The Exec: Shifting the Focus Back to the Patient and Saving Big in Rev Cycle

The AVP for corporate case management at Ardent Health Services details how its technology caught $1.76 million in potential missed inpatient revenue.

Automation in the revenue cycle is not an if, but when. As revenue cycle leaders know, automation has the power to transform the business of healthcare by streamlining repetitive tasks to improve efficiency and reduce financial waste while providing administrative support.

One healthcare system has done just that by implementing automation for strategic revenue management. Hillcrest HealthCare System, the Oklahoma market of Ardent Health Services, has created a system in which processes are designed to best serve patients instead of the other way around.

As a result, since technology implementation in 2020, Hillcrest’s clinical staff now focuses their effort on patients, not the administrative work, ultimately saving the hospital time and money. 

HealthLeaders recently touched based with Rikki Moye, assistant vice president of corporate case management, at Ardent Health Services, about how the system was able to shift its focus back to its patients through technology.

The health system represents eight major hospitals in the area with over 1,200 licensed beds across the system. Moye was brought on as the vice president of case management in 2016 to build a new case management model that prioritizes patients and is supported by processes instead of led by them, she said.

HealthLeaders: Tell us more about your role at the health system. Was it a challenge creating such a complex case management model?

Rikki Moye: It was a challenge to be sure, but eventually, I thought, ‘Instead of having siloed utilization review, care coordination, and discharge planning functions that sat side-by-side within Hillcrest, what would happen if that model was tipped on its side?’ I then realized that utilization review needed to be a top-down view of the patient where nurse resource managers could oversee the efficient use of resources for each patient as they progressed through their stay, and social work and care coordination could work together to manage the patient safely and efficiently with a seamless discharge handoff.

This model we call the ‘Right Care Case Management Model,’ encompasses five ‘rights:’ The right patient, care, setting, documentation, and billing/payment. Using this approach, patients are placed at the center of the conversation, with communication and care facilitated by a resource manager following that person throughout their encounter and beyond.

HealthLeaders: After implementing this new model, why was it important for your organization to throw new technology into the mix?

Moye: Hillcrest is very large in scale, so in order to set up the Right Care Case Management Model where patients come first and processes are designed to serve them best, we needed the right technology.

Historically, it’s been challenging to introduce technology that would enable this process to the level we need. The labor required is too great, the quantity of data needed is too vast, and consistency and leadership at scale are hard to achieve. However, in mid-2020, we implemented XSOLIS’ CORTEX® platform to address those challenges and allow clinical staff to refocus their efforts on the patient, not administrative work. With it, the staff has access to a real-time, artificial intelligence-driven view of each patient’s medical necessity, prioritizing cases by revenue sensitivity and risk while also using the platform as a channel to communicate with payers. 

The traditional Milliman and InterQual care approaches are binary, meaning it’s either red or green and then you have to move on. It’s also open to nurse interpretation, which means it’s at high risk for human error. Our new platform provides an agnostic, analytical assessment of patients, combined with a nurse’s clinical care skills, which enhances and encourages clinical expertise rather than defaulting to the binary clinical decision tree where you basically check your critical thinking skills at the door.

HealthLeaders: Where were you seeing gaps in the revenue cycle that made you realize a change needed to be made?

Moye: The problems we faced were the same ones that plague care management across the industry: unstructured data that is difficult to harness, gaps in compliance data, lack of consistency with education or supervision, and most impactfully, no way to prioritize the work that has the most significant downstream impact.

HealthLeaders: Case managers are arguably pretty in the weeds when compared to other leaders in the revenue cycle, so were there any hurdles with administrative or clinical staff buy-in? How did you make your case for adding in a new solution like this?

Moye: I was originally brought into bridge operations, strategy, and structure, and provide a gap analysis for where Hillcrest could go in the future. At the time, there was not a lot of case management structure at the market or the corporate level, and the organization was looking for a new way of doing things.

There’s always a learning curve when implementing new technology, but the platform is now a vital part of our nurses’ jobs. The way the tool is set up, it presents medical records and quantifies data in an extremely intuitive way, telling nurses upfront where their day needs to start so they don’t feel like they’re constantly trying to figure something out. In fact, a company-wide study found our nurses got back roughly two hours in their day once it was implemented.

The tool has also improved job satisfaction among utilization review nurses, as well as the relationship between Hillcrest’s hospitals and the payers it interacts with. Hillcrest has a contract with a national payer who also uses the platform, greatly improving our communication and contributing to a better working relationship because everyone sees the same thing. Nurses now know when to push back on decisions, and payers know when to spend time reviewing. Plus, other payers who aren’t currently on the platform are learning about the benefits, and the smoke and mirrors around the term ‘criteria’ are starting to disappear.

HealthLeaders: What kind of outcomes and improvements have you seen in your revenue cycle since implementing this tool?

Moye: In the first two years, CORTEX’s inpatient-only alerts have caught $1.76 million in potential missed inpatient revenue. Along with a 12% reduction in observation rates, this has resulted in an additional $3.28 million in inpatient revenue.

We were also able to improve observation-to-inpatient conversion rates from 27% to 52% while reducing inpatient-to-observation downgrade rates to about 4%, a 50% sustained reduction. Inpatient denials were reduced by 102.34% in the first year.

HealthLeaders: What will you be focusing on for the rest of this year and into 2024? What other goals do you have for revenue cycle improvement?

Moye: Our goals now include moving from a market/regional focus to an enterprise focus across all Ardent Health acute hospitals. Our ability to leverage technology to facilitate throughput and length-of-stay reductions is one of the successes of the Hillcrest team that we are sharing with other hospitals.