Over the past few weeks, we have been aiming a spotlight at the importance of strategy in leadership and operations at the functional level. However, there is another level of strategy that is often overlooked in healthcare organizations: business and revenue cycle management strategy.
While healthcare organizations are focused on patients and improving patient quality of care, the fact remains that every healthcare organization is only as strong as its ability to manage revenue and minimize costs. If a healthcare organization cannot realize profit, providers ultimately cannot serve the patient population in need.
At John Lynch & Associates, I support the leadership team and our clients with expertise in accounts receivable, revenue cycle management (RCM) system implementation, successful billing with minimal claims denials, and staff coverage at the director level.
Several of the Centers for Medicare & Medicaid Services’s (CMS) 16 Strategic Initiatives directly relate to and demand a strong RCM strategy, including the call for innovative payment methods and rethinking rural health.
According to CMS, a key objective is to “advance innovative payment structures to move our health care system to one that incentivizes value by rewarding quality and performance, lower program costs, innovation and improved health outcomes… These models are designed to offer clinicians an array of new payment models that are designed to reward them for doing the job they were trained to do – spending time caring for patients.”
As healthcare organizations are embracing the new initiatives under CMS, administrators and C-suite leaders are left wondering how these and other changes will affect the way the organization does business.
Specifically, how do these initiatives affect the entire RCM strategy and how can we plan for that strategy going forward? Such changes and reformations within the healthcare industry as a whole will certainly affect revenue, but will also affect the day-to-day operation of collecting payment from insurers with innovative payment models.
One of CMS’s top priorities today is measuring the performance of a provider for quality and how to track that quality from a reporting perspective. Organizations struggle to determine how to add certain criteria to visit documentation. While clinicians used to be able to simply see a patient, document the visit, apply a diagnostic code, and move on, now they have a new set of criteria and reporting they must track in order to show progress with patient outcomes and improved quality.
Such a structure is unprecedented, and yet organizations around the country are asked to make changes to the way they provide care, the way they document and report on their services, and the way they manage revenue through billing and reimbursements on a federal level.
In order to satisfy this new initiative and create a RCM strategy that supports the longevity and overall mission of your healthcare organization, it will be critical for leaders to understand what CMS is looking for so that the electronic health records (EHR) and RCM systems can be built in such a way that undue time is not spent on fixing incomplete or inaccurate reporting later.
Ensuring the systems are built to support extrapolating value-based information will enhance the efficiency of getting claims out the door in a way that will ensure that reimbursement rates will be appropriate.
One of the biggest challenges that organizations face is not only knowing what the requirements are, but also understanding how best to implement these new initiatives and requirements within current practices and doing so without losing revenue required to operate.
Thankfully, many of these CMS initiatives and movements do come with some form of reimbursement, either in the form of a payment, incentive, or grants that help offset some of the costs of implementing new systems.
Therefore, part of the RCM strategy must include figuring out what those most critical issues affecting revenue are, how best to go about resolving them, and then how to implement the changes that will move us closer to providing value-based care. Such a process requires a multi-phase, multi-step approach to improvement while still trying to balance the cost of implementation.
CMS has dedicated a strategic initiative to this very concept in order to “ensure that individuals who live in rural America have access to high quality, affordable healthcare through new and creative ideas.”
One of the challenges around the country is that we have many underserved populations and CMS is looking to ensure that people who live in rural America have access to good quality healthcare. To achieve this initiative will require outside-the-box thinking in terms of creating a RCM strategy that will allow a provider to spend one day per week at a low-cost clinic or implement a new remote care service into an existing practice.
Another significant trend in healthcare is one toward telehealth, which not only improves the convenience of engaging healthcare, but also allows the industry as a whole to rethink the way rural populations and underserved communities interact with healthcare.
For example, we at John Lynch & Associates recently worked with a client that was conducting rural health visits twice a month. We worked with them to set up certain telehealth services and schedules so that they were able to see the majority of those rural patients on a more regular basis through a telehealth platform.
As a result, these underserved patients were able to see the physician more than just once a month and they did not have to drive multiple hours to do so. Being able to provide services to those patients on a more regular basis, especially with patients with complex medical diagnoses or comorbid conditions within six months from concept to execution allowed our client to improve the quality of care and health outcomes for those patients with complex needs and minimal access to care.
Following implementation, we followed up with a four-month control and retrospective measurement period after we had implemented the program to see objectively how successful it was. We engaged the IT department to ensure the system continued to work correctly and protect the patient experience, we engaged the physicians to see if the new line of service was valuable to them and determined whether they felt they were making an impact, and we also engaged the patients by asking them questions through surveys and direct conversations to see if the telehealth system was actually helping their lives.
That measurement period gave us the greatest results because we were able to conclude that the program was working tremendously well for the specific rural health patient population. Patient satisfaction, patient happiness, and level of engagement all improved significantly. The organization went on to expand the program to not just patients that had certain diagnoses or comorbid conditions, but to also serve a larger audience altogether.
By coordinating the corporate strategy, functional level strategy, and revenue cycle management strategy, we were able to run a successful beta test and determine that the program was something that was going to be good for the company long-term and that would also serve more patients in need.
While the constant push toward value-based care coupled with the CMS’s 16 strategic initiatives is a lot to ask of healthcare organizations to take on, it is possible. Every organization is busy working in the day-to-day service operations, but these initiatives need to be put in place and with the least amount of resistance, pitfalls, and future corrections.
The key to doing so successfully is taking the time to create a meaningful strategy that represents the mission of your organization, accomplishes these new initiatives, and generates the improved outcomes we all want to see for our patients.
If you need help architecting your strategy, reach out to us and we will ensure you have the blueprints you need to carry your organization into the future.
Join hundreds of industry leaders and get our perspective on critical issues healthcare organizations face in a demanding environment, delivered to your inbox.