Why health systems are turning to clinically driven revenue cycle management


Clinically driven revenue cycle management requires effective communication and cooperation between clinicians and the revenue cycle team. With reimbursements on the decline, health systems can't afford to deliver care that doesn't yield the documentation needed to set up the revenue cycle team up for success on the backend. The clinically driven revenue cycle is a collaborative operation that requires bridges of communication between clinicians and the accounting team.

In October, at Becker's Hospital Review 5th Annual Health IT + Revenue Cycle Conference in Chicago, 3M hosted a workshop to explore how leading healthcare organizations are engaging physicians and incorporating clinically driven revenue cycle management practices into their operations. Keri Hunsaker, marketing manager at 3M, facilitated a panel discussion with revenue cycle, revenue integrity and utilization review experts.

The evolution of the clinically driven revenue cycle

As payers deny more claims and health system margins continue to shrink, increasing numbers of organizations are implementing clinically driven revenue cycle models. Nathan Hughes, senior director of RCS utilization review at Charlotte, N.C.-based Novant Health, explained, "My role didn't exist four years ago. The utilization review team and other groups that report up to me used to be a separate team that reported to nursing and case management."

The move to a clinically driven revenue cycle was a significant operational shift at Novant Health. While the change required considerable effort, it has also delivered many advantages. Fully informed partners at the bedside now analyze the financial implications of clinical decisions.

Greensboro, N.C.-based Cone Health has also recently integrated a revenue integrity department. Mike Simms, MBA, vice president of revenue cycle, said, "The revenue integrity department includes things we didn't control in the past, such as the chargemaster. We also have nurses that fight denials and a team that handles compliance. Everyone's coming together and that's great."

Durham, N.C.-based Duke Health has bridged gaps in the revenue integrity department by building clinical credibility. Stuart Fedderson, Duke's associate director of revenue integrity and CDM, noted, "Our nursing auditors and consultants are subject matter experts. We also have operational consultants who are MBAs and coders. Another big piece is Lean Six Sigma. Our Green and Black Belts focus on root cause analysis."

Engaging physicians in clinically driven revenue cycle management

At Charleston, S.C.-based Roper St. Francis Healthcare, executives invested in physician leadership education and around 50 physicians completed a nine-month course. Beth Wolf, MD, medical director of health information management at Roper St. Francis, said, "The system wanted clinicians to understand what's happening behind the scenes. Budget funds were also allocated so physicians could serve in leadership roles. They work with an administrative partner half-time to establish quality and financial goals, and then hold their peers accountable."

Both Novant Health and Duke Health have deployed similar leadership models where service line leaders in each specialty have an administrative partner. Every service line at Duke Health has a team that serves as the root cause analysis task force for revenue integrity. Mr. Fedderson commented, "The process is pretty seamless when physicians are engaged."

Objective data is the key to uniting physicians with the business. Duke Health recently had an external audit for cataract surgeries. A support team pulled the error rate and the surgeon in charge of cataract surgeries immediately took steps to address the problem.

Planning today for the future

Looking ahead, healthcare systems worry about the balance of power with third-party payers, especially Medicare Advantage Plans. Mr. Fedderson commented, "Payers are employing armies of physicians whose sole responsibility is to scrutinize claims."

In addition, every day new policies are issued by payers. Most healthcare organizations still use a manual process to deal with these changes. Mr. Simms said, "We need integration with the EMRs, so as new policies come in, they appear automatically in those systems."

Novant Health recently deployed a new product introduction committee. This group looks at individual products that are used as part of larger surgical procedures. Before approving the products, the group vets them through payer policies. Mr. Hughes noted, "This type of group can add a lot of value, but it takes a lot of effort to implement."


Clinically driven revenue cycle management is the responsibility of everyone in the health system, not just the patient accounting team. It must be a collaborative process from the time a patient enters the provider's office to the time they complete their treatment. Mr. Simms observed, "Everyone is responsible for financial performance. If we don't improve that, we won't be able to provide services to the community."

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