Harris Health System's Tina Strawn on revenue cycle workflow: 'If it can be automated, get it automated'

Tina R. Strawn, RN, administrative director of operations for patient financial services at Houston-based Harris Health System, has 27 years of healthcare experience.

Throughout her career, she has worked in patient care, bed management, transfer center coordination, case management, nurse auditing, denial management, charge descriptions master management, patient medication assistance, contract management and patient financial services.

Here, Ms. Strawn shares her proudest moment as a revenue cycle manager, discusses revenue cycle challenges and offers advice for other hospital revenue cycle leaders.

Note: Responses were lightly edited for length and clarity.

Question: What is your proudest moment as a revenue cycle leader?

Tina Strawn: We were proudest when our team achieved 84.5 percent 'clean paid claims percentage.' This placed us in Epic's top fifth percentile — nationally, and not just against other safety-net hospitals. The 'clean paid claims percentage' shows the percentage of claims resolved that were clean or never had a claim edit, denial or underpayment. A significant amount of work went into analyzing each edit, rejection and denial in order to identify and correct the root causes and minimize the issues that prevent claims from going through clean and paying without delay.

Q: What are the biggest challenges you're facing as a revenue cycle leader? 

TS: Our biggest challenge is the erroneous payer builds of contracts into their claims processing and payment systems. These erroneous builds lead to significant numbers of underpayment/overpayments. Based on our experiences, there are two issues. The first includes vague contractual language that leaves both the payer and provider interpreting intent differently, leaving the two systems out of sync.

The second issue includes completely egregious build errors. The build errors most concerning are ones where reimbursement is based on the state or federal guidelines of Medicare and Medicaid, the ones that should not be ambiguous, as the rules and the interpretation of the rules are well-documented. In these situations, when the providers identify a payer with payment variances that appear to be problematic, the provider can review Medicare or Medicaid explanation of benefits and validate the appropriate payment methodology. Then, the provider can provide redacted proof of the appropriate payment methodology to the payers. With that information available, payers typically agree that they need to make updates to their system.

Unfortunately, the time between payers agreeing they've built their claims-processing and payment system erroneously and then actually making the updates is extensive. Most of the time, it takes months. There are situations where it takes years. Once the payer claims-processing and payment system is updated and adjudicating claims appropriately, the providers are then forced to work with the payer to do special projects geared toward reprocessing all of the historically impacted claims. If those special projects are not handled perfectly, the providers are left with an increase in past filing deadline denials and recoupments on previously paid services.

Q: What are your financial goals for the rest of 2019? 

TS: Our financial goals are tied to payer report cards and our ability to compare payers: average days to first payment; percent of first payment denials; average days to denial resolution; percentage of accounts receivable greater than 35 days/no response; total resolved percentage; total outstanding with response percentage; total outstanding with no response percentage; and total pending claims percentage. We want to begin identifying our best performing payers and meeting with them to understand their best practice processes. From there, we'll meet with our poorest performing payers and work with them to implement workflow changes that improve their stats, our accounts receivable, our collections and the hassle factor associated with working their cases.

Q: What is one thing you'd do to improve the patient financial experience?

TS: In order to improve the patient experience related to their portion of a bill, there needs to be a tool that assists patients in their understanding of their patient financial responsibility (billed charges, allowed amount, coinsurance, copayment, deductible, out-of-pocket, premium, in-network vs. out-of-network, etc.) when compared to the monies they've already paid for the year. Based on our conversations with our patients, we find that our patients are highly dependent on their payers to pay the claims appropriately, and they trust the patient financial responsibility information coming from their payers. In fact, the patients are willing to accept the patient financial responsibility as assigned by their payer even when the information is wrong [i.e., the payer processes the claim as if the provider was out-of-network when the provider was in-network, increasing the amount the patient had to pay toward the services provided].

Q: What is a daily mantra that informs your leadership decisions?

TS: If it can be automated, get it automated. I find that staff morale becomes low when they are monotonously adjusting cases when they could be spending their time making calls and collecting underpaid/denied monies from payers. In an effort to make sure their workload keeps them focused on cases that require their attention, we encourage our team to identify system actions or adjustments that could be performed by the system. From there, we work with our information technology team to create criteria in the system that automates those activities. This keeps staff work queues to a minimum and allows them to focus their attention on accounts they need to work without feeling overwhelmed.

Q:  If you could pass along a piece of advice to other hospital revenue cycle leaders, what would it be? 

TS: One of the most successful things we've done when it comes to managing our accounts receivable (which is at 35.9 days or Epic's top fifth percentile) is to analyze payment variances created the previous day via two reports, a daily credit and a daily debit report. In both situations, identifying high-volume variances by payer will allow leaders to understand where to focus their attention. Finding the root cause of those variances is critical to managing accounts receivables by focusing on payers with contract load issues, our own contract load issues and/or ineffective system actions. The reports will also provide to you a way to compile all of the cases impacted when it comes time for the payer to do a special project to reprocess the erroneously paid cases.


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