A No-Cost or Low-Cost Ways to Improve Your Revenue Cycle

Recently on television I heard an analyst explaining that the medical profession was a recession-proof industry. Obviously, he did not understand our industry nor the impact of a severe recession or some would say depression. We are in an economic time when the trickle down theory has been replaced by a general spray and we are all going to get wet.

When times get tough for consumers, spending gets conservative.  Regular and prompt healthcare and/or preventive care may not have the same priority when weighted against keeping your house or feeding the family or even the potential of a lost job.  The consumer will be demanding more for their dollar in terms of service, quality and perceived value. Consumer/patients are going to be reluctant to spend money, seeking only necessary healthcare. When they do their condition will be more severe, their treatment more expensive, and their payments will be slower, or not at all. The insurance companies will also feel the pinch and will tighten their reimbursement policies due to adverse selection.  In order for the referring physicians to maintain their practices they are going to demand more and better service. In order to compete for referring physicians, facilities are going to need to have better processes and/or more resources to offer in order to retain referring physicians. Collection efforts will need to be ramped up to minimize losses, write offs and potential protracted collections. Hospitals around the country are already seeing the impact in their census, ER rooms and in their collections.  It is not much of a leap to know that this recession will likely prove to be deeper and longer than anything most of us have seen in our lifetime.

After having painted this bleak picture you will be pleased to know that there is a silver lining. Now is the time to effect change. Specifically changes that affect the revenue cycle where relatively small changes can generate huge savings and/or substantial service improvements. Resistance to change will never be lower; support for change will likely never be higher. Staff will embrace change as a positive enhancement to their job security. Hospital physicians will embrace changes that enhance the services presented to the referring physicians. If marketed properly referring physicians will view the changes as higher value

Changes made that affect the revenue cycle have the added benefit of making positive changes in the perception or perceived value of the services affected by the changes. For example a reduction in the time required for a referring physician to receive the diagnostic report or consult, if significant, would be perceived as a positive by a primary revenue generator, your referring physician. A positive change in your admissions process would result in a more positive experience on the part of the patient and his or her family which would reflect favorably on both the facility and the referring physician. The ability to access and/or release patient information to the appropriate party in a timely manner regardless of the price would almost certainly be viewed as a positive experience. For the nurse or the hospital physician to have rapid access to diagnostic reporting, consultative reports, etc. would make them more effective and better able to deal with the patient and their family. As unpleasant as it may seem for the consumer to receive a bill/invoice promptly, this would relieve much of the stress associated with a hospital visit.

The most productive and lasting changes to the revenue cycle can only be obtained by changes in your infrastructure. To shave one day off of your revenue cycle can save you literally thousands of dollars. The single most invasive infrastructure process that can be most easily changed is your document management processes. I am not speaking strictly about the transcription process but rather the entire document management process from scheduling and admissions all the way through to billing and collections. Below I have outlined key operational areas that are directly linked to your document management process. Saving even a few hours here and there will quickly add up to days in your revenue cycle.

Scheduling and admissions:
More and more facilities are offering up patient and or referring physician friendly self-service admissions portals. These portals allow the patient and/or the referring physician's office to submit patient information in a secure environment and often permit scheduling requests. The portals are secure and compliant with current regulations and relatively cheap to create and maintain. This pre-admission self service processing saves valuable time in the admissions department and insures that the patient information has time to populate and be reviewed in the EHR prior to admission and minimizes time spent in face-to-face interviews which is often viewed as a negative experience for the consumer.

Dictation efficiencies:
Dictation best practices indicates that the sooner and/or the closer the dictation takes place to the time and place of the encounter the more accurate and complete the report will be. Complete and accurate dictation and reporting is essential to responsive and effective patient care as well as accurate coding and minimizing the need for outcome management. Dictation can be captured by wireless, by phone, by PDA, by PC, by hand held recorder. It can be done at the patient's bedside, at portable stations, at nursing stations. Multiple methods for dictation provide the needed flexibility to accommodate many dictation styles of hospitalists, admitting physicians and consulting physicians.  The immediacy of dictation removes many of the hurdles and delays in completing the patient chart in the medical records department prior to coding and billing. The use of bedside stations, portable stations or computers at the nurses station can also enable the use of checklists and templates as well as giving access to reference material such as pharmacy formulary, patient information, previous diagnostic and consultative reports, all of which improve the accuracy and completeness of the dictation and report. In some cases the use of front-end voice recognition can further reduce completion time of the report.

Transcription efficiencies:
Transcription turnaround time is one of the most frequently examined components of the revenue cycle. It often offers a quick, but not always easy, reduction in the overall turnaround time of reports. As our technology surges forward, with improved equipment interfaces, the application of front-end and back-end voice recognition and with proper staffing, improvement in turnaround time can be very significant. If your in-house or outsourced vendor cannot meet or exceed turnaround times below you should consider making a change. Shorter turnaround time is primarily dependent on effective staffing and volumes and any cost difference to reduce that turnaround time will usually more than pay for itself with the reduction in your revenue cycle.

Inpatient diagnostic reporting... 2 hours or less
Outpatient diagnostic reporting... 4 hours or less
Emergent history and physical... immediate
History and physical... 6 hours or less
Consultative reports/letters... 6 hours or less
Inpatient progress notes... 6 hours or less
Discharges/death summaries... 24 hours

Report delivery:
As important as it is to get the report completed, it is more important to get it approved and/or signed. One of the many benefits of a short transcription turnaround time is it may enable many physicians and dictators to complete their reports/sign reports/approve reports prior to leaving the premise. However, in order to minimize the turnaround time for approving and signing of the reports it is critical to give the dictator flexibility by having multiple means available to approve or sign reports.  This can typically save many hours and make a significant reduction in the number of incomplete charts in medical records.  There are numerous methods for approving and signing reports that are compliant with all legal requirements.  These are available through your EHR, web portals, or through an auxiliary applications.

Coding summaries:
Effective integration between your document management applications where your patient reports reside and your coding platform is a key element to efficient coding and billing. With the use of phrase recognition technology in either the document management application or the coding platform turnaround time and accuracy can show significant improvement. If used by the transcriptionist they can produce a coding summary to be reviewed and approved by the coding department. If used in your coding platform they can greatly enhance the turnaround time of the initial coding process.  Where this would be the most cost and operationally effective depends on your system and processes.

Collections:
It is never too early to start the collection process. It should begin in the pre-admission interview.  Invoices should give all required information for handling questions and possible disputes.  The collection process should be automated to move in a timely manner to generate appropriately worded reminders with a fixed time frame to move to the next collection level.  Based on studies prepared on collection cycles, promptly moving to the personal interview with potential collection problems is the key to shortening the collection cycle. The sooner a challenge is identified and dealt with the shorter your overall revenue cycle. The obvious reduction in the time required to get settlement from the payer directly impacts the revenue cycle. A properly designed and effectively executed collection program can generate significant improvements.

Outcomes management:
Although "Outcomes Management" in collection terms, is commonly seen as our last ditch effort to collect revenues from the government and/or insurance companies, it is far more important to your revenue cycle as a feedback system to improve your overall processes to ensure and maximize reimbursement at the earliest possible point in the process. Properly defining costs associated with this activity and revenue recovery will give you a starting point from which to measure improvement. It will also provide you with a "key indicator" as to the quality and effectiveness of the feedback into your continuous quality improvement program. In the initial stages outcomes management costs can appear high but the rewards of a well-designed feedback program can be recognized in a matter of months.

Perhaps one of the few positive things we can expect to see from the tough economic times ahead will be the opportunity to make change. Our ability to affect change in the revenue cycle will pay dividends both in savings and improved services to our end customers. The results of infrastructure change will have far-reaching impact on patient care and overall costs.

Contact details:
John Cardinal
Vice President
T: 800-630-4733
E: JC@tsouth.com