Revenue Cycle Management

When the Appalachian Regional Healthcare System (ARHS) was formed in 2004, the organization’s vision was to build a regional healthcare system that enhanced quality of life and resulted in healthier individuals. Likewise, Rayanna Moore, BSHM, MSOM, system director of revenue cycle, had a mission when she joined the organization in early 2008.

Market consolidation has left payers with legacies of multiple, disparate systems and inconsistent data sets. Many plans have systems that exist in separate silos for various business functions; the systems are unable to routinely communicate essential data between them. This is evident in claims systems that were not designed to receive clinical information.

Blending with custom interfaces can yield efficiencies and shorten the time required to deliver diagnostic information to care providers.

Getting accurate information about imaging procedures to clinicians at various points of care can enable a healthcare organization to optimize the value of radiology studies, many of which incur significant costs. In the context of patient-centered care, participants across the care continuum should be able to effectively access, use and share information derived from radiology studies.

Gwinnett Health System reinvents revenue management with help from an unlikely hero.

Then Gwinnett Health System faced the challenge of reinventing its financial practices to deal with a changing healthcare industry, Cathy Dougherty could not stop thinking about a certain children’s movie. The assistant vice president of revenue management had visions of "Toy Story" – a film that depicts the secret lives of action figures and stuffed animals – dancing in her head. Dougherty kept thinking that even though the movie is an entertaining, creative children’s flick, the storyline contains a number of change-management lessons that could be applied in the healthcare setting. Leaning on the movie for inspiration and as a training tool, Dougherty led an initiative to reinvent the two-hospital health system’s revenue-management practices. First, she selected a next-generation revenue-management solution that provides the bandwidth to deal with emerging trends in the healthcare industry. Second, she drove a comprehensive change-management program designed to reinvent revenue practices. As a result, the Lawrenceville, Ga.-based non-profit provider improved efficiency, enhanced patient service and bolstered its bottom line.

The Next Evolution in RCM

By Tony Reisz, president, Ontario Systems

This year will bring an evolution to revenue-cycle management, bringing the focus to the front end of the revenue cycle to patient-access management. This is one of the last areas where hospitals can save substantial amounts of money.

By moving the revenue cycle to the beginning with patient access, healthcare organizations improve their upfront collections, set patient-payment expectations, manage denials and retrieve self-pay balances before the medical procedures take place. Patient-access management increases the bottom line by reducing the cost of healthcare and increasing the dollars collected. At the same time, it leads to improved levels of patient satisfaction.

Software is instrumental in helping perform root-cause analysis of coding errors and omissions, creating an early identification process of clinical practice charge-capture trends.

St. Joseph Hospital, a 112-bed nonprofit community hospital in Bangor, Maine, recognized that it had several pressing revenue-cycle challenges. Among these were concerns that as coding requirements continue to increase in complexity, capturing all charges manually and then ensuring accurate coding would become more difficult.

Claims editing is a step in the claims payment cycle that involves verifying that physician-submitted bills are coded correctly. While claims-transaction systems have some native editing and duplicate checking abilities, these systems are designed to adjudicate claims. As such, even the most robust transaction systems need some help to avoid overpaying claims. Faced with the need for additional editing, payers should decide whether to build an internal editing system or outsource the responsibility to a third-party vendor.

Among the lessons learned in pilot project is the need for comprehensive revenue-cycle management systems and processes.

San Diego County’s Scripps Health (Scripps) was one of many health systems across three states taking part in a three-year recovery audit contractor (RAC) pilot project. "Scripps had a number of challenges at the start of the process," says David Cohn, vice president, revenue cycle, for Scripps.