Revenue Cycle Reporting – Refocusing on Quality over Quantity

Do you feel like you have too many reports?  Do you feel like your teams measure the same things in different ways?  Revenue Cycle reporting and analytic solutions can take many shapes and sizes in today’s healthcare industry.  Some organizations leverage comprehensive reporting solutions that have the capability to provide self-service reporting and analytics tools while others rely on manually generated reports and queries from an IT group.  

Regardless of the approach, the purpose is the same: align operational objectives with clear metrics to measure progress and provide data to support decision making processes.  As a revenue cycle leader, these questions can help you determine if your organization is making the most of the available resources.

  • What reports are being used to drive operations? – While a seemingly obvious question, it is easy to lose track of what reports are being generated and used over time.  It is helpful for both operations and reporting resources to establish a dictionary that outlines what reports are being generated and key information such as frequency, time to create, and users.  This can be a way to free up capacity within the reporting team for other initiatives if reports are no longer being used or similar reports are being used by different teams and can be consolidated.
  • Do you have clear operational goals and metrics to measure performance team? – Once you have a clear understanding of what reports are being used and by whom, it is important to make sure a clear strategy is outlined and communicated.  Identify the key metrics that drive your operations (AR days, cash, denial rates, productivity, workflow backlogs, etc.). Ensure clear goals are established and communicated to all team members.  Establish regular time for your teams to report on their metrics compared to goal, review the key issues they have uncovered, and outline next steps to improving on the identified opportunities.
  • Do you have a strategy to address ad hoc reporting needs in a timely manner? – Developing an effective reporting solution requires balancing core standardized reports with the ability to run ad-hoc reports to research underperforming metrics.  Some solutions allow users to run reports and research their own questions. Others rely on key users or IT teams to run analysis to answer questions as they arise. The most important component is having a deliberate strategy and making sure the team leaders are trained and able to make evidence driven decisions.
  • Do you have a pipeline for reporting enhancements? – Regardless of how savvy of a reporting solution a team uses, there will always be a need to improve reporting to align with operational objectives and answer new questions.  When these needs require more technical intervention, it is important to have an established methodology to communicate and prioritize requests. Operations should be able to provide a clear business case on what is needed and why, which will help inform the priority, scope, and timeline required.  The technical and operational decision makers should meet regularly to make sure the priorities align to provide the most impact to the organization.

Reporting requirements continually evolve as the team members, processes, and tools change over time.  It is important to revisit these questions to ensure your teams have the most relevant data to make informed decisions that drive continuous improvement.  For additional information on building an effective reporting solution that fits your organization’s needs, please contact Nick Fortman at nfortman@pinnaclehca.com.

Kicking the Tires on Vendor Management: The Basic Questions to Ask

Vendors are an integral part of every revenue cycle solution. From software/technology to outsourcing/AR management – and everything in between. In an ideal world – vendors would run autonomously and produce expected results without management or oversight. Unfortunately, this is not the case – and if not managed effectively, can end up being costly from several angles: resources and time, patient satisfaction / customer service, and financial performance.

While vendor management is a broad and extensive subject, this article is going to focus on managing the basics of a subset almost all organizations are leveraging to some degree, outsourcing and AR management. Some of the more common examples are self-pay/early out, low balance and financial counseling etc. Regardless of the population – once handed over, the outcome is now in the hands of your business partner. While the size and scale of managing outsourcing vendors will vary based on organizational factors (location, technology, size/scale, budget, demographics, etc.), the core components remain constant.  

As a Revenue Cycle Leader – Here a few questions to ask yourself about your vendor management strategy.

  • Do I have standing meetings with my outsourcing vendors? – Setting up timely standing meetings with a standing agenda and set expectations is the first step to ensuring consistent and transparent performance. 
    • If so, how often? – Meeting at least monthly limits extended gaps in monitoring performance and helps maintain momentum. This can (and should) be adjusted up or down depending on project period and performance. E.g. If this is a relatively new vendor, or performance has been deteriorating – increasing the frequency to weekly or bi-weekly would be recommended.
    • Are the meetings driven by consistent, meaningful and timely reporting/data? It is important to have clear and timely data (not distributed 5 minutes before the meeting) to help drive the conversation. This should include goals and results for operational indicators (inflow, production/activities, untouched accounts, call volumes etc.)  as well as performance outcomes (collections, adjustments, conversions). Overall, it should be abundantly clear where performance is meeting expectations and where it is falling short. 
  • Have you developed structured workflows, process and procedures with your vendor partner? These help establish expectations, avoid process breakdowns and play a critical role in performance management (See audit program below). In some cases these can help build out structure and detail into the performance reporting. Both sides should be crystal clear on how populations of accounts are to be managed. 
  • Does the vendor have an effective audit program? The devil is in the details – especially when it comes to AR management. Vendors should have an internal audit process, down to the staff level that they are able to share and review with you. If not, it is critical to work with a vendor to set one up. These can include phone audits, account reviews, transaction reviews and portfolio evaluations. It is important to understand the vendor audit process and ensure it incorporates the process/procedure/workflow information above.
  • Is there a timely and consistent reconciliation process? Black holes and gaps in workflow are a constant concern within revenue cycle, especially as technology and data management becomes increasingly complex. Finding large populations of accounts that neither side has been working can be a backbreaking discovery. To help prevent these types of landmines, there should be at least a monthly reconciliation of accounts to identify mismatches or discrepancies. A portion of the standing meeting should be used to review and evaluate root causes, and ways to minimize discrepancies going forward.

While this is not meant to be a comprehensive discussion of vendor management – it does lay some of the basics for a solid foundation.  For additional information on effective vendor management, please contact Brian Felland at bfelland@pinnaclehca.com.

Black Holes the Watchlist Doesn’t Even Know About

What’s more dangerous than a black hole of accounts not assigned for anyone to work? A population of accounts that appear as if they are assigned, but are not being managed at all. This is what we call an “invisible black hole”. This might seem like a rare or abstract concept, but these are actually easier to create than one might think, and the more complex the system – the more likely they are to occur. Here are a few (of the many) ways these can occur:

  • Someone leaves the organization and their workqueue (WQ) is not reassigned/inactivated
  • Someone is assigned to a WQ that that they are unaware of 
  • Accounts are on multiple WQs and each owner assumes someone else is working the account
  • Accounts are on WQs that are not actively managed (reporting only, vendor outsourcing)
  • Accounts are on an active WQ, but are not ever worked (the account never qualifies as a priority on the worklist – this is more of a gray hole, but still poses a risk)

So, why are these more dangerous than the standard black hole? Accounts in a typical black hole (meaning they are not assigned to any WQ in the system) should be easily identified using the existing watch list in the Epic dashboard (or other reconciliation devices). Monitoring the volume and the impact of any fixes, is pretty clear. If you make a change to a WQ, and the indicator on the watch list spikes, you have a problem. Simple. The reason the invisible watch list items are so dangerous, is that they can be caused so many ways (see above) and can be very difficult to identify and monitor. 

So how do I reduce the risk of this potential threat? The first step is to ensure you have the appropriate checks, balances and structure. What exactly does that mean?

  • Structured approval/review process for system changes (wq, assignments etc.)
  • Structured testing and sign off process for system changes and implementations 
  • Defined approach to WQ naming and assignment convention 
  • Clear expectations for WQ management at each responsible level 
  • Tested and functioning dashboards/WQ reporting at the director, manager and staff level
  • Periodic audits of WQ assignments, ownership and rollups 

All of these will help reduce the likelihood that one of these invisible black holes has been created. 

So how do I know if I’ve created one and what to do with it? This is the tricky part, and unfortunately – there isn’t a one size fits all silver bullet solution for this. There are two general approaches to consider. 

  • Creating a reporting mechanism that identifies accounts that are not on any ACTIVELY managed worklist. This usually takes time and involves individual account sampling and workflow/workqueue review. It requires the creation and maintenance of a list of actively managed and monitored workqueues.  Eventually, the goal is to setup a report that will kick out accounts that are not on an actively managed workqueue (that should be). 
  • The second (and somewhat more comprehensive approach), is to create reporting that identifies accounts that have not had any user activity in an extended period (E.g. 90 days). This will help highlight breakdowns in system builds, as well as breakdowns in operational design/training (accounts aren’t worked because there aren’t enough staff, they aren’t a high enough priority). This is a somewhat more comprehensive evaluation of risk, but requires detailed exploration to identify the true cause of why accounts are not being worked. 

Overall, as the industry moves toward more complexity in its technical solutions, workflow and automation capabilities – it also introduces a higher level of risk associated with workflow and system gaps. These tips are intended to provide a light framework to manage and mitigate these risks. For more in-depth information on revenue cycle workflows, system configuration or reporting capabilities, please reach out to Brian Felland, who has led black hole rescue teams, at bfelland@pinnaclehca.com.

Addressing the Hidden Issues of Automated Cash Posting

15-20 years ago, the cash posting unit of a hospital was one of the larger units within the business office.  Lots of man hours were needed each day to organize and manually post paper checks/remits from the wide variety of payers in the marketplace.  Staff in these positions had to understand how the keystrokes they completed impacted the remaining accounts receivable after a payment was posted, along with the many differences in how each payer processed (and paid) on claims.  Is this a full payment? Partial Payment? Denial? Does the remaining balance need to move to the next payer or to the patient? While the process was 100% manual, with the right team in place you could ensure the remaining accounts receivable was clean, allowing follow-up staff to focus their attention on accounts that truly needed follow-up.  The key challenge was ensuring staff had adequate training and controls were in place to minimize human error.

Fast forward to today and most organizations are operating with a fraction of the staff, relying on enhancements in technology and automation to complete the daily cash posting process.  Many hospitals are utilizing 3rd party tools/vendors to organize incoming electronic remits from payers that can be posted through an automated process into the Electronic Health Record (EHR).  The promise of eliminating human error through automation has always been a key selling point to moving away from manual cash posting. Do the same job with less staff at a higher level of quality; sounds great!  In a perfect world, a cash poster would simply import the electronic remit into the EHR and payments/adjustments would post automatically and accurately with little to no intervention. While this process can (and does) work very well for some organizations, the simplicity promised is not reality.  There is now a new set of critical points in the process/configuration that can lead to less than optimal results:

  1. ANSI/CAS code usage by payer varies – While there are standards in place, there are numerous inconsistencies in the codes used across payers that indicate denials, contractual adjustments, etc.  Usage for an individual can also change suddenly without warning. Cash posters need to be aware of the differences AND be on the lookout for changes so that configuration downstream can be adjusted.
  2. Paper EOB Interpretation – For payers that still provide paper EOBs, many hospitals use conversion tools that convert the paper EOB to the 835 format – but is the interpretation correct?  While there are fewer and fewer payers out there that still provide paper EOBs, they do exist. Converting what is on the EOB has to not only be accurate, but also has to be evaluated periodically to ensure the payer hasn’t changed their format or usage of codes.
  3. EHR Configuration – One of the most important pieces of the process is the configuration within the EHR on how the electronic remits are interpreted and automated actions are performed on the account.  Should certain ANSI/CAS codes be interpreted as contractual adjustment? Should certain codes hold the remaining balance with that payer because it is likely a denial? Should certain codes automate a non-contractual adjustment?  When should the balance move to the next payer or to the patient?
  4. Process Monitoring and Adaptation – Lastly (and equally as important as the technical configuration), cash posters need to be able to identify and resolve errors in the automated process on an exception basis.  The idea of simply hitting a button and everything working is unfortunately not the reality. Cash posters also need to be able to spot and escalate key themes/issues in #1-3 so that they can be addressed in the configuration and/or how they are “fixed” on an exception basis.

Missing the mark with any of the items above can lead to numerous issues and rework:

  1. Erroneous credits
  2. Inaccurate patient balances/statements
  3. Adjustments on denials that still have cash opportunity
  4. Inflated accounts receivable from inaccurate insurance balances requiring additional clean-up, but no additional cash value
  5. Staffing constraints leading to unposted cash or cash research backlogs

Are you experiencing any of the issues above with your cash posting process?  

For more information related to the cash posting process or revenue cycle management, please contact Andrew at Ajacobsen@PinnacleHCA.com.

Are Your Epic HB Workqueues Broken? Here’s How to Fix Them

Are your epic HB workqueues broken? Here's how to fix them.
Workqueues (WQs), worklists, spreadsheets, reports.  They are all trying to help us answer the same question: What accounts should we work and in what priority? How frequently is your PFS management team asking staff to re-sort their workqueues, work off spreadsheets for special projects, or work through a stack of paper denials?  Workqueue build in Epic is one of the most critical pieces of your install and ongoing maintenance. After all, these are the primary workdrivers for your exception-based workflows. But are you really working the exceptions?  Are your workqueues setup as effectively as you’ve been led to believe? Below, we’ll outline the questions you should be asking as you assess your current state workqueue build.

What is my workqueue structure?

On the surface, this seems like a simple question.  Most of us have been through a workdriver design session where we outline what we need.  Typically, the conversation centers around how many staff we have, who has expertise in what areas and what our volumes look like.  Voila! Workqueue structure is complete. Seems simple right? Did anyone ever stop to ask the question about whether an account should be able to qualify for one or all those workqueues at once?  If a patient has an outstanding balance on their primary insurance bucket due to an underpayment and an outstanding patient balance, the account could conceivably be in three places at once (insurance follow-up, variance, and self-pay).  Who do I go to on my team to get the account resolved? This doesn’t even include any billing indicators that may drive it to specialty queues.  

This is where an effective workqueue waterfall structure comes into play.  Understanding how you need to break out your account populations (billing, government, commercial, self-pay, denials etc.) but also, prioritizing within those populations so that an account can’t move to point B until it has cleared point A.  For example, an account shouldn’t be on a secondary insurance workqueue until the primary insurance has been resolved and has a $0 balance. Similarly, an account shouldn’t be on a self-pay workqueue if there is an open denial. The overarching goal should be to get as close to a 1:1 account to worklist ratio as possible with the understanding that there are always exceptions to the rule that are unique to each provider.  

Do I have transparency?

The methodology behind workqueue build tends to slip over time.  Issues are identified and workqueues are hastily put into place to house special projects.  Staff and management transition in and out of roles and before you know it, your six months post live and your workqueues are out of date.  The problem only grows over time.

There are a handful of “optional” components that are part of workqueue build that should be considered requirements both at the time of workqueue creation and as part of long term workqueue management.  This includes descriptions, owners, supervisors, and groupers. Additionally, while workqueues do require a name, they do not require a consistent naming convention.
  • Name – To help drive reporting transparency, similar workqueues should have similar naming conventions.  For example, all billing workqueues could start with BIL, follow-up with FUP, and denials, with DEN. When developing workqueue reporting, this will help ensure like populations are grouped accordingly.
  • Description – When a workqueue is three years old and the people who built it and worked it have long since departed, this is the best way to understand how and why this workqueue is in place.  It is also critical for new hires that are starting to get their heads around their new workdrivers. A good description outlines the purpose of the workqueue, broad scope of what is included, and any specific carve outs.  If WQ scoring is in place, the description should also provide an overview of high priority scoring logic.
  • Owner – Who is the primary resource responsible for working the account populations?  This is useful to drive reporting and accountability throughout the department. For reporting, you can see which staff have a large workload and triage accounts as necessary to help ensure I’m touching all high priority account populations.
  • Supervisor – Similar to the owner, this can help leadership group and monitor their workqueues closely while also driving reporting transparency.  As a PFS Director, if a workqueue doesn’t have a Supervisor, it either isn’t on my report or if it is, you don’t know who to go to for a status update.
  • Grouper 1 and 2 – How quickly can you find all of your Medicare follow-up workqueues?  Do you search the name for Medicare and get billing, follow-up, and denial results? This is where groupers come into play.  Using two sets of groupers allow for multiple layers of filtering to more quickly access the workqueues you’re after. In the scenario above, grouper 1 may be follow-up and grouper 2 may be Medicare.  These categories can also drive reporting and query functionality to allow for targeted report sets specific to the appropriate audience. Finally, groupers can help designate reporting only vs. actively managed workqueues to ensure reporting and workflows are clear and concise.

When was the last workqueue Clean-up and Refresh?

Anyone who has been live on Epic for more than six months likely has at least a handful of workqueues that can be removed or re-purposed.  Frequent offenders include:
  • Old special project queues – We frequently run into issues with account populations and the response is to create a workqueue and transfer all the accounts.  12 months later, there are still a handful of accounts sitting there and nobody is looking at them.
  • Queues that haven’t been recently accessed – Search for workqueues that have not been accessed within a certain period.  Inevitably, there will be some “holding” workqueues that need to remain, but those that haven’t been accessed recently either need to be assigned to staff or removed/re-purposed.
  • Queues without ownership/supervisors – If a workqueue doesn’t have an owner/supervisor and if the volume of accounts is miniscule, odds are it needs to go or be re-assigned.  Missing owners and supervisors can send accounts into a workqueue black hole where the account doesn’t qualify for the Watch List black hole metrics since it’s on a workqueue, but nobody knows the workqueue is in place, so the accounts aren’t being reviewed.

Parting Thoughts

  1. Epic HB workqueues provide tremendous flexibility to triage and route accounts.  Having a well-defined workqueue structure in place for each department can help minimize over-utilization of workqueues and keep workflows streamlined.
  2. Accurate routing and workqueue rules are critical to ensure that the functionality is aligned with the design structure.  Specific metrics can be developed to monitor effectiveness.
  3. Key components of workqueue design and build should not be overlooked due to their impact on reporting and accountability.  This includes workqueue names, descriptions, owners, supervisors, and groupers.
  4. Regular review and maintenance of your workqueue structure is critical to reduce overbuilding, maintain streamlined workflows and eliminate workqueue black holes.  Dashboard functionality can be a useful tool to measure the health of your overall workqueue structure.
For more information related to Epic optimization or revenue cycle management, please contact Kevin at KBlanchard@PinnacleHCA.com.

Accounts Receivable Outsourcing – 3 Keys to Making a Decision

Three Keys to Outsourcing Success

In our last newsletter, we introduced the blog series: Why AR Outsourcing Fails and How to Avoid Common Pitfalls. We introduced two primary dangers with outsourcing arrangements:

  1. Hospitals that outsource frequently relinquish full control to the vendor and end up in an “out of sight out of mind” situation
  2. Vendors many times interpret “silence” from the hospital as positive reinforcement for the program they have implemented

There are lots of opportunities to avoid these common pitfalls, most of which occur in the stages before a vendor has been selected and during the implementation.

In this article we will focus on the first step to improving accounts receivable (AR) performance:  Making the Decision to Outsource…or Not

In our experience, we have seen two common scenarios frequently occur when hospitals consider outsourcing their AR:

The first is the “shoot from the hip” or reactionary approach. 

  • Your AR continues to grow and/or age
  • You know you have accounts that your internal staff just can’t get to or doesn’t have the expertise to work
  • Outsourcing seems to make sense, and
  • The next thing you know you are placing accounts with a vendor

The second is the “apathy” approach.

  • You know about that you have a bucket of AR which continues to age, yet you haven’t addressed it
  • You suspect that you need to outsource, but simply haven’t taken the time to build a business case and act
  • The result: you continue to incur avoidable write-offs, bad debt, etc.

So let’s focus on the tricky scenarios where the outsourcing decision could go either way.  We’ll stay away from the obvious populations that make sense to outsource like early out self-pay and bad debt, and will instead focus on populations which require a little more analysis.  These can include:

  • Aged insurance AR
  • Low balance insurance AR
  • Specialized populations (such as Auto/WC)

Many organizations rush into outsourcing without a lot of thought, or conversely, do not act when the decision should be obvious.  Pinnacle Healthcare Advisers recommends a methodical approach to evaluating the outsourcing opportunity.  Some questions to consider include:

  • What problem are you trying to solve?
  • Do you have a clear method for calculating the ROI of an outsourcing approach?
  • What are the alternative solutions?
    • What it would take to do the work internally?
    • Do you have the expertise, capacity, and tools needed to effectively work the population internally?
    • What are the costs associated with building a team internally?
  • If the decision is made to outsource, what are the goals and how will you measure success?
    • What is the cost?
    • What is our expected ROI?
    • What are the expectations of the firm two which you would outsource?
    • Are they clear from the start and can they be measured?

Let’s look at an Example:

A small, rural hospital is struggling to keep up with their third party (auto insurance related) receivables.  While the hospital attempts to stay on top of this population, the general feeling is that there isn’t enough staff to do the work – and that the team doesn’t have the right expertise. The requirements of managing this population include keeping up with state and federal lien laws, case law, etc., and maintaining proactive follow-up with patients, insurance companies, and involved attorneys

A proposal was made to outsource this population to a vendor with specific expertise.  Pinnacle Healthcare Advisors recommends the following decision-making approach:

  1. Complete a staffing analysis to understand how many FTEs would be necessary to work this population internally
  2. Identify the tools, training, and resources necessary for an internal team to be successful
  3. Calculate the cost associated with outsourcing this population (assuming current performance is maintained)
  4. Compare the projected internal cost (fully staffed and trained) to the anticipated vendor cost
  5. Factor in expected improvement in performance based on each scenario

In our example, this hospital had a single FTE dedicated to working this specific AR population.  The staffing analysis showed that in fact, 3 FTEs would be required to adequately cover the volume of activity.  While hiring 2 additional FTEs might have been an option, the internal staff did not currently have the right tools or expertise to respond to attorneys’ inquiries which were occurring throughout the process.  This resulted in a significant amount of unrealized reimbursements.

Alternatively, when factoring in the expected improvement (which could be achieved by engaging a partner with the right expertise) it was determined there would be a measurable ROI associated with outsourcing this AR population.

While this example may seem obvious, hospitals often fail to methodically evaluate different populations when making outsourcing decisions.  We regularly find that hospitals either shoot from the hip or make no decision at all.

The hospital described above went through a simple evaluation exercise and has accomplished two things:

  1. They can clearly demonstrate why outsourcing this population makes sense
  2. They have a clearly defined outcome and ROI that can be measured once the program has been implemented

We’ve helped many hospitals just like yours assess their AR outsourcing opportunity.  Some have identified skilled partners, and some have bolstered their internal capabilities.   All have seen an improvement in their AR performance.

If you’d like to have a more detailed conversation about outsourcing, give us a call or send us a note.

Our next topic will cover vendor selection – where we’ll discuss how to objectively choose the right vendor partner for your outsourcing program.