Becker's Speaker Series: 4 questions with TransUnion Principal, Revenue Cycle Management, Health Care Solutions, Jonathan Wiik, MSHA, MBA

Jonathan Wiik, MSHA, MBA, serves as Principal, Revenue Cycle Management, Health Care Solutions for TransUnion.

On Friday, September 22, Mr. Wiik will speak on a panel at Becker's Hospital Review 3rd Annual Health IT + Revenue Cycle Conference. As part of an ongoing series, Becker's is talking to healthcare leaders who plan to speak at the conference, which will take place September 21 through September 23 in Chicago.

To learn more about the conference and Mr. Wiik's session, click here.

Question: Please share the state of revenue cycle management at your organization. What is your payer mix? What about your revenue cycle is working well, what needs improvement and what do you find yourself spending more time on?

Wiik Jonathan headshot

Jonathan Wiik: Our payer mix was 50% Commercial, 30% Medicare, 10% Medicaid, 5% self-pay / uninsured and 5% TPL (WC/MV/SELF PAY). The revenue cycle had many moving parts and multiple systems. Capturing lost revenue, and insulating existing revenue were our main tenants. We had a robust POS collections program, centralized registration and scheduling, as well as a state-of-the art kiosk check in system. Denial management was very good, as well as cash flow. A/R days remained challenging, as well as treasury management (lock box), and had some opportunities in staffing, especially on the front end in patient access. This was atypical in the market I feel, as I have been in 20 other hospitals since, and they are all over the board with payer mix, challenges, and cash position. Future initiatives were to look at consolidating 3rd party systems, contract modeling, lost reimbursement, and reducing cost to collect. In my new role, denials management seems to be the issue plaguing our providers. Authorization, Pre-certification, and medical necessity denials represent significant challenges as the payer rules become more sophisticated. I am also seeing a large spike in patient bad debt, specifically from HDHPs and the inflation in BAI. Significant effort is being placed in the patient financial experience and moving as many RCM practices as early in the process as possible. As our patients are becoming consumers, the billing and coverage mechanisms in health care need to pivot to meet them as a new payer. Mobile payments, e-scheduling, pre-service estimates, financial clearance, and portal adoption appear to be gaining momentum. I believe the future of the revenue cycle will follow that of the airline and banking industries. We will see more things become automated and less human – patients will be able to on-board and purchase their health care as easily as a boarding a plane in a few years. Financing options will also become more prevalent as health care costs and coverage become more un-affordable.

Q: How have alternative payment models affected your line of work? Can you share 3 specific steps, if any, has your organization taken to adapt to bundles and ACO payments?

JW: Our hospital was a CPC+ site. The program was centered on transitions in care, reducing readmissions, and PCMH. It was making tremendous progress – we were one of the few hospitals that did not have a readmission penalty, and also had a very successful PCMH program. I cannot speak to bundled payments as those have evolved since my transition. In other hospitals, I see a large focus on these initiatives, specifically in the physician space and MACRA, As complex as the rules are, I see more organizations struggling with the documentation and reporting elements. I feel most will take their chances with a MIPS and then try for APM in 2019. Bundled payments may actually increase provider costs in my opinion – the variability in delivery and coordination of care may not afford savings. Commonwealth Fund also did a study, where they listed four problems with bundled payments – 1). comorbidities that fall outside the cost package, 2). care coordination could be hindered/isolated, 3). adverse selection and 4). Infringe upon ACO profitability.

Q: Percent-wise, roughly how much of your revenue cycle is automated? Do you plan to maintain that percent or increase in the next 1-2 years? What effects have you seen from automation, good or bad?

JW: Our Revenue Cycle was approximately 60-75% automated. Areas that were manual involved scheduling, financial clearance, order clarifications, rejected claims, and cash posting. In my experiences with other hospitals, I see lower and higher levels of automation. Best practicing organizations have robust pre-access centers, where patients and physicians can rapidly achieve access and financial clearance for the hospital’s services. Centralizing wherever possible in pre-access, registration, and back office is paramount, affords economies of scale and fosters automation. I see every hospital attempting to automate wherever they can to decrease the cost to collect and bend the cost curve. Positive effects of automation are efficiency, exception based work, throughput, and analytics. Negative impacts are all the manual/paper checklists or verifications that were left at the station when the paper chart become an EMR. Most EMRs focused on the clinical aspects of documentation and ignored those of revenue cycle. Eligibility, Estimation, Benefits Prior authority, Med Nec, Financial Assessment, IP/OBS, PAR/OON, Claim Status, and Denials management all are elements necessary to ensure profitability for a revenue cycle, yet the EMRs are frankly not evolved or capable of submitting, obtaining, consuming, or analyzing those important data sets for the most part. Exception based workflows, connectivity and interoperability to clearinghouses or data warehouses is lagging in my opinion. The reimbursement model for hospitals and health systems has outpaced the EMR capabilities, and until revenue cycle elements are consumable, revenue losses will continue.

Q: What is one investment you've made in RCM that has surprised you in terms of ROI? How so?

JW: Estimation stands out as one. It easily was a 15:1 ratio. Collecting up front from just a handful of the patients, significantly impacted cost to collect, bad debt, denials, and others. Patients were also thanking us for providing them estimates. I do not see this prevalent in the market and am puzzled by it. Patients now represent 30% of collectibles, where just 10 years ago, they were only 10%. Patients are the new payer, and putting in an estimator, along with a robust POS collections and Financial Clearance process affords the revenue cycle many efficiencies that otherwise wait until an envelope arrives in the mail to the patient. Coverage Discovery is another investment I encourage folks to closely examine. Typically, large providers can experience a 1-2% lift in their net revenue, just by putting in a coverage discovery solution. Inevitably patients are going to have (or qualify for coverage that is unknown. Without that awareness and correction, that is money that is left on the table. Finally, financial clearance solutions are quickly evolving. As patients make up more of the revenue, analytics for propensity to pay and financial assistance become integral to revenue cycle. Providers are put into the difficult position of differentiating between a patient’s willingness or ability to fund a bill often. Without know that difference up front, bad debt risk can climb quickly, as well as your cost to collect. Segmenting these accounts, and having the right conversation, with the right patient, at the right time can ensure a collaborative outcome clinically and financially.

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