Creating a single billing office (SBO) during an Epic implementation: 5 Lessons

The multi-facility Carolinas HealthCare System managed to create a Single Billing Office Department during their Epic revenue cycle conversion—while also achieving top quartile conversion metric results. Here are the lessons learned and initial experiences with the implementation:

As patients assume greater financial liability for care via high deductible health plans and larger co-pays, they also deserve greater transparency—including a single, well-designed, and fully intelligible bill. In fact, according to PwC's Health Research Institute, one of the top demands of today's healthcare consumers is receiving a single bill. Similarly, a review of over 30,000 online reviews of medical practices revealed customer service, including poor treatment by front-desk staff and confusion over billing, to be far and away the primary source of patient dissatisfaction (by contrast, only 4% of the complaints were tied to the quality of care or misdiagnoses).

To meet consumer expectations, reduce confusion around billing, and improve patient engagement around balances, one health system opted to implement Epic's Single Billing Office (SBO) module during a multi-facility revenue cycle system conversion.

The Revenue Cycle Context
Carolinas HealthCare System, a nonprofit multi-stated health system which operates a broad spectrum of services including hospitals freestanding emergency departments, urgent care centers, post-acute services and medical practices, decided to begin converting its legacy revenue cycle system to Epic in late 2013. The phased rollout is currently underway, and is scheduled to continue through 2018. Carolinas HealthCare System partnered with McKinnis Consulting Services, now a part of Navigant Consulting, to maintain revenue performance during the design and implementation of the project. With each new phase, Carolinas HealthCare System has achieved excellent results in key leading indicator areas including Cumulative Gross Revenue Capture, Claims Acceptance Rates through the Clearinghouse, and Candidate for Bill.

In addition to this metric success, Carolinas HealthCare System created the SBO, renamed the "Unified Business Office" or UBO. The System confirmed or discovered 5 lessons that other health systems should keep in mind as they undertake similar efforts.

5 Lessons

1. Understand the Scope of the Change ...
Revenue cycle conversions are complex enough on their own. Carolinas HealthCare System added complexity by retaining its legacy clinical suite of applications and by adding the new UBO's integration of hospital and professional balances. Here are just a few of the considerations that must go into such an endeavor:
• How should combined patient liabilities be illustrated and conveyed on the statement? (Statement design should be analyzed according to the perspective of the patient as well as with an eye to the organization's goals.)
• How should partial payment of patient balances be allocated? What will the reconciliation process be for the general ledger?
• The various entities and offices that have handled self-pay receivables must identify and communicate their established way of doing things (including relationships with banks, policies and processes for small-balance write-offs and financial assistance, etc.). These policies must be standardized and aligned across the entire healthcare system so that they can be supported by the UBO.

2. ... And Make Sure Employees Do, Too.
At this level of complexity, technical change not supported by organizational and operational change will certainly fail. Plan to consolidate organizational structure, policies, facilities, training, and performance tracking well in advance of the Epic conversion.

Staff who previously specialized in either hospital or professional processes must be retrained to understand the other side (and across both Epic and legacy systems). The goal of patient satisfaction depends on it.

Finally, patients themselves will need awareness of the new process; effective communication and outreach is key to proactively educating the patient population of the change.

3. Handling Payment Allocations and Provider Expectation.
Since a single patient payment must be applied across multiple accounts, the distribution of the patient payments must be managed appropriately. A large concern at Carolinas HealthCare System (as well as a number of other organizations) was the pushback from providers in instances where their patients may post a payment that historically would go to an outstanding balance for a clinic visit, but in the UBO environment could be applied to a larger hospital balance. To account for this, Carolinas HealthCare System made design decisions to alleviate these concerns:

• The site of service that collects the cash up front will receive full credit for that payment
• The patient will always still have the option to mail, call, and use the online payment portal to post payments to a specific encounter(s) of their choosing
• Accounts on active payment plans always receive priority (followed by any bad debt accounts), the distribution logic then applies payments to the oldest balance based on date of service. When there is a facility and professional balance with the same date of service, the design prioritizes professional balances, and finally applies remaining amounts to hospital balances. All things equal, doctors are paid first.

4. Staff Location: Staff for hospital and professional account follow-up had historically been located in separate locations. The need existed to obtain a consolidated location for customer service, patient responsibility follow-up, and patient cash posting staff. This presented a significant challenge as limited net-new or existing facility space was available.

Carolinas HealthCare System was eventually able to successfully "go-live" with the new UBO across the legacy platforms over six months prior to the initial Epic conversion. During this time, staff were able to sit side-by-side, shadow cross-departmental workflows and systems to gain exposure to the most common questions, resources, and paths to resolution. The leadership team could also proactively manage the culture of the new team.

5. Find Out How You're Doing
The UBO implementation requires continuous evaluation of all processes and procedures throughout hospital and professional billing. Inconsistencies must be identified early and dealt with quickly.

With the extended rollout period, Carolinas HealthCare System was able to perform Six Sigma Lean analysis across each legacy workflow area to determine inefficiencies and opportunity areas to increase overall staff productivity, as well as maximizing the opportunities within a shared model.

Post-Epic Go-Live Success

While the Epic rollout is well underway at Carolinas HealthCare System, the majority of facilities will not transition to the new platform until later into 2017. It is still too early to determine system-wide long-term cost benefits across the entire patient population; However, Carolinas HealthCare System has begun to see early returns within the UBO across a few sample areas:

• Increased patient satisfaction due to the ability for one customer service representative to resolve both acute and ambulatory questions and issues including ability to establish one payment plan for hospital and professional balances
• Average length of patient calls maintained in the Epic environment (as compared to both legacy systems) indicates increased staff efficiency to resolve multiple balances in less time
• An initial projected 5% (or roughly $100,000) patient statement cost savings long-term (across initial go-live volume projections)
• Increased patient self-service resolution percentages through new IVR workflows
• Decreased call transfer volume to external overflow vendor resulting in roughly $200,000 in projected annualized cost savings
• Implemented a propensity to pay patient follow-up workflow across acute and ambulatory that segments populations and drives prioritized accounts to value-add internal vs external resources (this was new to the ambulatory environment at Carolinas HealthCare System)
• Reduced legacy system call transfer volumes

Author(s):
Matt Onesko, Associate Director - Navigant Consulting
Chris Johnson, Vice President, Patient Financial Services - Carolinas HealthCare System
Steve Burr, Senior Vice President, Patient Financial Services - Carolinas HealthCare System
Mike Hill, Assistant Vice President, Information and Analytics Services - Carolinas HealthCare System
Natalie Porter, Senior Consultant - Navigant Consulting

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