With public and private healthcare spending significantly outpacing that of other countries, U.S. hospitals face intense pressure to find new ways to capture greater value. More and more, organizations are finding that partnerships with existing vendors can help unlock next-level performance gains in a transformative environment.
Take Nebraska Medicine, for example. In the early 2000s, the health system created multidisciplinary committees to boost revenue integrity and adopted new revenue cycle management processes that strengthened performance—with strong results. But best practices alone are no longer enough to fuel revenue cycle gains at a time of decreased reimbursement, rising out-of-pocket costs, and staffing issues. “You’ve got to be able to get to the data,” says Jana Danielson, Executive Director, Revenue Cycle for Nebraska Medicine—a $1.8 billion academic medical center with two hospitals, ~450 revenue cycle staff, 913,000 hospital billing claims, and 1.6 million physician billing claims per year.
“Without real-time access to data and data analytics, revenue cycle teams risk making decisions based on emotions, not facts,” Danielson says. “Our partnership with a vendor enables our revenue cycle team to more effectively use data to identify our pain points and empower team members to take the right steps for improvement.”
Nebraska Medicine’s experience points to four ways healthcare organizations can establish partnerships with vendors that drive innovation and performance excellence.
1. Look for a partner that will challenge your assumptions around performance
The right partner will dig deeper, not only tracking key performance indicators (KPIs) but also taking a hard look at how these KPIs were calculated.
For example, in revenue cycle management, there are many ways to track clean claim rates, a measure that reflects the quality of claim data that is collected and reported. Some organizations consider a clean claim rate to be the percentage of claims accepted by the payer on the first pass. Others calculate it as the percentage of claims that pass through the organization’s billing department without manual intervention before being submitted to the payer. Depending on how this metric is calculated, sometimes a percentage that seems to indicate above-average performance in comparison with peers may not reflect breakdowns in processes that have occurred before a claim is submitted.
At first glance, Nebraska Medicine’s clean claim rate in 2017 was strong:
95.87 percent for a physician billing and 87.59 percent for hospital billing. However, using claims analytics, the health system uncovered a hidden challenge. Some billers were bypassing the claim edits. In those instances, claims were being submitted before corrections were made. The result: a lower-than-expected clean claim rate.
Nebraska Medicine’s revenue cycle leaders worked with the organization’s vendor to tackle this challenge. The revenue cycle department developed scorecards by individual employees that showed their performance against key metrics, including their rate of bypassed edits, and reiterated expectations for revenue cycle processes. Within three months, the number of bypassed edits significantly decreased. Today, Nebraska Medicine’s clean claims rate averages 93.78 percent—well above the industry standard—for more than 900,000 hospital claims per year.
At Nebraska Medicine, Reduction in Bypassed Claim Edits Drives High Clean Claims Rate
2. Make sure the vendor has both product knowledge and operational expertise
Many vendors make the business case for partnership based on the quality of their product or system, such as a 99 percent clean claim rate or a 3 percent denial rate. Some back up their product expertise by regularly working with clients to optimize their use of a technology or service—and it’s a solid step toward a true partnership.
But the best vendors also commit to understanding the context in which their products or services are used in your organization. They examine your team’s work processes and draw upon their operational expertise to make suggestions for improvement, even when the modifications they propose fall outside their paid relationship with your organization.
Consider that 90 percent of patients expect out-of-pocket estimates before care is delivered—not surprising, given the rise in high deductibles and patients’ expected contribution toward their healthcare costs. Providing a patient financial “concierge” at the point of contact not only helps patients better understand their out-of-pocket obligation but also bolsters an organization’s ability to:
– Collect copays upfront
– Explore barriers to payment and patient-tailored solutions
– Increase point-of-service collections and revenue
The right vendor will offer both tried-and-true and out-of-the-box suggestions to drive increased efficiency and revenue, regardless of whether this boosts the vendor’s bottom line.
3. Ask bold questions—and expect thoughtful responses
We’re at the tip of the iceberg when it comes to using artificial intelligence (AI) in healthcare. AI offers a massive set of capabilities for innovation and improvement in healthcare, including in revenue cycle. For example, the use of machine learning has the potential to elevate revenue cycle performance by predicting:
– When a claim will be paid—and how much—down to the hour of remittance
– The probability that a claim will be denied payment—and why
– Whether a patient encounter will require prior authorization before the date of service
– Whether new edits need to be incorporated into existing workflows based on payer responses and denials
But is now the right time for your organization to invest in AI for revenue cycle, or are there other, more foundational competencies your team should hone first? The best vendors keep a pulse on the industry’s newest innovations and partner with you in determining the right approach for your organization. They also help make the business case for innovation to senior leaders, when appropriate.
As Nebraska Medicine examines opportunities to leverage AI in revenue cycle, it has worked with a claims analytics vendor to assess how payer behavior affects revenue, both in the short term and long term. At a time when the nation’s biggest health plans vary greatly in their time to payment, instant access to payment trends by individual payers empowers Nebraska Medicine to have more candid conversations with payers around performance. It also strengthens Nebraska Medicine’s contract negotiating power.
“We want to make sure we’re not at the bottom of the pile when it comes to our relationships with payers,” Danielson says. “If we are, we need to be able to dive into the specific issues that need to be fixed to improve performance.”
4. View your vendor as a strategic ally
Sometimes, you don’t know what you need until you see it. Other times, the pain points you’re sure to require dedicated focus turn out to be pebble-sized problems, not boulders. The key to finding a true partner in innovation is to actively seek a vendor that demonstrates not just a superior level of service, but also a strong willingness to listen to clients and share candid feedback.
For example, senior leaders at Nebraska Medicine once asked revenue cycle leaders to uncover what they viewed as “skyrocketing denials rate.” Danielson partnered with the health system’s claims analytics vendor to drill down, by payer, into first-pass denial rates, partial denial rates, and more to provide a complete picture of denials status. These efforts showed one payer’s clean claim rate was 10 points lower than that of its peers.
However, the payer did not account for significant patient volume, translating to a small impact on revenue cycle performance. Nebraska Medicine determined it could make a bigger difference in lowering denial rates by focusing on the organization’s largest payer—avoiding a complete overhaul to the revenue cycle team’s payer relations approach.
Creating an Innovation Mindset
The bar for revenue cycle performance is rising, especially with continued dips in reimbursement rates, an uptick in challenges to claim payment, and an environment where consumers are the new payer. Moving past the traditional mindset of what a vendor relationship should look like toward an innovation mindset enables leaders to more fully benefit from a vendor’s subject matter expertise and accelerates gains in performance.
About Eric NilssonEric Nilsson joined The SSI Group, LLC (SSI) as the Chief Technology Officer to lead SSI’s long-term technology vision. He brings nearly 30 years of experience in the software industry with the last 10 in healthcare technology. Prior to joining SSI, he served as the chief technology officer at Nextech and Surgical Information Systems (SIS), where he focused on SaaS, on-premise EMR and practice management solutions as well as inpatient and ambulatory surgery providers from large hospital networks to surgery centers.