Innovative Approaches to Optimizing Revenue Cycle Operations at Healthcare Providers

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ROUNDTABLE Innovative Approaches to Optimizing Revenue Cycle Operations at Healthcare Providers Lean value-based payment models and

expanding the scope of revenue cycle staff activity into new areas such as patient registration and postacute patient engagement.

denials, convey value to patients in easily comprehensible ways, and craft comprehensive billing statements that avoid unleashing

PANELIST PROFILES OLUSEGUN ISHMAEL Medical director of occupational health and ER physician, Paris (Illinois) Community Hospital SPONSOR

KRISHNA RAMACHANDRAN Chief administrative officer, DuPage Medical Group, Downers Grove, Illinois MELINDA RAMSDELL SVP and senior treasury

1 ROUNDTABLE Innovative Approaches to Optimizing Revenue Cycle Operations at Healthcare Providers Lean value-based payment models and increasing consumerism in the healthcare sector are driving innovative approaches to revenue cycle management (RCM) at health systems, hospitals, and physician practices. RCM innovation is not only transforming traditional revenue cycle functions such as insurance claim and billing processes but also expanding the scope of revenue cycle staff activity into new areas such as patient registration and postacute patient engagement. This roundtable examines strategies for success in launching and operating RCM innovation initiatives, including efforts to reduce claim denials, convey value to patients in easily comprehensible ways, and craft comprehensive billing statements that avoid unleashing avalanches of bills on patients. PANELIST PROFILES OLUSEGUN ISHMAEL Medical director of occupational health and ER physician, Paris (Illinois) Community Hospital SPONSOR General disclaimer for Bank of America Merrill Lynch, visit baml.com/disclaimer. KRISHNA RAMACHANDRAN Chief administrative officer, DuPage Medical Group, Downers Grove, Illinois MELINDA RAMSDELL SVP and senior treasury sales manager, Southeast healthcare and institutions, Bank of America Merrill Lynch, Orlando, Florida MARTI STRAND Chief revenue cycle officer, Allegheny Health Network, Pittsburgh CHRISTOPHER CHENEY (MODERATOR) Senior finance editor, HealthLeaders Media, Middleton, Massachusetts AR# ARJY9DSD MAXSATTANA/ ISTOCK / GETTY IMAGES PLUS DANA THOMAS PHOTOGRAPHY 10 HealthLeaders n June 2017 Sponsored Material n

2 HEALTHLEADERS: What are some of the innovative ways you can ensure claims are clean before they are sent to payers? Roundtable Highlights LISTENING TO YOUR DATA KRISHNA RAMACHANDRAN: We have had the advantage of using the Epic practice management system since We ve made a long-term investment in registration, revenue cycle, and scheduling. We ve also invested in two other big pieces. One is a claim scrubber from Optum, which we use to make sure we are checking on bundling edits and checking on any sort of modifiers needs that are required by our payer partners. The other big piece is we have work queues in Epic. Those are used to spotcheck claims and make sure they are truly clean or not clean. There is a series of logic that is baked in to sort the claims into different buckets, then people work in the queues before claims go out. MARTI STRAND: We look at how we can start from the moment a physician orders something. For example, we had an issue with inpatient-only procedures. We were able to intercept orders right from the moment doctors submit for a surgical procedure, and route that to a specific coder. We check those orders throughout the process to make sure the moment somebody tries to change an order, we act. So we can use the clinical data streams to get in front of a problem before it even begins. HEALTHLEADERS: Dr. Ishmael, from your perspective as a former payer executive, what are the keys to generating clean claims? OLUSEGUN ISHMAEL: There are many simple things that get past providers even simple matching of the patients to the provider number. You have claims where it s a male on the claim and the procedure is a female-related procedure. A lot of it is just simple documentation. That s where making claims automated is critical, especially Olusegun Ishmael Medical Director Paris Community Hospital There are many simple things that get past providers even simple matching of the patients to the provider number. with EHR systems in place. All of the simple things can be caught early on. MELINDA RAMSDELL: We sit right in the middle between the payers and the providers. The undeniable fact is that the number of denials are increasing. Although everybody is struggling with that, there are several solutions that third parties offer. You mentioned Optum, and some financial institutions provide denial management technology as well. What we have heard from our clients is the nonfinancial information that comes along with those payments the correspondence can be a problem. In the traditional workflow of utilizing our receivable solutions, there is a lot of paper that gets sent in to our lockbox environment, and that ultimately goes back to the provider. What we have done is try to organize that paper. We have developed a solution that sorts the paper correspondence in a way that enables accelerated distribution of this work out to your teams, so that they can begin to actively work on responding to whatever it is that happens to be causing a claim denial. RAMACHANDRAN: For me, a denial is a failure in some upstream process. Taking care of denials can be like swatting flies, when you should be shutting a window somewhere. What we have been doing is investing in technology. We took all the data from Epic and n Sponsored Material HealthLeaders n June

ROUNDTABLE: OPTIMIZING REVENUE CYCLE OPERATIONS put it into the Tableau platform a data visualization tool. The idea is looking at trends over time. How can we drill into certain specialties?

3 ROUNDTABLE: OPTIMIZING REVENUE CYCLE OPERATIONS put it into the Tableau platform a data visualization tool. The idea is looking at trends over time. How can we drill into certain specialties? Who are the top doctors? What are the denial causes? Shutting a window varies from case to case. Are we not precertifying? Are we not getting a referral somewhere? ISHMAEL: I always went back to providers and said, You didn t give me enough documentation. I ll give you an example: A patient comes into the hospital. They put the patient on Levaquin. The patient gets Levaquin IV, and I deny it. I get an irate physician or medical director who asks, Why did you deny my claim for this patient? I say, You admitted the patient. You put them on IV Levaquin, and IV Levaquin is similar to pill Levaquin in terms of viability. He says, Well, the patient was nauseous. I say, Nowhere in your documentation, nowhere in your coding, did I see nausea or vomiting. Once we had the discussion, the patient was truly sick and covered. But based upon the codes I got and the billing statement, the patient did not look sick enough to me. Taking care of denials can be like swatting flies, when you should be shutting a window somewhere. STRAND: One thing we are doing now is what we are calling denial crushes. We have a big classroom that has an overhead display and plenty of seats for everybody with computer systems. We bring in payers, we bring in clinicians, our CFOs come to the meeting, the heads of departments come to the meeting, our coders are in the meeting, and utilization review is in the meeting. We pull up accounts together Krishna Ramachandran Chief Administrative Officer DuPage Medical Group and watch what happened with them from every angle. It is so enlightening not only to fix the denial, which we do during the sessions, but also for everybody to walk away educated about what they are doing in their departments, or from the physician s angle, or for the CFO to have a new level of understanding. ISHMAEL: One of the systems we ve used in the ER actually tells a provider where, based upon the documentation, they are at in terms of billing. It tells you when you have missed a step or you have not documented enough. The key thing is it pushes back on the provider and says, No, you can t close this chart out. HEALTHLEADERS: How can healthcare providers rise to the challenge of sending one consolidated bill to patients? RAMACHANDRAN: DuPage Medical Group (DMG) is a large medical group with ancillary specialties, and primary care nurses are one group, with one [tax identification number]. So we inherently have the advantage of a multitude of services and service lines offered under one umbrella. We have always produced one bill whether it s radiology services, whether you get physical therapy in the process, whether you use one of our labs, or whether you use a specialty doctor. Nobody is happy with a bill, but at least people like the fact that it is one bill that they can pay online in their patient portal on our website or through our payer-partner gateways. STRAND: We have 850 employed doctors and a number of hospitals, and we use Epic s SBO technology that basically creates one bill for all of our network. So that does accomplish a lot, and that part of our business is incredibly important not only because they are our customers and our patients, but also because it is a big part of the revenue cycle if you look at the dollars involved. 12 HealthLeaders n June 2017 Sponsored Material n

RAMSDELL: The financial piece of a transaction can come in electronically, but you don t always get the data that supports that financial payment at the same time or in the same format.

4 RAMSDELL: The financial piece of a transaction can come in electronically, but you don t always get the data that supports that financial payment at the same time or in the same format. As a result, it is truly all about matching payments and capturing all the different points of entry for receipts. HEALTHLEADERS: How are you addressing the challenge of presenting price and quality information, particularly online, that patients can understand? RAMACHANDRAN: Quality is probably one of the hardest things to define and communicate briefly. Price is one of the easiest things to communicate but gives the most angst for most people. ISHMAEL: There is a problem are the payers going to release the data? Right now, a lot of people are very gun-shy about releasing data. They are holding it very tight, because if they share all their data, then they don t have control anymore. HEALTHLEADERS: What are the best practices for staff who offer financial guidance to patients? RAMACHANDRAN: It is becoming a clinical and financial journey for many patients, especially in our high-risk clinics. We see it in oncology and some of our spine procedures, where the care is complex with multiple pieces. So the financial adviser role is moving to where it is holistic, with appointments, follow-up, next steps, financing, coverage, payment plans, and all those aspects. It is a hard role to fill because you need a counseling background and knowledge of the healthcare system healthcare finance and the processes involved. It has been tricky for us, but we like that direction a lot more than the pure sort of financial counselors, which is where we started about four years ago. STRAND: The job is five things. First is locating coverage, because a lot of Melinda Ramsdell SVP and Senior Treasury Sales Manager Bank of America Merrill Lynch The financial piece of a transaction can come in electronically, but you don t always get the data that supports that financial payment at the same time or in the same format. times, especially if you come through the emergency room, you actually had coverage that no one found. We find millions of dollars where patients had coverage right from the beginning that we should have arranged, or we find out about coverage so late that patients can no longer utilize it. The second thing is helping patients get coverage. Financial counselors apply for Medicaid, disability programs, crime victim programs, and various other programs; so you have to educate financial counselors on all of those programs and their criteria. Third are the pricing estimates and explaining how we calculate them. We need to communicate that to people, which helps collect dollars at the time of service. Fourth are payment plans and helping patients if they can t pay bills in full. I always say to people, I don t mind having bad debt because I know I m going to have it, but I like to know it at the beginning. So financial advisers figure out how to manage that well, together with the patient. The fifth part is charity, and knowing our charity program. Financial advisers need to know how to process patients in a way that is good stewardship for the organization, without torturing a patient with documentation. ISHMAEL: Unfortunately, I am typical of most physicians: We truly don t understand the payment process. So there is a knee-jerk reaction to go to case management or the social workers in the hospital, or to call a n Sponsored Material HealthLeaders n June

ROUNDTABLE: OPTIMIZING REVENUE CYCLE OPERATIONS RAMACHANDRAN: We are very much playing in this space. There is an inpatient component, and we have two flavors.

5 ROUNDTABLE: OPTIMIZING REVENUE CYCLE OPERATIONS RAMACHANDRAN: We are very much playing in this space. There is an inpatient component, and we have two flavors. In one, we work with our hospital-partner discharge coordinators. We share Epic with two hospital systems, so they have access to make appointments. The other flavor is automatically prioritizing any hospital follow-up appointment very high in our call centers. In some cases, every time we get a discharge summary, the hospital sends it to our central scheduling team, which then makes outbound phone calls and gets the follow-up appointments set, which is a huge win for us in terms of making sure patients are seeing either the admitting doctor or the specialist that they saw within the same week of discharge. navigator. We find that to be the most useful approach. The payment process is not part of our training, whether in residency or in medical school, and definitely not in practice. So we just fall back to whatever system is within the hospital. RAMSDELL: You will never create a perfect curriculum, but it just feels like we are talking about baseline education 101. Teaching doctors how the insurance community and the governmental aid community all work hand in hand would be a step in the right direction. We do hear a lot of clients talk about the changing job description for financial counselors, and the struggles that some providers have internally in messaging the need to change resource allocation from a compensation perspective. We have heard that some providers only hire bachelor-degreed associates for that role. HEALTHLEADERS: How are revenue cycle teams getting more involved in the Marti Strand Chief Revenue Cycle Officer Allegheny Health Network We find millions of dollars where patients had coverage right from the beginning that we should have arranged, or we find out about coverage so late that patients can no longer utilize it. postacute care and post outpatient surgery spaces? STRAND: The main best practice is scheduling follow-up appointments while the patient is inhouse. If they need a follow-up appointment after admission, that should happen before they leave. ISHMAEL: When I was a hospitalist, we made sure that when patients were discharged back to their primary cares, they got their appointment before discharge. As patients got discharged and the discharge summary was created, a probational discharge went automatically to the mailing address and an address for the follow-up physician. That way, the primary cares knew what was going on versus patients just showing up in their offices. We always made sure that on discharge, besides the patient, there was also another individual in the room who got the discharge information. As you are talking to the patient and I have done this a million times they are nodding, but they are not truly listening. They say, Yeah, yeah, yeah. Let s go, let s go. Then all discharges from the hospital were followed up within 24 hours with a phone call. Whether they got discharged from the ER, whether they got discharged from the hospital, somebody called you. RAMSDELL: The key to it is taking action before that individual is out of your grasp. Reprint HLR HealthLeaders n June 2017 Sponsored Material n

Moving from paper to electronic with HealthLogic revenue cycle solutions can help take the pain out of patient payments. It s how forward-thinking hospitals operate more efficiently every day. bofaml.

6 Moving from paper to electronic with HealthLogic revenue cycle solutions can help take the pain out of patient payments. It s how forward-thinking hospitals operate more efficiently every day. bofaml.com/healthcare Bank of America Merrill Lynch is the marketing name for the global banking and global markets businesses of Bank of America Corporation. Lending, derivatives, and other commercial banking activities are performed globally by banking affiliates of Bank of America Corporation, including Bank of America, N.A., Member FDIC. Securities, strategic advisory, and other investment banking activities are performed globally by investment banking affiliates of Bank of America Corporation ( Investment Banking Affiliates ), including, in the United States, Merrill Lynch, Pierce, Fenner & Smith Incorporated and Merrill Lynch Professional Clearing Corp., both of which are registered broker-dealers and Members of SIPC, and, in other jurisdictions, by locally registered entities. Merrill Lynch, Pierce, Fenner & Smith Incorporated and Merrill Lynch Professional Clearing Corp. are registered as futures commission merchants with the CFTC and are members of the NFA. Investment products offered by Investment Banking Affiliates: Are Not FDIC Insured May Lose Value Are Not Bank Guaranteed Bank of America Corporation. ARFWBN

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