In this episode, we are joined by Olga Barone-Allan and Meliza Weiner of BESLER to discuss their experiences creating cross-functional initiatives to improve the revenue cycle.
Highlights of this episode include:
- Working with a Chief Finance Officer (CFO) and Chief Information Officer (CIO) on cross-functional initiatives to strengthen revenue cycle.
- Creating tools to improve processes – key performance indicators, denial rates, unbilled charges, late charges.
- Overcoming objection and indifference to changes meant to improve processes.
- Advice on initiating cross-functional processes to improve revenue cycle.
Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast
These days, it’s important for hospitals to collect on every dollar that they’ve earned. And one way to do that is to strengthen the healthcare revenue cycle. And there are many ways to go about that.
But what we’re going to bring to you today is the actual experience (or a case study, if you will) from two of our team members who, in a former life, worked at a hospital together and worked on some pretty interesting initiatives around their revenue cycle and saw some pretty dramatic results.
So today, I’m joined by Olga Barone-Allan who is a Client Relations Manager here at BESLER and Meliza Weiner who is a Manager and Clinical Review Nurse. So welcome to the show both of you.
Olga Barone-Allan: Thank you for having us.
Meliza Weiner: Thank you Mike.
Mike: So, as I’ve mentioned, you were both involved in a cross-functional team effort to improve revenue cycle operations at a hospital here in New Jersey. Tell me what motivated the team to put a working group like this together.
Olga: So, my role at the hospital was Director of PFS. Meliza was the Director of Case Management. And she’ll probably speak a little bit more about that. But when we first met each other, we were asked by the CFO to initiate a collaborative meeting between the various departments involving the revenue cycle.
Previously, these departments were working in silos. So there was really no communication. And the impact of some of the decisions or some of the actions that were taken in these departments would affect the reimbursement at the end of the cycle which really geared the CFO to pull all these departments together in conjunction with the CIO, having the CIO’s backing.
So, as part of the initiative, she had pulled together the registration department, the case manager at HIM, PFS, and the ancillary departments. They were called into the meetings. They were weekly meetings. We would all attend. And we would start creating tools. We had KPI tools, key performance measures, and denial rates, unbilled charges, late charges. These were tools that we used to try and improve processes.
One of the major things Meliza and I—one of the top items that we had to focus on was the observations. And the problem that this provider was having at the time was that they were changing the patient status of these accounts from an observation to an in-patient to an ER patient. And this was happening within the mainframe system.
What impact this was having was missed charges and incorrect reimbursement rates.
So, we collaboratively met each other and really believed in the initiative. And I’ll let Meliza speak a little bit from her perspective what this meant and how this enlightened her and her department in the initiative that we took.
Meliza: I think, to all these point, one of the issues that was also brought up, like she mentioned, one of the key performance indicators that we were having an issue with is denials and also the switching back and forth between observation and in-patient. And what was happening because of that on her end as far as the finance end, they were having problems with billing. Are we billing observation? Are we billing the days? Are we billing in-patient?
And because of this, it was creating sort of a chaotic scene on her end, not to mention also on the in-patient scene because of switching back and forth. It requires physician involvement as far as documentation, writing the order. So, there was a lot of, should we say misunderstanding. And then, it was impacting our denial rate; and at the end, it was impacting dollars that was bringing into the provider we were working for at the time.
Mike: That’s one great example of how you can collaborate as a team to address what’s really a clinical and a financial issue. I do want to unpack this a little bit more.
So, when you got together in this large group, how did you go about thinking about the goals that you wanted to achieve, deciding what they would be, and then prioritizing them?
Olga: So, what we did the first month that this group started to get together, we started to pull together denial rate, unbilled charges, our DNFB, any billing edit, scrubber edits. And what we did was we sorted it high to low by volume, number of accounts, and total dollars obviously.
And the common theme that we saw on all these reports were the observation.
So, we dug down to see what was the core issue, what was creating our observation claims from not being billed because they were being prevented from the billing, and then the few that were going through the process, why were they being denied?
So, what we did was we took the regulations for Medicare. We analyzed that. And it was also an educational process for everybody because what we learned during this process was how to really identify carving out hours from transporting patient from one area to another. And that’s not always on the forefront of everybody’s agenda.
So, it was very manual. And that’s where we needed the buy-in from the CIO and the CFO because it was a very manual process. And as you know, rounding up/rounding down hours for transport, it’s a very tedious job, keeping track of that.
So, with the collaboration and support of the CFO and the CIO, we were able, within the mainframe system, and with case management and HIM and the ER department, registration, to be able to identify these claims and make sure that from day one, they were going to the various departments that needed to actually code it correctly, make sure the patient’s status was the correct patient status from day one, and then calculate the hours, carving out the transfer hours out before the bill.
So, the DNFB for those claims, we reduced it down to maybe four or five days which was tremendous because we had claims that were out there for three to four months…
Olga: …sitting there which impacts, obviously, reimbursement.
And what we did was we took that education. Meliza can speak to the education part. She was bringing this back to the nurses.
Meliza: Correct. So, to what Olga was saying, we also identified the education piece. And I understand, clinicians went to school to be clinicians. And we wanted to keep it that way. But we want to make sure that the processes in place started at the beginning and identify them early on. And if we are moving them from one department to another department, we have to streamline that.
So, we also involved other departments like the radiology department, the lab department, the emergency room department, so that when we are working with these patients, we know how to work on this claim. Is this an observation from the beginning? And if it’s an observation, we already know how we’re going to bill them, what we are looking for as far as hours. If they were considered in-patient, then we already know how we’re working with that.
So, getting the right status at the beginning, so at the end we’re not switching back and forth between observation and then changing them to in-patient, and then switching them back to observation. That alone is just tedious, trying to keep track of what the charges are going to be.
Olga: And like Meliza said, the issue we were finding was not only were we missing charges because of the patient’s status changing, but we were also missing specific codes that need to get on the bill.
And I think that one of the things that, once everybody in the room—the various department heads, the ancillary departments, ER, case management, HIM—we realized…
I mean, the motto became, “Hey, we want to get paid on everything we did.” And that was our goal. That was our mission. That was what drove us. We realized—they realized more than we did because we knew we weren’t getting paid properly. They realized, “Wow! We did all these work, and we’re not getting paid?” They were amazed!
Meliza: It was like an “A-Ha!” moment.
Olga: Yeah, it was an “A-Ha!” moment. And then, they were really motivated and passionate about the service, that procedure.
Mike: I want to drill in on something you said a few minutes ago around working with the CIO because, as anyone that’s involved in health IT as we are these days know, the CIO is overwhelmed. Probably many of them would say that they are. There are so many different aspects that they’re responsible for, not only from just running the technology at the hospital, making sure all that goes smoothly, but cybersecurity and lots of other things that fall under their aegis.
And so, how do you get that CIO engaged if you’re coming in from sort of a mid-level or hopefully from a CFO perspective? How do you get them to understand that this is an issue?
Meliza: I think it’s to bring them at the beginning when you’re in the planning phase and what the goal is and to get them to understand how their department plays a key role in the initiative. And I think the other thing with our CIO at the time is also being backed up by the CFO because that’s another tie-in there, having the CFO backing it up and knowing that it was a collaborative initiative and it was all our goal.
To get where we want, it involves everything. Having the CIO at the beginning and understanding how much of an impact and how much revenue we’re going to lose if we don’t put this in place, putting that, quantifying it for them as far as their impact I think is one of the key aspects of getting the CIO involved.
Olga: Yeah. And the other thing was when we sat down and initially showed the trend between the various reports and the highest impact opportunity that we had, when we explained to the CIO and the CFO the manual process that was involved in getting this achieved, they were like, “Why are we doing this? You need five people to handle this, one from each department. Why can’t we do this systematically?”, we’re like, “That’s why we need you.” So we were able.
And then, the savings. What we were able to achieve by this was that by improving this process, they realized how much more money they would be able to attain for an organization. And it makes them look good. If they’re able to report at senior leadership meetings that they’ve improved their cash collection by this much because of an improvement that departments that were not talking previously are collaborating and improving, it makes them really look good.
So, they were really engaged.
And don’t get me wrong. They didn’t attend every single meeting. They attended the first couple of meetings, and then they handed it off to me. And then, Meliza was the representative from case management. We would report back on a regular basis to them, and then we would show numbers. So we were constantly showing the improvements.
And it showed in our clean claim rate and in our DNFB (we were able to bring that down and turn that around). The numbers don’t lie.
So, when we were showing them that feedback, they were so engaged. And with the CIO’s involvement and his support, we were able to load a slew of—like 23 work cues within the mainframe which is really even before it gets to the billing scrubber.
So, that was a major accomplishment.
Mike: We talked about ways to get people onboard and the satisfaction of how that looks when it works. Who wasn’t onboard?
Olga: I would say, initially, the ancillary departments were not onboard. They just did not understand. They were convinced that every charge that they provided was making it to the bills. And when we proved to them that the bills were not representative of everything, and they had a budget to adhere to within their own department, and they realized that the loss of revenue was tying into their budget, then it clicked.
Initially, contract management was not involved. And that was tough because when you adjust a claim or change a claim in the mainframe, you have to re-prorate a claim, so that it’s calculating to the net, so it’s not sitting on your receivables at gross. And we were a bit behind on that as an organization.
The other thing was we didn’t have a charge master department. So that was very key. Our charges needed to be updated, needed to be created. There were certain services, we didn’t even have charges for because there wasn’t a designated department. So we were able to convince the CFO to get a vendor to come in and help bring us up to speed.
So, all those things, really, it was a whirlwind of different actions going on. But ultimately, everybody within that team (and still to this day) remembers it. In the beginning, it was rough. But at the end, they really realized the major impact.
And a lot of it was copied over to corporate. So everything we did was cookie cut. It was copied and brought over to corporate. So it was a great initiative.
Mike: What advice would you give a hospital that’s considering putting together a cross-functional initiative of any kind related to improve revenue cycle?
Meliza: I think one of the things that needs to be addressed at the beginning is, one, you have to make sure that you have the buy-in of every department that’s going to be impacted by this collaborative initiative. You can’t work on a collaborative and not involve certain departments.
One of the things that we did is we involved everybody at the beginning and saying at the beginning, “Look, we’re starting this. And if, for some reason, it was determined that we don’t need you to come on a weekly basis, we’re going to invite you on a monthly basis if it affects your processes…”
I think just starting that at the beginning and starting proactively would work.
The other thing also is to see the knowledge and doing an assessment of the knowledge of the teams that you’re going to get involved. How much do they really know on what this initiative is going to be?
The first thing—and I will tell you this from experience—when they say, “Okay, we’re doing this collaborative project,” they’re first saying, “another thing on my plate, another thing for me to do. I have all of these going on in operations.”
I think it’s to educate them first at the beginning “This is what we’re going to be doing. And these are the reasons why. What is your understanding of it?” If they don’t understand, educate first before getting them to do some work because they get defensive.
Olga: I would say definitely show them the numbers. Showing them the numbers and the impact that it has to their department directly, just a light bulb goes up. They really don’t know the impact. A department knows they perform a service, and they record it. They don’t know that it’s not making it on the bill or the way they’re putting it on a bill is the incorrect way.
So, by showing them loss of money or the denial rate or the missed charge has a tremendous impact on them.
Meliza: And then, you have to celebrate the success. Even if it’s so small or so tiny, you have to celebrate the success.
I remember I’d go back to what we had at that time the Medical Quality Council where the physician head sit on it. I would bring in the report from our team. And I said, “Just this small initiative of what we did when we implemented case management in the emergency room, our denials went down. We were able to bill more when it comes to observation charges.“
They were happy. They were ecstatic because just this little effort made a great impact. And so they kept wanting to do more.
Mike: Olga and Meliza, thanks for coming by and sharing that very rich experience with us. We certainly appreciate it. And I’m sure our audience does as well.
Olga: Thank you for inviting us.
Meliza: Thank you.