The Turning Tide in Revenue Cycle Management
Lisa Leonard Tonkinson HFMA-Des Moines, Iowa July 17, 2019
Today’s Objectives • Review “Traditional” Revenue Cycle Management • Define Value Based Economics • Outline change management that supports an outcomes-based care model • Discuss data integrity concerns • Technology challenges • How to innovate from past mistakes • Achieving Better Outcomes for All!
Traditional Revenue Cycle Management
Traditional Revenue Cycle Complexities
Is Any Thing Missing in the “Old” Revenue Cycle?
VALUE BASED ECONOMICS IS MOVEMENT AWAY FROM TRADITIONAL “OLD SCHOOL” REVENUE CYCLE MANAGEMENT TO UNDERSTANDING THE UNDERLYING PRESSURES ON MARGIN AND ITS BIDIRECTIONAL CORRELATION TO PATIENT OUTCOMES.
Setting the Stage for Future Success • Initiate change from status quo of traditional revenue cycle • Communicate “change” across the revenue stream
• Adopt a cross-functional team approach • Strong data integrity to align with Decision Support/Value Analysis
• Explore alternative resourcing considerations • Technology driven data approach • Patient-centric focus • Outcome-based results • Paradigm shift towards root cause analysis and issue-based resolution
Change is Driving Innovation An evolving healthcare marketplace is rapidly driving shifts to new financial performance metrics focused on value. Revenue Cycle Management Capitation
Fee for Service
Previous
Recent
Value Cycle Management FFS/Value Based
Now
Population Health
Today/ Tomorrow
Traditional Revenue Cycle • One chargemaster supporting billing • Claims based denials management • Compliance “concerned” • Pharmacy & Supply Chain existed in “silos” from other services • Clinics operated independently from other hospital departments • Focus on increasing volume, spend & cost cutting initiatives • Reliance on vendors to lower prices & supply the “newest” widgets • Disparate systems linked though interfacing • “Need-to-know” information sharing
Revenue Cycle
Value Cycle
• Fee-for-service
• Improving margins in fee-for-service while enabling success with value-based and other alternative payment models
• Connect charges to units of service provided
• Connect costs to units of service and charges • Evolves from acute/ambulatory to comprehensive care strategy
“All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue”
Patient Access
Service
Charge Capture
Coding
Claim
• “The process and culture by which healthcare providers pursue quality patient outcomes and optimal financial performance through the management of clinical, operational and financial assets.”
Denial Mgmt.
Clinical Data
Operational Data
Financial Data
Value Based Economics Driving Revenue Integrity • Operate in cooperative, interdepartmental alliance • Codependence of hospital departments for success • Strategic initiatives based in revenue integrity model • Vendors partnerships forged on economic dependencies • EAPs, pricing tables, multiple CDMs • Root-cause identification
Value Based Economics Driving Revenue Integrity…continued • Shift to compliance focused • Episode of Care costs • Transparency & visibility • Integration in EHRs, ERPs, systems, etc. • Interoperability (TBD)
Change Management Steps Lead Change Educate Resolve Issues Create Shared Need Engage Teams Communicate Vision Share Information Replicate Processes Standardize Measure Effectiveness Celebrate Success
Data Integrity Accuracy Affects Outcomes
FINANCIAL DATA
OPERATIONAL DATA
CLINICAL DATA
Pharmacy & Supplies
Pricing Transparency
Your Population
Billing Claims
Contract Management
Right Treatment
Remit & Audit
Cost Analytics
Right Cost
Decision Support
Service-Line Analytics
Right Payment
Data: Driving Real Results • Data normalization for today’s decision support • Zero tolerance for “garbage in” mantra • Responsibility factor in managing all this data • Data safety / cyber security training and enhancements • Ransomware – don’t be held hostage for bitcoin
• Usability and scalability for strategic objectives • IT overload, delayed project starts due to data needs-issues of the past
• Information sharing • Relevant data driven dash boards • No longer measuring to say we have metrics; meaningful tracking
Technology Driven Approach • Invest in technology that makes sense • ROI may really be just a number! • Evaluate other forms of return • Time, labor, capacity vs. investment • IT demands • Interoperability needs • Education to support learning curve • Product adoption • Application support & maintenance • Options that limit output of overcommitted internal resources • Vendor managed software
Future State: The Value Cycle • Innovation driven • Intra/inter-departmental communication is mission critical! • Data normalization crucial for outcomes based decision support • Pharmacy & Supply Chain can no longer operate in a vacuum • Physician Practices & Clinic interoperability • Global direction supporting departmental success • Change “Adaptable” • “No” to Status Quo • Diminished tolerance for business as usual • Dashboards demonstrating success management • Patient Satisfaction • Think Google, Amazon - anything is possible when we think outside of the box
CDM / REVENUE INTEGRITY
OPERATING ROOM
PHARMACY
INFORMATION SYSTEMS / IT
SUPPLY CHAIN / MATERIALS MGMT
Thinking Outside of the Box • Alternative Resourcing Options • Employee-only resource model to “functioning for success” • Remove the threat factor by elevating internal resources as dynamic performers • Impactful external consultant use • Virtual / flexible staffing • Vendor resource alignment • Stimulate technology success by assuring product adoption • Identify automation opportunities • Technology • Processes • Adaptable work force
Achieving Value Based Economics • Cross functional approach with interdependencies • EMRs with relational databases driving a team approach • Value based care / outcomes driven • Strategic Vendor Alliances • Lean oriented with reproducible, standardized processes • Metric determined • Interoperability dependent • Financially solvent • Patient Centric • Increased Patient Satisfaction
Innovation Driving Better Outcomes • Value Cycle Revenue Integrity • Option to outsourcing Revenue Cycle • Efficiency based processes • Revenue Cycle Software Solutions (EHR agnostic)
• • • •
Expert Consultants (SME, Product, Lean, etc.) Root cause analysis Data driven decision support Utilize Vendor supported technology/reports/resources • • • •
Exception based results Clean claim submission Optimized reimbursements Pricing transparency
• Data integrity • Linking clean data to product viability, provider performance & patient outcome
• Increased Patient Satisfaction!
Lisa Leonard Tonkinson Revenue Integrity Executive, Craneware
[email protected] LinkedIn
