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Optimism and Daily Challenges: The Leaders of a Rural Oklahoma FQHC on Revenue Cycle Management

January 4, 2018
by Mark Hagland
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The leaders of a rural Oklahoma FQHC share their perspectives on revenue cycle management issues

Central Oklahoma Family Medical Center (COFMC) is a federally qualified health center (FQHC) in south-central Oklahoma, with two locations, in the towns of Konawa and Ada, located about 90 minutes southeast of Oklahoma City, near the Texas state line.

Like the leaders of other FQHCs, the three physicians, five mid-level practitioners, three licensed clinical social workers, and all the other members of the 75-member staff at COFMC, are deeply committed to their 6,000-some patients and to the two isolated rural communities in which they deliver care. That said, the economics of FQHC operations, with increasingly straitened finances and manifold regulatory requirements, are as challenging as ever.

It is in that context that Central Oklahoma Family Medical Center’s leaders turned to the Richardson, Texas-based Aprima Medical Software as a partner in the area of revenue cycle management (RCM), in February 2017.  Since that time, the organization has outsourced its RCM functions to Aprima.

Late last year, Memory Coker, L.P.N., COFMC’s chief administrative officer, and Charlie Vest, its chief financial officer, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the policy, payment, and RCM challenges facing their organization, and their work to put the FQHC on a firm financial footing. Below are excerpts from that interview.

Can you share with me some of the core challenges and opportunities facing your organization, in the revenue cycle management arena?


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Charlie Vest: The challenge is the unknown. Seventy percent of our federal grant could be cut by the end of the year. That grant came from the ACA [Affordable Care Act]; the funding is set to expire—it’s the same one that was set to expire Sep. 30, with CHIP [the Children’s Health Insurance Program]. HRSA [the federal Health Resources & Services Administration], our governing agency, had money until January. Thus far, the funding has not been reinstated; so if Congress doesn’t come up with something by January, the total $5.1 billion allocated to everyone, will be cut by 70 percent. Our grant makes up about 20-25 percent of our budget.

Charlie Vest

So you’re potentially facing a 13-15-percent cut to your budget?

Yes, that’s correct.

So what are the key things you need to do, as an FQHC, in terms of revenue cycle management, in order to keep your organization operating effectively?

It’s all about timing. It all has to be quick. I can’t have bills set out for months. If we can get a clean claim out and get paid in 14 days, that’s very important. The providers have to finish their notes in a timely way so that we can get a claim out quickly. So we switched from NextGen to Aprima EHR [electronic health record] in November 2014. We had Synergy Billing. And in February, we switched to Aprima Billing. And that’s been very helpful for us; they know their own EHR; they’ve been able to streamline our process, to get the claims out the door and to lower our days in AR. You’re right, I don’t have excess cash sitting in the bank for a rainy-day fund. We have to pay our bills.

Can you share what your days in accounts receivable were then, and what they are now?

So in April 2017, they were 40 days. Now, they are 30.

That’s significant.

Yes. Since Aprima has taken over, we’ve had a ten-day drop in our AR. And that correlates to our monthly working capital. We went from 1.014 month’s [reserves] in working capital in April to 1.5. So we’re starting to get cash in the bank, to plan for expansion, etc. We’re getting some cash on hand, finally, instead of having a bad month and figuring we’re toast.

Every clinician has to play their part to document quickly and well, in order for all of this to work, correct?

Yes, that’s right. We’d like their notes to be done by the end of the next day. We really don’t have much of a problem with that. Aprima RCM has done an audit of our charts, to let Memory educate the providers.

Memory Coker: The audit actually went very well. Our finance department did an audit of one provider so far, that looked at their documentation versus their E&M coding, and found the documentation was in very good support of that coding. As Charlie said, we usually do require that their notes be done within 24 hours after a visit, but 98 percent of the time, all the providers have their notes complete and ready for billing by the end of the day of service. That’s a testament to their efficient use of the EHR.

Memory Coker, L.P.N.

The EHR is user-friendly?

It is user-friendly, yes. And we had reviewed a lot of workflows and analysis as we were implementing and training for Aprima, and we did not have to change any of that workflow; it was easily customized to what the providers were doing; and that helped a lot.

If you had all the money in the world, what would you ideally like to do? And what can you do realistically?

Vest: We’re looking into expanding into the Ada market, because it’s so much larger than Konawa. We have a very large concentration in Konawa. But in Ada, primary care is lacking. And we’re trying to get primary care into Ada where the patients are. Some have a lack of funds to access care. So just trying to get that to the patients there. We have two providers in Ada and are renting space, but we’d like to purchase property for a central location, and to provide pharmacy. And our 340B drug pricing system is something we can offer as an FQHC. And the cost savings to patients under that program is huge. So we’re trying to get that model to that location where all the patients are. So it helps where we’re starting to get some cash to plan for that. But we’re holding off to see where this funding situation is going.

Do you have advocacy representation in Congress?

Yes, the [Bethesda, MD.-based] National Association of Community Health Centers. And we’re told that everything is set to be approved before the end of the year, but until that’s done, I’m always hesitant.

For FQHCs and others serving underserved populations, what would you say are the key success factors in revenue cycle management?

Coker: One of the biggest myths we battle is the idea that we’re “free healthcare.” We’re not. The grant provides about 25 percent of our budget; the rest we have to make up through billing control or working with our population. You still have to do a good job at billing and connections. And we’re still a business, even though we’re not-profit entirety, we still have to act like a business, and collect the money due to us. And this involves a cultural change; you cannot rely strictly on government handouts, we’re going to have to make it on our own.

Can you speak to the value of the analytics part of the RCM equation?

Vest: The most help that the analytics has given us has been to show us where bottlenecks have occurred. Simple things like, we have a Medicare contract and a Medicaid contract. And Medicare and Medicaid had different NPI numbers; well, no one knew that. And now everything is flowing electronically. I’m a big proponent of pushing everything I can, to electronic, and Aprima has been very instrumental in that. It expedites our payments and everything else. So those simple changes to our clearinghouse, to make sure we’re paid as quickly as possible, has been really helpful to our cash situation.

Do you have dedicated IT people?

We have two IT people. Memory oversees IT. And we go to Aprima with all of our issues.

What would you say is the key to success in managing IT processes in such a small organization?

Coker: I’m not a technical person as much as I am a health information person. I oversee more of what IT processes can do to help the workflow of the clinicians.

But, from a strategic standpoint, the key would be…?

I think understanding the flow of the patient, from the time they check into the clinic, to the time their prescription is sent to the pharmacy. Everything—the flow, timing. We have in-house lab and x-rays. So orders being sent, etc. Optimal efficiency of flow is critical. We’re that one-stop shop. And I am a nurse as well. So having that clinical background and having the knowledge of how everything affects the process, from patient check-in and registration to the visit, to checkout and having prescriptions and orders move forward—I can explain to our IT pep the flow from a clinical standpoint and how that should go—and getting them to help me achieve what needs to be done technically, is key. The practice management developer at Aprima was here last week, helping us. And they’ve been amazing in helping us help them improve their software to help them meet the needs of the clinicians.

How do you see your organization’s future trajectory over the next couple of years?

Coker: I see expansion, and I see increased revenue. We’ve seen that since Aprima RCM took over. I see that continuing to grow, not just because they’re helping us bring down days in AR, but because we’re seeing more patients. Our goal is to increase patient population, and we’re well on our way.


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