November/December 2019

Working in Tandem
By Maura Keller
For The Record
Vol. 31 No. 10 P. 10

It takes a concerted effort between the clinical and financial sides to make revenue cycle a smooth-running operation.

For most health care organizations, proper revenue cycle management can be traced to solid coding, billing, and accounts receivable processes—all of which can result in a shiny bottom line. From multilocation health systems to single hospitals, revenue cycle management requires the input and alignment of both clinical and finance teams. However, this fundamental component of aligning procedures, processes, and people for the organization’s greater good is often easier said than done.

In the pay-for-performance era, coordination between the clinical and revenue cycle teams is vital, says Tim Brundage, MD, CCDS, medical director and CEO at the Brundage Group, which provides clinical documentation improvement and revenue cycle solutions to health care organizations.

“The clinical team needs to understand how their documentation creates the coding that will then track to quality metrics,” he says. “Quality metrics are used by Medicare in the calculation of value-based care. The clinical team needs to become savvy as to how documentation affects the quality metrics that are publicly shared, as well as the potential penalties or bonuses based on Medicare’s value-based programs.”

Brundage, a diplomat for the American Board of Internal Medicine who earned his CCDS certification through the Association of Clinical Documentation Improvement Specialists, travels the country educating physicians on clinical documentation and speaking at national industry conferences.

“[Bringing the teams together] is an ideal role for physician advisors who should understand the clinical side, the documentation side, and the quality side while acting as a liaison between the clinical provider and the coding team,” Brundage says.

To address all facets of the revenue cycle effectively, Dinesh Pai, CFO at ApprioHealth, says it is critical to engage clinicians and finance professionals. Quite simply, both parties have a role to play in the revenue cycle and several issues can be remedied by engaging all areas as stakeholders.

As Pai explains, engaging clinical teams can ensure that documentation is performed as timely, thoroughly, and accurately as possible. This can facilitate charges being coded properly and provide the highest probability of accurate and timely payment from payers.

“Finance team engagement and alignment with clinical teams also can ensure strong and effective communication to ensure that performance to key performance indicators (KPIs) are measured and communicated to all accountable clinical and finance leaders,” Pai says. “This coordination allows both teams to have strong partners to ensure optimal revenue cycle performance.”

Pai stresses that it is essential to identify the key clinical and finance leaders who can positively impact the revenue cycle and also be in position to influence others in the facility to assist as needed. Additionally, communicating the current state of the revenue cycle, KPI performance, and any issues that require attention will help the teams focus on the correct areas.

“It should also be said that the teams must assist one another on educating their counterparts about concepts that may be foreign to them,” Pai says. For example, finance teams should explain the significance and meaning of revenue cycle metrics, while clinical teams can discuss any clinical documentation issues.

When the finance and clinical departments collaborate, patients are charged for all documented services correctly the first time, which results in less audit risk, less time spent correcting coding and billing issues on the back end, and realization of the appropriate reimbursement, says Jennifer Bishop, vice president of product content at Vitalware.

“Hospital departments have been divided into silos for far too long, with each group working diligently to accomplish the goals of the hospital as they understand them but not fully appreciating the contributions of the other departments,” she says. “Too often, this leads to a culture of misunderstanding and frustration, as each department can feel that the other teams are working against them instead of with them.”

Naturally, clinical departments must focus on patient care. However, they are also responsible for generating charges for procedures and services, which makes them integral to the billing process.

Bishop says the finance department understands that quality patient care is the primary goal but must focus on the financial health of the facility. “When these departments work together, the facility will ensure financial viability and quality patient care. Most facilities have revenue leakage in the form of unnecessary write-offs that occur because the clinical departments are incorrectly charging patients for a particular service repeatedly over time,” she says. “Without collaboration between the departments, the business office may write off the charge rather than taking the time to educate the clinical department about the proper way to charge patients. Worse yet, they may try to correct the charges themselves, which can result in a claim that doesn’t accurately reflect the services provided and documented.”

Communication Strategies
At its core, the revenue cycle management process represents a complex set of procedures, all of which require streamlined communication among the stakeholders.

According to Bishop, it’s important to establish a common language between the two teams. There are many acronyms used by clinical teams and finance departments that may not be clearly understood and may even overlap with different meanings. There must be a focus on ensuring that each group understands what the other group is saying.

“With repeated exposure, a common language will develop,” Bishop says.

As Brundage explains, a physician advisor should serve as the liaison between the clinical and finance teams. “There should be direct, physician-to-physician communication to increase awareness and education that quality tracking is determined directly from the coded record and is publicly shared,” he says.

While this methodology seems straightforward, Brundage says there is a lack of understanding by physicians that coding is derived directly from their documented words. “The physician often assumes that the coder can look at the chart with a clinical eye. However, this is not allowed, and the coder reads only the words in the chart,” he notes.

Securing reliable data and analytics on revenue cycle performance also can help the two teams discern what issues need to be addressed and by whom.

“Quint Studer of the Studer Group has famously explained, ‘What gets measured, gets done.’ Having proper analytics for the revenue cycle can ensure the team remains focused on addressing performance and also directs its time and energy to meaningful and material issues within the revenue cycle,” Pai says.

Focusing on the top three to five metrics that address the majority of revenue issues will help both teams maintain focus, he notes. However, keep in mind that going beyond five metrics can lead to distraction or lack of focus.

“Encourage and appoint clinical and finance leaders to partner together in a dyad model to lead improvement efforts,” Pai says. “This ensures that perspectives from both teams are considered in any action plan.”

One way to begin the communication process is to require the finance department to send an e-mail on a weekly or monthly basis outlining changes in billing guidelines or identifying problem issues. “A brief e-mail that is pertinent to each particular department has a better chance of being read and inspiring action,” Bishop says. “Additionally, it can be very helpful to invite a member of the finance team to the last 10 to 15 minutes of a monthly departmental staff meeting to talk about identified billing and coding issues during the previous month.”

Conversely, Bishop says it can be helpful to have a member of each clinical department attend the finance staff meetings as a guest speaker to talk about a day in their lives and the challenges they face.

“The glimpse into the inner workings of each department and the challenges faced helps to foster a spirit of collaboration over time,” Bishop says. “If feasible, getting the groups together in a more social setting is very helpful. A shared potluck between finance and clinical departments can go a long way to making both groups feel that they are on the same team.”

Facing Challenges
As with many collaborative efforts, handling revenue cycle management initiatives by aligning finance and clinical teams can be challenging. For instance, in some cases, either team can blame the other instead of working together to solve the issue.

As Pai explains, this can lead to long-term dysfunction and frustration. Having strong coleaders from both teams who are objective and possess a “big picture” perspective can help in overcoming resistance.

“For example, it is likely more effective for a strong physician leader to work with any resistant physicians instead of a finance leader,” Pai says. “In addition, clearly articulating the issues via effective reporting and displays can help both teams understand the role they both play to address the issues in a positive manner.”

What’s more, the tone from the hospital’s top leadership—particularly when it comes to the C-suite emphasizing the importance of the initiative—is vital to ensure full engagement from both clinical and financial participants.

“If the C-suite recognizes and communicates its focus on the revenue cycle, both teams will likely feel reinforced and supported to function effectively,” Pai says.

In all likelihood, the effort will have to overcome pushback from staff members claiming they just can’t spare the time to take part. In addition, Bishop says each department may believe that cross-departmental interaction will not be beneficial because others can’t possibly understand their challenges and responsibilities.

“Regular involvement in each other’s meetings is a good way to start this process and counteract the time argument since the time allotted for each meeting has already been established,” Bishop says. “This exposure also helps each department to understand the challenges of the other and helps to foster a team atmosphere over time.”

Helpful Tips and Common Mistakes
To further streamline the process, Bishop says finance departments must understand the value brought by nurses and help educate them on billing and coding changes without expecting them to be experts on the rules and regulations.

Conversely, nurses must make concessions of their own. “Nurses must understand that coding and billing regulations must be followed, even when they are counterintuitive to best practices of care,” Bishop says.

It also may be helpful to hire a revenue cycle manager who understands the daily workings of both the financial and clinical sides, she notes.

Brundage advises hospitals and other health care organizations to train their teams effectively, thoroughly, and continuously. Clinical documentation improvement, coding, and the physician advisor should partake in ongoing training to encourage continuous improvement and support the clinical team.

Likewise, it’s vital to choose the right clinical and finance leaders to participate. Pai says these individuals should have open minds and understand the larger perspective at play within the revenue cycle.

Even if all these boxes are checked, plans can go awry. For example, chasing after too many metrics and diluting the bandwidth of the combined teams can crimp progress.

The scope of any health care organization’s revenue cycle is broad, with many stakeholders involved, which makes it imperative to take a streamlined strategy that asks key questions such as: What are we trying to accomplish? What are the problems that need to be addressed? What are the proposed solutions?

“Don’t expect to see results overnight. This type of culture shift takes time and patience, but it is well worth the effort,” Bishop says. “Aligning these teams will help to ensure that the financial goals of the hospital are met and will ultimately result in fewer denials and increased reimbursement as claims go out the door correctly the first time. Denials and rejections should be monitored over time with results reported out to both groups. This process should result in fewer denied and rejected claims, which will encourage continued interaction.”

 — Maura Keller is a Minneapolis-based writer and editor.