Fall 2021  
Scheduling Template Optimization – the Foundation for Improved Access
By David Francis - VP Management Consulting
  • Academic Medical Center
  • 2,200 Beds
  • > 3,000+ employed physicians
  • 6,500 Affiliated physicians
  • Majority implemented EHR/PM/RCM enterprise-wide
  • Long call times for appointment scheduling
  • Long wait times for primary care and specialist appointments
  • Referral leakage to competitive health system due to long appointment wait times
  • Schedules are not optimized – variances in visit types and durations
  • Assumptions that scheduling templates often failed to support contract patient facing hour expectations
  • Centralized call center often called providers administrators to check availability before scheduling appointments regardless of schedule availability
  • Patient self-service scheduling not broadly deployed and reduced during COVID surge timeframe
  • Overall lack of accuracy in appointment availability/transparency to support expansion of patient self-service scheduling
A sample of optimization initiatives include:
  • Interview administration, managers, clinic and call center staff, and providers
  • Collaborative project tasking with direct involvement of providers, resources, and support staff
  • Collecting documentation and data extracts, including provider templates, scheduling guidelines, and various practice and patient access metrics from each Department and provider
  • Assess practice and call center strengths and challenges in the areas of call wait times, managing incoming requests, patient screening protocols, process for overriding the schedule and need to contact clinics and providers
  • Remote video conferencing system demonstrations with providers and staff to educate on schedule/template functionality to best understand design and implementation
  • Complete review, assignment, reassignment, and enablement of all visit types and visit type durations across enterprise provider templates
  • Assessment, design, and implementation of schedule template sessions, blocks, appointment reasons, and instructions
  • Standardized and reduced visit lengths, expanded slot availability, and contact hours
  • Oversight of self-scheduling enablement at Department and Provider levels to meet template optimization design
  • Enterprise template governance policies and procedures, best practice tips and toolkits, and post-implementation maintenance transition handoff
  • Optimized >7,500 templates
  • Aligned scheduling templates to ensure providers contact hour obligations are met
  • Instituted scheduling template best practices to avoid losing patients to competing healthcare facilities due to inability to see patients timely
  • Added patient self-service scheduling across multiple specialties for nearly 1,700 providers
  • Doubled online scheduling rate from 2.6% to 5.6%
  • Added 291K Online Appointments and 55K New Pt. Visits
  • Q1 call center savings >$900K from online scheduling improvements
  • 45% increase in new patient Primary Care office visits booked online
  • 260% increase in new patient Specialty appointments booked online
  • 4-day improvement in average appointment lead time
  • Bump rate improved from 2.1% to <1%
Optimization of Charge Capture & Coding Operations
By Brad Boyd - President
Spotlight Article
Engagement Background
Culbert Healthcare Solution was engaged by a large medical group who provides comprehensive care for cancer patients. Over 400 clinicians provide services in ten medical and surgical specialties out of 80 practice locations.
Charge capture and coding workflows are very complex. Clinical documentation and capture occur in their core oncology-oriented EHR, while other systems capture charges for laboratory, radiology, pharmacy and inpatient related charges. All charges flow into a single practice management system for billing and A/R management. The EHR and practice management systems in place have been in place for almost two decades. These applications were selected when the practice was comprised of 14 medical oncologists.
Organizational growth, service line expansion, and the complex nature of charge capture processes led to the request for an independent review of their coding and charge capture processes to identify opportunities for improving the overall efficiency and effectiveness of these processes. The goals of this assessment were to identify and qualify financial improvement opportunities derived from the following:
  1. Income statement improvement opportunities through revenue enhancement by capturing missing charges, cash acceleration by decreasing charge and claim lag, and reduction in coding related denials.
  2. Improving RAF scores through enhanced HCC coding.
  3. To identify balance sheet improvements through reduction in Days in A/R.
Culbert conducted a comprehensive review of current KPIs, workflows, policies, procedures, staffing roles, responsibilities and costs, and IT system design. A critical component of our analysis was to determine the extent to which their antiquated IT application infrastructure supported or hindered optimal workflows and staffing efficiencies.
Findings & Recommendations
From a missing charges perspective, Culbert identified an opportunity to increase annual net patient revenue by $8.7M. These charges should have been captured through enhanced EHR configuration, automated coding rules, and charge reconciliation processes.
Culbert identified a $97M balance sheet improvement opportunity by mitigating coding related denials before claims went out to payers.
Lastly, the reduction in charge lag and claim lag associated with coding issues would result in a $9M balance sheet improvement.
Culbert developed a detailed implementation roadmap which included the necessary changes to people, processes and technologies in order to realize these improvement opportunities.
Culbert recommended the creation of a centralized Revenue Integrity team. This team centralized management of the following activities:
  • Coding for all procedures was shifted from physicians to the coding team. Providers were only responsible for E&M coding.
  • Shift of coding responsibility for certain specialties from their compliance team to the revenue integrity team.
  • Coding related claim edits and coding denials were shifted from billing office staff to this team to be worked by coding specialists.
  • Centralized CDM maintenance.
A major driver of workflow inefficiencies relates to limitations of their practice management system to support a large multi-specialty billing operation. With the adoption of our IT recommendations detailed in the following section, revisions to workflows included:
  • Coordination and communication of revenue cycle performance information between practices, billing office and IT staff.
  • Established an End of Day charge reconciliation processes, with defined responsibilities between practice managers and revenue integrity teams.
  • Capture of charge edits before the charges hit the billing system (pre-A/R as opposed to post-A/R).
  • Implemented HCC coding process to improve Risk Adjusted Factor.
  • Developed formal coding education program and feedback loop between revenue integrity and providers.
  • Management of annual coding updates.
Culbert provided short-term IT recommendations to address immediate opportunities with defined ROI opportunities, as well as longer term IT considerations which would align IT priorities with the strategic goals of the organization (growth, patient experience, research, service line expansion, operational efficiencies).
  • Address backlog of EHR optimization initiatives related to order management and closing encounter functionality.
  • Updated Order sets in the EHR to capture appropriate charge information.
  • Selected RCxRules Revenue Cycle Engine as coding workflow tool for centralized management of all coding edits/reviews/rules pre-A/R, and to support new HCC coding workflow in real time. Move all EHR and interface rules associated with coding edits into RCxRules.
  • Develop automated charge reconciliation reports.
  • Evaluate new practice management system with more robust rule-based functionality to automate workflow, assign and prioritize accounts, and improve staff productivity,
  • Consider integrated EHR/PM platform
Minimizing Revenue Loss from Inpatient to Observation Status Downgrades
By Charlie Brown, MBA
Hospital revenue reductions associated with reclassing a patient’s status from inpatient to observation based on medical necessity continues to be a growing concern for hospital providers. Enhancing technology, workflows, and ensuring interdepartmental engagement and coordination throughout the organization is required to minimize revenue risk. Understanding payor contracting requirements and escalation protocols is paramount to preserving the organization’s appeal rights when payors deny the status billed by a hospital provider.
Hospital providers are challenged with understanding and complying with payor-defined medical necessity requirements to meet inpatient criteria. Payors continue to reduce hospital provider revenue by denying inpatient status and paying for much-needed inpatient care under observation rates which can be eighty percent lower. Nowhere is this more evident than from the managed Medicare payors. Inpatient criteria is relatively straightforward for traditional Medicare-covered patients that stay more than two midnights, but managed Medicare payors have created a medical necessity and authorization gauntlet to prevent providers from getting reimbursed appropriately. CMS globally expects managed Medicare payors to provide hospitals with reimbursement equal to the rate providers would receive if the patients were covered by traditional Medicare. However, some of the more egregious payors deny as much as 50% of their covered enrollees inpatient reimbursement based on internally-developed medical necessity and authorization criteria. Managed Medicare is not the only patient group where these payor reductions occur. Commercial and managed Medicaid payors have also developed complex criteria to the detriment of hospital revenue and patients.
Understanding the magnitude of lost revenue from patient status downgrades can be challenging. Too often hospital providers take the path of least resistance or get weary of fighting with payors to be paid appropriately and self-deny or submit claims to the payor with an observation status when inpatient reimbursement is warranted. Therefore, providers must ensure that organizational workforce, processes, and technology are aligned to fully document care, submit claims appropriately, and dispute improper denials.
       People – Multiple departments and teams must work together to minimize the risk of lost revenue from status downgrades. It is vital to have engagement and coordination from hospital teams including Patient Access, Case Management, Physician Advisors, HIM/Coding, Patient Accounting, Denial Management, Payor Contracting, Information Technology, and Legal.
       Process – Process maps will ensure that responsibility is well defined, and handoffs occur timely. Any breakdowns in the process could result in the loss of appeal rights. Payor contract terms including clinical criteria and the appeal process needs to be well-documented and aligned with the process map. A payor matrix defining appeal and dispute criteria should be available to all teams to ensure proper payments are received and appeal rights preserved.
       Technology – Technology should be developed to support the process and assist team members to mitigate revenue reductions. The use of system flags and work queues will ensure team members are alerted when they need to act, and system prompts will identify when steps are delayed. Leveraging technology to automate and monitor the process will ensure each individual payor requirement is completed and documented.
It’s time to stop payors from inappropriately reducing revenues to hospitals by reimbursing inpatient care with lower observation rates. Hospital providers should thoroughly analyze the revenue lost from these downgrades and develop a playbook that includes a path to litigation to mitigate the risk. Analyzing the revenue differential from managed Medicare payors compared to traditional Medicare for patients staying in the hospital at least two midnights is a great starting point. Using strategies to integrate technology with well-defined processes will help interdepartmental teams ensure revenue is appropriately captured and appeal rights are preserved. Organizational perseverance is required to capture accurate reimbursement from every payor and every patient population. Hospitals across the country continue to provide excellent inpatient care and save lives, and they should be reimbursed accordingly.
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