Revenue integrity and data analytics are top of mind for healthcare CFOs, according to a 2019 survey conducted by Healthcare Business Insights. To address denials and underpayments, one in three hospitals are outsourcing those parts of the revenue cycle. Many organizations are deploying technology solutions to recoup revenue that has been earned, but is at risk of being permanently lost.
At Becker's 5th Annual Health IT + Revenue Cycle Conference in Chicago, TransUnion Healthcare hosted an executive roundtable discussion on how technology can aid revenue cycle management teams as they strive to prevent denials, find additional insurance coverage and protect revenue. Jonathan G. Wiik, MSHA, MBA, author of Healthcare Revolution: The Patient Is the New Payer, and principal of healthcare strategy at TransUnion Healthcare, facilitated a conversation with two healthcare leaders to explore this topic.
Brad Tinnermon, vice president of revenue cycle management and revenue integrity at Phoenix-based Banner Health, and Jason Petrasich, national VP of revenue cycle at Los Angeles-based Prospect Medical Holdings, shared how they have leveraged technology internally and with third-party systems to maximize reimbursement efforts.
Denial prevention: The importance of data and tools
Real-time feedback is essential for denial prevention. Mr. Petrasich observed, " I’ve been doing revenue cycle management for a long time and I’ve always found it frustrating to get denial reports that were two months in arrears. I needed to know what was happening last week, not months prior. If a process has broken or a payer behavior has changed, the revenue cycle management team needs to address it quickly." Healthcare organizations must obtain denial data in a timely manner so they can insert it into a feedback loop and act. Along with this, it’s essential to have granular information to determine why claims aren't being paid. Prospect Medical Holdings revenue cycle leaders have found it eye-opening to have a denials tool that calculates line-item reimbursement, clearly showing exactly where payment errors exist.
Technology-based tools are also critical. When Mr. Tinnermon first joined Banner Health, revenue cycle management was fairly immature and many processes were handled manually. "As I was assessing the situation, I wanted to put in safety nets. TransUnion Healthcare's insurance coverage discovery solution enabled us to catch missed coverage opportunities before they turned into problems and it also assisted the patients," he explained.
Ongoing management of technology tools: The key to effective revenue cycle management
Contracts are one of the biggest factors that differentiate healthcare from other industries. Mr. Tinnermon noted, "Can you imagine going into a Target and everyone that walks in the door has a different price list for products? When they go to check out, the cashier has to figure out what they need to pay. This is what it's like in healthcare."
Contract information is used throughout the revenue cycle. Yet, this information often changes or healthcare organizations and payers aren't aligned on contract details. For instance, Medicare rates change every year and this affects the factors used in reimbursement calculations. Sometimes payers don't update those factors or they change them at the wrong time.
Line-item reimbursable items are also an issue. Mr. Petrasich noted, "You can't write a contract that includes every possible combination of services that would ever happen. You have to generalize. The problem is when you generalize, you get different interpretations. The little add-ons to the claim at the line level don't always line up with how payers have modeled payment on their side."
To combat these challenges, healthcare organizations must invest in technology tools, maintain them over time and use them throughout the revenue cycle. This includes continual updates to contract information.
Mr. Tinnermon echoed this theme. He observed, "The 'mystery of the 835' has been out there for 10 years. We know how to map the workflow and root causes, but the consistency hasn't been there. Staff turns over, the technology breaks and we don't maintain the systems. Why isn't denial management a program? I think we all know how to do it. Once you put denials management in place, the real key is keeping it operationally managed."
Structuring revenue cycle management to support sustained improvement
At Banner Health, analytics and continuous improvement are at the core of revenue cycle management efforts. The organization's enterprise data warehouse normalizes data across multiple platforms, including physician groups, pharmacy, medical groups and the retail pharmacy. An analytics tool generates a standardized view of the information.
Mr. Tinnermon said, "Our analytics group includes a project management arm that focuses on continuous improvement. They play watchdog over metrics that fall outside the norm, either positive or negative. This group is charged with capitalizing on opportunities; these could be compliance, net revenue or efficiency opportunities. Then they measure the results."
Prospect Medical Holdings is early in its journey to consolidation and standardization. The organization has 20 hospitals and six different patient accounting systems. Its goal is to look at data in the same way across the enterprise and to drive consistency in processes based on data-driven work queues and exception queues.
Denial prevention requires human resources, as well as technology
The panelists and roundtable attendees noted that denial prevention requires both technology tools and human resources. They highlighted three best practices related to the "people aspect" of denial prevention:
- Collaboration with finance is required. Revenue cycle management typically works in the world of transactions, while finance doesn't. The two functions must truly collaborate and understand all the moving parts related to revenue and quality.
- In today's world, different kinds of talent are needed for revenue cycle management. Leaders wants employees with analytical, critical thinking and problem-solving skills. As the opportunity to upskill staff is underway, this shift requires a culture change.
- Processes must be continually monitored and employees must be continually educated. Banner Health has implemented intensive financial clearance processes. These include a workflow with third-party information to secure accounts and collect on services. Due to employee turnover, Banner also provides education on an ongoing basis. Mr. Tinnermon said, "We educate more than once a year. There is a lot of face-to-face communication and discussion. Putting a dashboard in front of someone speaks a thousand words."
The next frontier: Advanced business rules, patient self-service and payer-provider collaboration
According to Mr. Petrasich, robotic process automation at its core is scripting, and healthcare organizations have been doing that for 15 years. He explained, "The next frontier is to add logic, business rules and sophistication into the scripting. You can call it artificial intelligence, but it's really just advanced business rules. Healthcare providers can scrape payer websites for claim status. The next step is to make decisions based on that data. There are many simple tasks that employees do every day to fix claims which could be automated by building a rule into a script."
Mr. Tinnermon agreed, "The insurance companies have so many different cards. It's very difficult for our team members to find the right insurance. If you get that wrong, then you're playing by the wrong rules. I would love for someone to automate the process so you can scan an insurance card and kick the process off, so there's no decision to be made."
The patient experience also can't be underestimated. Banner Health wants to make it easier for patients to do business with the organization. It has invested heavily in self-service technology so patients can interact via smart device. Banner Health is moving to self-service financial clearance where patients scan their ID and insurance card, set up payment plans, get estimates and schedule their entire event.
Banner is also working with payer partners to move the financial experience back to the payer. "Payers already have the relationship and contract with patients and employers. They are already drawing money out of patients' accounts," Mr. Tinnermon said.
Conclusion
As healthcare organizations focus on recouping earned revenue, many are leveraging technology internally and through third-party providers to manage their revenue cycle and improve yield. As evidenced by Banner Health and Prospect Medical Holdings, pairing technology tools with well-defined processes and employee training helps ensure that organizations are paid at the levels they should be, rather than leaving money on the table.