, and many failed to collect and monitor related data.
The agency is putting in effort to better assist SDOH data capture in the revenue cycle.
In a push toward its broader goals of improving healthcare quality and reducing costs, CMS recently published an infographic illustrating methods to improve the way providers and revenue cycle staff collect social determinants of health (SDOH) data.
Revenue cycle leaders have begun placing more focus on capturing SDOH data to better predict healthcare utilization patterns and allocate resources more efficiently, potentially reducing unnecessary hospital admissions and readmissions, thus lowering healthcare costs. Keeping up with new guidance will ensure your teams are best collecting data on the back end.
This infographic plays into CMS’ recent focus on streamlining SDOH capture. The trend suggests CMS will be placing a heavier focus on future reimbursement for these services as well.
The infographic provides fundamental information on Z codes and how they align with SODH in a flow chart format, along with a list of new codes and their descriptions, including those recently added in August.
Z code categories Z55-Z65 are used to document SDOH data, like issues related to a patient's education and literacy, whether they have adequate housing and utilities. For children, the codes will enable providers to keep track of their custody and any domestic conflict within the home.
According to the infographic, documentation from social workers and case managers can be used if they're included in the patient's official medical record. SDOH data can be screened at each health care encounter to keep up with changes in a patient's status.
'Most organizations focus on protecting the patient and less on protecting the home care worker,' a Johns Hopkins professor says.
Private duty and home health administrators must tackle many industry challenges as leaders, such as worker shortages and reimbursement issues. Another of those challenges is workplace safety and how to keep in-home care workers safe from abuse and bodily harm when taking care of clients.
Nancy Glass, PhD, MPH, MS, RN, began examining workplace safety for in-home care workers during a study in 2010. She says, “Most organizations focus on protecting the patient and less on protecting the home care worker." Listening to workers, primarily women, tell their stories, she found that many were afraid to report instances where they'd been harassed, threatened, or physically hurt by patients or other individuals in the home.
"They had very little support and resources and felt like in some cases they couldn't report it; that they would lose their jobs," Glass told HealthLeaders.
A professor at Johns Hopkins School of Nursing and associate director of the university's Center for Global Health, Glass has a background in prevention of violence against women and children.
The home care workers she spoke with for the study said they felt vulnerable in the workplace, concerned about being believed after abuse had occurred, and unable to quit because they needed the health benefits. There were also concerns about false accusations against them, which could affect their ability to get work in the future.
"They're walking into a home where there's a lot of complex issues, and they really want to support the patient, but there's conflict in the household that they're witnessing, safety issues. Sometimes it's directed at them when they're there," Glass explained.
"They do believe in the importance of their work and the passion of their work, so it is very hard for them to walk away from a situation when they know it's bad."
So, what can in-home administrators do to ensure safety for their workforce?
As for interventions and methods of supporting in-home care workers, while Glass acknowledges agencies and providers can't afford to send workers in pairs, they can encourage their employees to develop their own support system. Maintaining that network and mentoring new workers is one way to combat the isolation that many can feel while on the job.
Glass also suggests teaching workers to set and maintain boundaries to prevent conflicts with clients and their families.
"It's really about safety planning, being confident when setting boundaries on what you will and will not do," she said. "A lot of times when there was a home care worker in the home and other family members were living there, their role would bleed into taking care of everyone."
Workers should also have a fundamental knowledge of self-defense, so if they find themselves in an unsafe situation, they're able to get out of it. It's important, Glass noted, that agencies or providers have a safety plan in place for their workers and that they know what to do in an emergency for themselves and their clients.
"An ideal situation would be [providers and agencies] investing in more training and working with patients and family members about expectations and their behavior," Glass said. "[That way] it's not all on the home care worker to manage the situation."
The private duty caregiving franchise lets potential partners lead expansion, with their interest identifying new markets and territories.
As home care franchises are expanding their reach and presence in different territories throughout the country at varying rates of growth, it’s crucial to temper that growth by ensuring proper support and resources to franchise owners once they join the system, says one industry executive.
In the aftermath of the pandemic, more older adults are preferring to age in place in their homes, and that number is only going to grow along with the demand for home care services, according to Jennifer Chaney, vice president of franchise development for Right at Home based in Omaha, Nebraska.
HealthLeaders spoke to Chaney about Right at Home's plans for future expansion, their owner-operator business model, and the importance of pacing in franchise growth.
The following transcript has been edited for clarity and brevity.
HealthLeaders: What is the first step to begin expansion into a new territory?
Jennifer Chaney: We've got very specific marketing behind the scenes, geo-targeted on the exact territories that we have left in the United States that are available. Our website has an interactive map where potential partners can see the territories that are available.
For us, expansion begins when people inquire about Right at Home franchise ownership. That can happen on that very first phone call with one of our development directors where we look at where they live or where they're moving to.
HL: What does Right at Home look for in franchise partners?
Chaney: The on-paper qualifications are that you need to have at least $150,000 of liquid capital readily available. We don't require previous home care or medical experience. It's certainly nice to have, but not a requirement.
What's most important to us is that you have that passion for care. Whether you work for somebody in corporate America or have your own business, what you're looking for is missing from what you currently have—success with significance. That’s what we're looking for.
Our mission is to improve the quality of life for those we serve and we're looking for franchise partners who have a passion to do the same.
We are an owner-operator business model, so we do require that you as the franchise owner are involved in the day-to-day operations. You'll have to find, and we assist with this, an actual physical office location centrally located in a territory that you purchase, so you can't run the office out of your home. We have all the help and support for that.
HL: How does the owner-operator business model engage with franchise owners to ensure efficient operations and hold them accountable?
Chaney: It's important to us that the franchise owners are highly engaged with us here at the corporate headquarters here in Omaha. We've got a staff of over 90 people that help and assist our franchise owners with their day-to-day operations.
The reason why we have an owner-operator business model is that the franchise owners who are highly engaged with us tend to perform really well in our system versus the franchise owners that aren't engaged. Those who are highly engaged, we have seen time after time perform head and shoulders above those who aren't.
HL: How important is pacing in franchise growth?
Chaney: You have to think about the future in order to implement a strategy for right now. You have to take it step by step.
You can't just have a ton of growth all at once without really having the proper systems in place to support those franchise owners once they're a part of the system. If you grow too much too fast, you've got to make sure that you've got the support in place to properly provide resources and support to those franchise owners once they join the system.
Every baby boomer is going to be 65 or older by the year 2030. Thinking about the future and where we're headed, we have goals that we set every year as far as footprint and franchise growth, stretch goals, realistic goals, and where we want to be with a goal of having all those territories sold by a certain point in time in the future. It's really tough to look ahead even five years from now, because five years ago the world was drastically different.
Our CEO will tell you the same thing. When we're getting together, talking about strategic planning, and thinking about the years to come, things get pretty gray past, I'd say, five years.
If people ask, "Where do you see Right at Home 10 years from now," that's a difficult question to answer because times are constantly changing. Technology is changing, data is changing, the business is growing. We had a global pandemic that, years ago, nobody would've anticipated and put into their strategic plan.
We have to adjust as the world grows, as the industry grows, as the senior population grows and ages. But you also must be methodical and strategic about your growth plans because it can be too much all at once. You want to spread that out to make sure that you're properly covered with all the support and resources in place that you need.
