follows below on these categories and how to
Process, Process, Process
The first category is process issues. Process
issues often include write-offs for lack of timely
filing, no prior authorization where needed, no
advanced beneficiary notice (ABN) on file, and
certain non-covered service denials.
The root cause of these issues is often a lack
of an established standard process, lack of
knowledge of payer-specific requirements, or
operator failure to follow the process if established. Documentation of process standards
in current policies and procedures is critical
to making improvements in any process and
sustaining reliable change.
Approaching process issues requires an organized effort to understand the required steps in the
process to create effective flow across the revenue
cycle. In a clinic setting, there is value in evaluating
the current processes across the entire revenue
cycle from pre-visit activities, the visit-related
steps, and then post-visit work (see Figure 1).
Evaluation of current state can start simply by
observing and asking staff how the steps work for
various processes. If there are obvious problems,
ask what type of training they have received.
Identifying what prevents efficient completion of
tasks and how well staff understand the implications of the work they do—as well as how their
work affects other members of the team—are
key findings of observing processes in real time.
All too often, the reality of day-to-day operations
is different from how processes were intended to
work. For leaders, ensuring that staff understand
the interconnectedness of their work can yield
improved performance that is sustainable.
A comprehensive approach to improvement
includes understanding the flow through all the
above components, developing standard process
testing to ensure the standards achieve intended
outcomes, communicating and training for the new
standards, and, finally, monitoring performance.
In addition to understanding the current state
of the processes, additional analyses may help
in planning and prioritizing of the work. Analyzing the reasons for the process write-offs
by location, by provider, and over increments
of time can be insightful when trying to identify
your biggest opportunities.
The second category of write-offs we consider is
contracting issues. These may include bundled
payment adjustments, specialty carve-outs,
certain non-covered services, and other contracted adjustments. The solutions to these
issues are longer-term in nature if they can only
be addressed in the next cycle of negotiations
with the payer. Regardless, it is important to
understand this category for future negotiations.
Shorter-term solutions can be identified with
detailed analysis and development of standards
around training, systems changes, and communication of contract changes.
Similar to the process issues category, special
analyses will provide a more detailed roadmap
for improvement opportunities. Start by looking at the sheer volume of write-offs by payer.
Beyond payer, consider analyses by provider,
diagnosis code, or procedure code. These
perspectives may identify a process issue with
a location or a provider, or they may point to an
issue with the application or interpretation of
a contract. If write-offs in this area increased
materially at a specific point in time that aligns
with a new contract term, for example, it may
mean there is an issue with interpretation of the
contract. Intervention by the CFO or managed
care department may lead to a reasonable resolution with the payer in the next contract.
All too often, the
reality of day-to-day operations
is different from