How many times during the silence of the night do we come up with the best solution to a problem we've been dealing with all day, or remember that we forgot to return that one call.

Healthcare is a very hectic, complex environment, so we recently asked one of Georgia's Patient Accounts Directors to give us his feedback on his "sleepless nights."

David Torrento is the Director Patient Accounts, St. Joseph's Hospital, Atlanta, Georgia, a 346-bed, tertiary care hospital, recognized as one of the leading acute-care, specialty-referral hospitals in the Southeast.

"What keeps you up at night?"

Actually I don't have any trouble sleeping at night. My days start very early in the morning, usually around 5 am. I play basketball and work out at my health club every weekday from 5:30 am to 7:30 am. I then head to the hospital for an intense and exhaustive 10 - 12 hour business day in revenue cycle management. By 9 pm … I have no problem sleeping.

What are the top 3 issues you find in managing the department?

The three major challenges I face in managing my scope of revenue cycle management responsibilities include;

• Managing cross-departmental issues related to overall "clinical delivery of care" and the actual "reimbursement and collections" on the generated revenue for services provided.
• Our medical facility is currently experiencing strong patient volumes and associated revenues. However, there is an enormous opportunity for us to increase operating margins by improving case management and enhancing revenue cycle operations through education, multi-disciplinary partnerships, and continual promotion of global ownership in the management of the hospital's revenue cycle operations throughout the organization.
• With ongoing expansion of managed care in the Atlanta area, the volume of contracted service plans and the associated complexities of various payment methodologies taxes the limited resources of the business office department. Continual education, orientation, and associate awareness of government regulations, third-party contract provisions, and compliance, is an ongoing challenge and critical element in the successful management of our accounts receivable.
  • The hospital is facing increased challenges in accurate and timely third-party reimbursement from non-government and government payers due to increase in payer contract administration. This would include;
  • Timely and accurate identification and verification of patient eligibility from payer prior to or at the time of service;
  • Obtaining confirmation and guarantee on pre-certification / pre-authorization at the time of service,
  • Contract administration and interpretation between payer and provider,
  • prompt payment from payer in accord with contract provisions and those stipulated under Georgia Prompt Payment Law, regardless of insurance plan ( self insured or otherwise ),
  • Government and non-government payer reliance on the hospital to be the "intake gatekeeper" regarding restrictions on medical necessity and associated enforcement and penalties are directed primarily at hospitals.

Given the theory that "Cash is King" what do you see as obstacles with your cash flow?

Our current major obstacle in "hospital cash flow" is the challenge we are facing in balancing the type of service offerings we provide to fulfill our mission and community-care objectives while at the same time addressing the appropriate management of those services to ensure that reimbursement covers the cost of our initiatives.

In an attempt to offer as many medical-care programs and services to fulfill our commitment to the patients in our community, revenue is generated, and there is an associated cost in the creation of that revenue. However, it does not always translate into reimbursement or as the theory implies "cash".

Therefore, attention should always be to have ALL areas of the organization take ownership in revenue cycle management as patient registration, utilization review, case management, nursing services, ancillary departments, medical records, manage care - administration, and the business office can have a profound impact on the actual success the organization has on cash flow.

Do you feel you have been successful in improving your cash flow over the past 12 months? Give specific examples, if possible.

Yes.

Over the past 2 years, there has been significant opportunity for us to improve on our organization's revenue cycle operations. Due to a complex computer conversion 2 years ago …our average days in accounts receivable increased from the increased three-fold and cash flow was extremely restricted. After working diligently on process improvements throughout our revenue cycle operation, we have been able to reduce the average days in outstanding AR to 63.9 as of May 2002.

Our internal action plan to address accounts receivable and cash flow included the establishment of a "revenue cycle management task force" that unified our administration, clinical, information services, and finance divisions.

Together, our organization addressed the traditional AR indicators that affect accounts receivable; discharge not final billed, coding, clean claim via electronic transmission, accounts receivable aging by payer, etc., as well as the incorporation of new programs to monitor denial management of claims (underpayments and denials), contracted vendor quality assurance programs, and internal Q.A. reviews on patient registration and patient care management with respect to pre-certification and pre-authorization of services.

All areas of our revenue cycle were assigned "best practice AR performance indicators" and progress was monitored on a weekly basis. Areas needing immediate attention were given high focus and action was taken without delay.

Our internal quality assurance programs resulted in a number of operational changes, however, the most significant contribution to our improvement in AR and cash flow can be attributed to the implementation of Care Medic to handle the submission of our hospital Medicare claims (representing approximately 50 percent of our patient mix). Another benefit of the change to Care Medic was the installation of the "accelerated secondary payer application" that allowed our business office to file secondary claims to Medicare on the same day we received acknowledgement from Medicare that the primary claim was accepted for payment. In addition, we elected to install the Care Medic "Local Medical Review Policy application" to monitor compliance for medical necessity at all patient access service areas.

Other areas and programs that have had a major impact on our cash flow include the improved management of our coding process and DNFB by our medical records department and the support and cooperation they have received by our medical staff. Also, open communication and feedback on denial management issues between our business office and patient access, patient care management, and Synergy (managed care corporation) has reduced the incidence of unnecessary claim denials with managed care payers.

Hospitals basically have two sets of customers, the physician and the patient. Which customer do you feel takes more of your time? Why?

Actually, at Saint Joseph's Hospital of Atlanta, the business office as well as ALL associates within our organization define our customers as any individual that an employee interacts with at all times, both in and outside the workplace; including patients and their families, visitors, physicians, co-workers, volunteers, vendors, payors, other health-care facilities, government agencies, accreditation bodies and others.

Therefore, to answer the question, I believe if the customer is handled appropriately the first time in granting requests, resolving concerns, and addressing needs, the time dedicated to the process becomes a valuable investment in time-management as follow-up requests and unpleasant feedback can be minimized.

Do you feel staffing issues is still a problem in the Patient Accounting Department?

Yes.

Although I believe my organization has been supportive in providing the necessary resources to manage the business office assigned patient accounting functions, the number of associates is no longer our greatest concern when attempting to achieve operational goals and objectives. It is the skill set or the "type of candidate" we are empowering to perform the revenue cycle duties assigned.

Saint Joseph's Hospital - Atlanta has over 130 individual managed-care contracts outlined with complicated legal language, in addition to complex government regulations, compliance, multiple coding methods, carve-outs, and fee schedules, etc., the revenue cycle registrar, biller, collector, and other support associates require a high degree of specialized knowledge that in many cases cannot be recruited with low entry level pay scales.

Do you have productivity standards in place to measure the success of your staff and the department? Give examples of measurements.

Yes.

We have quality and productivity standards that measure both individual and departmental performance. For example, as a department, we generally focus on traditional revenue cycle performance indicators;

Average Net Days in Accounts Receivable,
Cash Collections by Week and Month,
Percent of Net Collections to Net Revenue,
Discharge Not Final Billed,
Bill Hold by Category,
Clean Claim Percentage ( UB92 & 1500 ),
Aging Accounts Receivable by Payer or Financial Class,
Bad Debt / Charity Care Percentage of Gross Revenue
Denial Management by Reason Code,
Credit Balances, etc.

Each of the aforementioned revenue cycle indicators are assigned an " industry best practice" standard of which our internal goals and objectives are defined. My obvious favorite for the month of April was average net days in AR; Goal for our organization was 65 …. actual for the month 64.3.

As for individual standards, we measure the success of ALL of our patient access and business office associates via weekly quality reviews and productivity assessments. Patient access and patient accounting managers are required to perform weekly quality assurance (data accuracy, integrity, and account documentation) and productivity reviews (number of accounts registered, verified, billed, contacted, resolved) on a sample of accounts by assigned associate.

Any Q.A. or productivity deficiency requires coaching and further reviews until such time the associate can reach the targeted standard established by management. All quality assurance and productivity standards are outlined in the associates job description and has a direct correlation to the associate's probationary and annual performance evaluation and any merit or bonus increases that the associate may be eligible to receive.

Have you or your staff attended PFS Forums this past year? If so, did your find them helpful?

Yes;

In an attempt to encourage my assigned associates to pursue continual education, we attempt to provide an opportunity for them to attend and participate in internal and external workshops, forums, and other career development programs.
The greatest resource I can personally control is my staff that I currently have.

An overlooked reason behind the success of Saint Joseph's Hospital - Atlanta business office has been the retention, stability, and professional growth of the staff. We have invested a great deal of time in working together to address the daily challenges facing our organization and the strength of our organization is through our dedicated associates. Over the past 24 months, 20 members of the business office team have become Certified Patient Account Representatives and we have had close to zero turnover over the past 12 months.

Jim Phillips, author, is the Vice President, East Region for Integrated Revenue Management, Inc Integrated Revenue Management, Inc. is headquartered in Carlsbad, California.