Strengthening the Structure: Improving the Healthcare Revenue Cycle

You probably recall the child folk song Dem Bones. The song helps children learn and remember how bones in the human skeleton system are connected to each other.

The hip bone's connected to the back bone,
The back bone's connected to the neck bone,
The neck bone's connected to the head bone,
Now shake dem skeleton bones!

If only there were catchy song lyrics to help people learn and understand how each piece of the revenue cycle is connected to each other! Let's give it a try.

The scheduling's connected to the no show rate,
The no show rate's connected to the low revenue,
The low revenue's connected to the low cash flow,
Now check dem balance sheets!

Or what about:

The financial clearance is connected to the delayed billing,
The delayed billing's connected to the high denial rate,
The high denial rate's connected to the low cash flow,
Now check dem balance sheets!

Not quite as catchy as the original song, but you get the point. Everything in the revenue cycle is connected to each other. Issues in one area will have an impact on areas further downstream in the revenue cycle. The earlier you can identify and fix issues, the healthier your revenue cycle will be and the quicker you will be able to go from seeing a patient to getting a paid claim. Here are some suggestions to help you get started.

Think with the Beginning in Mind

We already know what the end goal is, a paid claim, so it doesn't help to think with the end in mind. We need to focus on the beginning. Where is the first place we can capture the information we need to get a paid claim? Where else can and should we capture that information? Capturing the required information as early as possible, you can free back-end staff to focus on other claims and edits. EHR systems offer capabilities to capture information early and ability to check for it often, you just have to make sure you are using the system appropriately to capture claim information as soon as possible and then validating it is correct every step of the way.

Ignorance is not Bliss

Ask yourself: are your front-desk staff maliciously trying to cause denied claims by purposefully not collecting and documenting needed information? Are your coders purposefully excluding a modifier from the claim just to see what happens? Of course not! Chances are they don't even know they are making mistakes, how it is impacting users on the back-end of the revenue cycle, or how it is preventing claims from getting paid. This is why it is important to provide feedback to the users who are making the mistakes that result in denials.

Stop the Denials 

In this case, you can start from the end and work backwards. What denials are you getting? Are they coding, registration, or billing? Which department is the source? Are they aware they are causing denials? Healthcare staff may not know the correct workflow, why they had to follow that workflow and why it was important. How can we help educate them? Running the right reports to collect metrics and asking the right questions allows you to follow the denials back to the source to fix the root cause, whether that is in system setup or end-user education.

So, the next time you see a registrar skip over a field with a yellow yield sign or a charge reviewer resubmit a session past a warning message, remember that the issue will likely surface again, but next time there will be real money involved.

Nicole Ranere is an EHR Manager at Avaap, where she helps hospitals and healthcare systems get the most value from their EHR investments and implementations.