At the beginning of a revenue cycle implementation, one of the first things I do is find out what’s important to senior leadership. Invariably, the first and second metrics on everyone's list are revenue and accounts receivable days, so the bulk of our mitigation planning centers around how to safeguard revenue at go live. Surprisingly to some, the majority of these strategies do not center on the actual implementation. Those should be in place well before any system implementation work begins.
Step 1: Create a culture of revenue awareness
The first step is to figure out who monitors revenue. If the answer is only a few people within the finance or revenue integrity teams, we've got a starting point. Reviewing revenue should occur at all leadership meetings and should be discussed collaboratively. Discussing revenue openly and often also allows leadership to take advantage of lessons learned from one department to another.
One of the most effective ways to empower departments is by decentralizing charge review. This suggestion is often met with skepticism by the department managers, but it's often the most effective use of staff time overall. In centralized charge review, the reviewer has to spend time reviewing a chart to catch missing procedures, and will usually be less effective than someone with knowledge of that specialty and that particular department. When I’ve implemented decentralized charge review, I find that most of the time the department charge reviewer (whether manager, supervisor, or staff) can usually pick out a missing procedure immediately because they know what went on in the department the previous day.
Step 2: Define the revenue management process
Clinical departments are primarily concerned with treating their patients, so if we’re asking them to spend time reviewing and investigating revenue, we must make it as easy and user-friendly as possible. Without accurate baselines and effective reporting, revenue review becomes a chore placed on the clinical teams, so any kind of revenue reporting or charge review requirements should be delayed until the proper reporting capability is in place.
Baselines should always include sufficient data to trend, be normalized for department change and be specific to the day for effective comparison to current revenue. When pulling data for baselines, I always go back 18 months to two years. Once the raw data is available, the next step is to normalize it for department changes. If a department has seen changes that affect volumes, additional reporting must be done to quantify these effects. Without it, we will hold a department to an unrealistic standard or underestimate the revenue a department should be generating. The third step to baselines is to report them in such a way that allows for meaningful comparisons and trending. For example, my department may have a reduced schedule on Tuesdays, or may experience higher volumes during the winter months. So, while I may want to compare my current day to my average daily revenue, I probably also want to see historically how my Tuesday was compared to past Tuesdays, or compare this month-to-date to the previous two years' months-to-date.
Step 3: Implementation ownership and go live
Now that your clinical leadership and departments are on board with measuring and following up on their revenue, you're in a prime position to safeguard your revenue at go live. During the implementation, it's important to have three owners for charge build and charge testing: a clinical system IT owner, a billing system IT owner, and an operational owner. The clinical system IT owner should be responsible for coordinating all of the clinical system teams to ensure that the clinical systems are set up to generate the correct charges for the correct procedures. The billing system IT owner should be responsible for coordinating the creation of new charges and working with the clinical IT owner to ensure the correct charge generation methods. The operational owner should be someone who knows your current charge description master (CDM) inside and out, can coordinate the crosswalking from old charges to new, serve as a resource for the IT owners and project teams, and coordinate department managers/charge reviewers' involvement in testing and revenue review at go live.
The two most crucial times in an implementation for revenue are testing and go live monitoring. If you’ve already implemented the first two steps, the go live monitoring ownership shouldn’t be much different, but the frequency should increase. I usually ask all managers to come to a daily go live meeting for the first week to report on their revenue, and then after that, hold meetings with just the departments experiencing revenue issues. This meeting allows the department revenue owners to identify issues and gives the project teams an idea of what areas need troubleshooting.
The testing process should involve testing all charges from each possible source to ensure the system is generating charges correctly, and I also recommend a full-spectrum test of the system from registration through claims. The most successful way I’ve seen this accomplished is to have the project teams take legacy patient scenarios and generate a test script starting in registration. I then have end users conduct the actual testing (usually with project team members at-elbow) over the time frame of the original admission or appointment. Testing with end users on this scale requires a large amount of coordination and availability of resources in order to be able to accurately test the scenarios as they occurred in the legacy system, but is invaluable in identifying errors prior to go live instead of when they’re impacting actual revenue and AR.
Given the high visibility of revenue at go live, it is imperative that your organization is well prepared to take on the challenges a new system introduces. Putting revenue ownership where it is most effective and thorough testing pre-live will position you for a strong revenue cycle go live and help keep your revenue management strong post-live.
Dani Voss is a Senior Advisor at Impact Advisors