Revenue Cycle Exchange: Rising to New Financial Challenges

Executives at this year's Revenue Cycle Exchange in San Diego say they're making significant progress accounting for alternative payments models, transitioning to new electronic health record systems, and boosting patient experience.

This article appeared in the May 2016 issue of HealthLeaders magazine and was based on Christopher Cheney's online column from March 28, 2016.

There is light at the end of the revenue cycle transformation tunnel.

Southwest General launched Medicare's bundled payment program for congestive heart failure in January 2015. "There was a million dollars at risk, and the question was, 'Do you budget for that? Do you budget for the potential shared savings? One of the reasons we chose CHF was that the data showed that if we were successful, we had an opportunity to get a check from Medicare for over $1 million," says Jill Barber, MHA, director of managed care and payer strategy at Middleburg, Ohio-based Southwest General Health Center, a 358-bed facility.

"And again," she says, "the question was, 'Do you budget for that? Do you plan for that?' What we chose to do is just say, 'If we lose, there will be some other contingency planning to fall back on.' Still a risk, but not incorporated into the budget. We actually felt we were going to be successful. For us, CHF and that $1 million opportunity represented a 'fish-in-a-barrel' opportunity. How hard could it be? We needed to save Medicare $80,000 and the rest would be for us."

As part of the effort to ensure bundled payment success, post-acute strategy is key. At the onset of the bundle, Southwest General closed its skilled nursing facility. "We didn't want to force leaders in our organization to be focused on volume and keeping days of stay ramped up and bodies in beds, which is the exact opposite of working with an alternative payment model like bundled payments. For many reasons, we chose to close our SNF and work with our community SNFs because there was capacity in the market."

Southwest General Health Center has made great strides over the past year in operating and financially managing bundled payments, says Barber. "One of our biggest results has been that our board members, our physicians, and our community members have a better idea of what's going to happen with alternate payment models. They're more comfortable with us taking risk. This is not nearly as scary as it was a year ago," she says.

Since starting the Medicare CHF bundle, she says the revenue cycle team at Southwest General has risen to multiple challenges, including legal and financial obstacles linked to apportioning gainsharing with physicians and satisfying auditors. As the community hospital has taken on more bundled payment initiatives such as joint replacement, more challenges have arisen. "You have to plan per episode. We have a CHF strategy for bundled payments, we have a joint replacement strategy for bundled payments, we have a strategy for sepsis bundled payments, and never are any two of these the same."

While Southwest General fell short of its $1 million CHF gainsharing goal for 2015, the hospital is expecting a $300,000 check from Medicare for 2015 and much better performance this year.

"And by the way, this is not just about finances," Barber says. "We did achieve the triple aim. We increased quality, we decreased costs, and we also increased patient satisfaction."

Launching an EHR Without Losing Your Shirt
The loss of revenue during the installation of a new electronic health record system ranks near the top of every revenue cycle leader's worst nightmares.

From June 2014 to September 2015, Columbus-based OhioHealth installed the Epic EHR at seven hospitals, 343 physician practices, eight urgent care centers, and three medical buildings. "We called it Big Bang," says Jane Berkebile, system vice president of revenue cycle.

"A lot of the problem with these EHR implementations is lost revenue, so we decided OhioHealth was not going to do that. We were going to make sure our revenue was intact," she says.

Berkebile's revenue cycle team pursued a multi-pronged strategy to limit revenue flow disruption, including efforts focused on charge generation, revenue reconciliation, revenue education across the organization, and integrating the clinical staff into revenue cycle functions.

"We decided to bring in a consultant for this portion of the project—revenue and revenue recognition as well as training and educating the organization about revenue. That was the best step we could have made. We have exponentially paid for it with the success from the entire project," she says.

"We wanted to establish a collaborative environment, not only with the consultants, but also with our entire IT staff, the Epic representatives onsite helping us with the implementation, our Finance Department, our clinical departments, and our physicians. We tried to bring everybody into the fold thinking about revenue."

OhioHealth was adamant about having a robust testing regime. "We insisted that we process 5,000 claims for every facility. We brought in our own frontline billing staff from revenue cycle to do the testing."

The EHR implementation results were impressive.

When the first two OhioHealth hospitals went live with Epic, regular revenue flow was re-established within 10 days. "By the time we got to hospitals three, four and five, we were back to our expected revenue by Day Four. So as you can see, as we got a few hospitals under our belt, we really started clicking."

Engaging Patients as Financial Partners
Revenue cycle teams are just beginning to achieve significant progress in improving the patient experience with the financial element of their care, says Mark Norby, chair of revenue cycle at Rochester, MN-based Mayo Clinic, which which has 4,200 staff physicians and scientists at facilities in Arizona, Florida and Minnesota.

"Our focus in the revenue cycle has not really been about the patient. It's been about churning out bills, which is important, but our staff has not been thinking about the consumer the way they think about themselves as consumers," he says.

"When we look at our patient satisfaction, clinical care is off the charts. When we see what our satisfaction scores are in the revenue cycle, they're average, but we're not average. We need to be above average," Norby says.

More than a year ago, Mayo's revenue cycle staff started paying closer attention to information from patients, including focus groups and recording conversations in the revenue cycle department's call center. They heard complaints about too many billing statements and confusion over the health system's website pages related to billing and insurance. "It's just chaos. It just goes to show you that we did not design this stuff with the consumer in mind. We designed it for ourselves."

Over the past year, Mayo has launched several initiatives targeted at improving patients' financial experience, he says. "We're going to change. We're only going to send statements to patients when they owe something. The key there is going to be fewer statements, you owe something to us, and it's going to be easy for you to understand."

Mayo also is committed to providing greater price transparency to patients such as an online cost estimation tool that will eventually provide real-time information on health plan benefits eligibility, including co-pays and deductibles, Norby says. "That's really what we believe patients want. They want to know, 'How much am I going to have to pay.' They don't care quite so much about the sticker price if they don't have to pay for it."

Livonia, MI-based Trinity Health, which operates more than 80 hospitals in 21 states, is making a subtle change in its revenue cycle staff that could have a major impact on patient experience, says Michael Grant, MBA, regional director for patient financial services in Indiana and western Michigan. "In planning a long-term strategy, our people said they were not financial counselors but more like benefits counselors," he says of the initiative to create a "benefits advocate" job title.

Dropping the financial counselor job title in favor of the benefits advocate designation recognizes that the position requires extensive healthcare benefits know-how such as Medicaid enrollment, Grant says. "These have been entry-level positions; but with all the things we're asking of them, they can't be entry level positions."

Benefits advocates play a critical role in revenue cycle teams, he says. "You're getting people at their most vulnerable time. We do surgery on patients' bodies, but we also do surgery on their wallets and bank accounts. You need someone who has knowledge, intelligence, and a heart."