Combating the most pressing revenue cycle challenges: 2 healthcare finance execs weigh in

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Revenue cycle leaders continue to face challenges in several areas, including navigating complex payer dynamics, EHR optimization and meeting price transparency requirements.

During a session at the Becker's October Health IT + Revenue Cycle Virtual Event, a panel of finance executives discussed the most pressing revenue cycle challenge at their organization and how they are combating it:

Panelists were:

  • Gerard Brogan Jr., MD, senior vice president and chief revenue officer, Northwell Health (New York City)
  • Peg Burnette, CFO, Denver Health and Hospital Authority 

Here is an excerpt from the conversation, edited for clarity. To view the full session on-demand, click here.

Question: Gerard, can you share how your organization is combating the top challenge you mentioned of payer denials?

Gerald Brogan: We centralized the authorization process. We have a central denial prevention unit, which is staffed by nurses and physicians that get the information from our case management system that there's been an urgent or emergent admission to the hospital. That team reaches out to the payers to secure the authorization. In the denial prevention unit, an initial nurse collates the information and forwards it to the payer. If we get an authorization, great. If we don't, then that goes to the physician advisers within that unit who then request a peer-to-peer conversation with the commercial payer and try to adjudicate the claim. If we get an authorization, great. If we don't, the patient is still admitted. We care for the patient as we think medically is necessary. But then that information immediately goes to the back end of that office, which we call the central denial office, and they immediately start constructing the appeal letter that's going to be used when we try to internally appeal with the payer, and then eventually almost always go to the external appeal agencies, essentially an arbitration-type system. That has been fairly successful to the degree that now most of the denials are based on the [diagnosis-related group], not on medical necessity.

Q: Peg, can you share some concrete steps that Denver Health is taking to address the most pressing issue you mentioned about the delay on implementing revenue cycle improvement efforts due to COVID-19? 

Peg Burnette: We set up a structure starting with leadership, a revenue cycle steering team. The team has executives, as well as director-level people from revenue cycle and operations. That team reports once a month to the CEO. So we're all held accountable for our performance. It was suspended a little bit with COVID-19 because it was chaotic, but we've really gotten back into the regular routine of meeting. There's also a working group that reports [to the steering team] that includes different people from revenue cycle, operations and the clinical documentation improvement team.

One example of something we were able to get ramped up was a documentation improvement project with our surgery department. What was happening was there was no reconciliation going on from between surgical documentation and billed items and charges.

What we were able to do is work with a contractor to have a coder who's very articulate and can relate well to the physicians. She reconciles each day, but she not only does that, but she then gives education to our providers about their documentation. She's not coaching, because we all know that's prohibited under coding. But she gathers data, and then looks at trends, tracks the trends and gives feedback to the physicians.

Our internal coders are focused on production … let's take the charts and code as much as we can. The [contractor] coder is focused on education. We've already seen evidence of improvement and learning on the part of our physicians and their documentation. We think that that will pay off in increased revenue. Or even if it's not increased revenue, the idea is to code and document everything appropriately, whether it's a higher or lower code, because it might be increased revenue, or it might be that we're at risk for compliance if we overcoded something.

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