Revenue Cycle Leaders’ Top 3 Focuses for 2020 Within Healthcare

Jerica Hopkins: Welcome everyone and I hope you’re all having a successful 2020 thus far. This is Jerica Hopkins with HBI and I’m excited to have you join us for this month’s webinar given by HBI: Mitigating Denials, Engaging Staff, and Advancing Automation – An Overview of Revenue Cycle Leaders’ Top Focuses for 2020.


Dial-in information is provided on slide 2 and the special note here. We have a lot of topics and information we want to get through with you, with the goal of helping you confirm or supplement your strategic plans for the year. So, we’ll be doing some polling today but ask that you send any questions directly to the research team. here to continue


We will provide our email addresses at the end, and you can get in touch with us directly, or of course with your HBI representative. We encourage you to reach out and ask questions any day of the year, really make use of our Analyst Advisory service, where you can request research on any revenue cycle topic from our team at any time, and that’s included with membership. If you should need assistance at any point during this webinar, please call our client services team at 888.700.5223 for personal attention. And as you know, this program is being recorded. Also, as we always do, webinar materials will be sent to all registered attendees following the conference within about a day’s time. These slides will also be available with playback on our site in less than a week.


We’re going to go through the preliminary results of our state of the industry survey, so I hope you’ve had some time to participate. If not, please do fill out the link provided at the end of the presentation and you’ll be able to compare your areas of focus and level of advancement with the rest of the membership community. We will also share insights on what proved to be the top areas of concern for 2020: denials, staff, automation, and as honorable mention, price transparency.


These are who you’ll be hearing from today and who you can reach out to you with questions. We will provide our emails at the end of the presentation. Beth Reed is going to kick us off with some data. She is our resident data and Revenue Cycle Scorecard guru. Selby Rodriguez will share her insights into staff engagement and development, a topic that is near and dear to her as a remote worker. I will talk about the state of automation and AI in the revenue cycle. Kelli will discuss her true area of expertise: price transparency.


All of these fine ladies have given presentations on these and other pervasive topics across the country. So, let’s go ahead and jump into it, and Beth start us off with that data.


Beth Reed: Thanks so much, Jerica. As Jerica mentioned, these are the results from our 2020 state of the industry survey. Many of the questions are similar to ones we either asked last year in 2019, or in other surveys in the past. When available, I’m going to be showing you a comparison to past results so that we can start to provide some insights into the trends in the industry.


Here we’re taking a look at the average importance that was applied to revenue cycle initiatives in preparation for 2020. You can see there’s a ranking down the side and then the average importance score on the right-hand side of that table, 1 is least important and 10 is most important. As a group you all ranked denial management and prevention number one in importance for 2020, with an average score of 8.4. And that’s not surprising. We actually left denial management and prevention off the 2019 survey knowing that it is perennially a major area of focus for revenue cycle leaders. We did want to gut check ourselves this year, so we included it back in, and are not surprised to see it at the top of the list.


Going down, we have staff satisfaction and engagement ranking at number 2, a three-way tie for third place for automation, price transparency, and measuring and improving the patient experience, followed up by revenue integrity, payer relations and accountability, reducing compliance risk, professional revenue cycle oversight, case management and utilization review, point-of-service collections, patient recruitment and retention, vendor optimization, patient-facing technology, AI, and at the bottom, outsourcing and insourcing strategy, with a score of 6.3.


Comparing these to the 2019 results, staff satisfaction moved up on the list of priorities. Back in 2019 we had this topic area split into two initiatives: hiring and engaging new talent, and flex and remote scheduling for staff. Based on our research, those were two primary areas of focus for revenue cycle members looking at how to improve their staff satisfaction. Back in 2019 those two initiatives rank down at number 8 and number 13, and now we’re all the way up at number 2 for the year. That’s really not surprising, because taking a look at our ad hoc questions that you’ve been asking us throughout the past year, team structures were the most common topic for those questions, and staff management overall with number 3.


Another trend compared to 2019, AI and automation diverged. Last year, we asked a combined category of AI and automation, and that scored pretty low, which was surprising to us. But this year we broke them into two areas, and we realized the reason that it had been lower in 2019 is that many folks are not yet implementing AI, but automation is very prevalent. So, you can see automation moved all the way up to be tied for number 3, while AI is still pretty low on the table down at number 15.


Professional revenue cycle is a growing priority compared to last year. It’s moved up the list a little bit, and we’ll see in an org chart in just a couple of moments how ownership of professional revenue cycle is growing.


And then another trend, case management and utilization review, and revenue integrity both dropped down a little bit on the list. The org chart that I’ll be showing you in just a moment does show that it’s less prevalent now for those areas to report to revenue cycle than it has been in past years. But we do know this is still a common area of focus for you all, based on the questions that you were sending in last year.


Let’s go ahead to the next slide and we’ll take a look at some of the areas that are reporting to the revenue cycle, and I’m going to open our first poll for the day, which is taking a look at whether project management also reports to revenue cycle. You can see that’s not something that we’ve already included in the table here. So, we’d like to gather some data today on whether your organization has a project management team or department centralized under the revenue cycle. The options here are: yes, we do; no, we do not; we plan to in 2020; or we’re unsure.


As you’re entering your answers in the pane on the right-hand side of your screen, let’s take a look at the results from the pre-webinar survey. Case management and UR has dropped in terms of reporting to the revenue cycle from past years. We asked a question on this back in 2016, case management about 46% of the time reported to revenue cycle back then. And you can see here that it’s down closer to 10%. A similar trend with UR, back in 2016 about 60% of respondents had UR reporting to the revenue cycle. Now, it’s closer to 17%.


We see that it’s much more common now for vendor management to report to the revenue cycle. That was down at about 36% in 2016, and now it’s up at 61%. Payer credentialing, more common now to report to the revenue cycle. It was at 16% in the past. Now, is that about 24% managed care, previously about 32% of respondents had that reporting to the revenue cycle. That’s gone down a little bit, and we split that here into hospital contracting and physician/medical group contracting, but they’re both in about 20s.


It’s less common now for compliance and legal to report to the revenue cycle. But it’s more common for physician/medical group areas to report. You can see that about 15% of organizations have physician/medical group patient access organized under the revenue cycle. Mid-cycle, about 39%, and the business office about 54%, which is interesting because it looks like we’re integrating with the professional revenue cycle from the back forward. Whereas patient access has some of the greatest likelihood to prompt denials, which is something we’ll get into in a little more detail later in the presentation today.


In terms of some flat trends from back when we asked this in 2016, it’s about as common as it was then for clinical denials to report the revenue cycle. Same for data analytics and same for IT.


Going on to the next slide, as we’re integrating hospital and professional revenue cycle, it’s also not surprising to see that the back end is the most common area for combined roles, where a single staff member handles both the hospital side of an account and the professional side. You can see that the top three results here—self-pay collections, cash posting, and customer service—all fall in the business office.


There has been a lot of interest in the past year in single-path coding, where a single coder codes both the hospital and professional charges, and also some interest in a similarly combined denial team, where one appeal staff member will handle both sides of the claim. This makes sense because once you’ve built that expertise in your staff member, you’re improving efficiency and you’re integrating those roles, it streamlines the reporting structure.


As we go on to the next slide, you can see that there are a lot of other ways you all have been looking to improve efficiency in the past year. One of them is by offering patients self-service options. This has a two-fold effect. First, it improves your patient experience because they’re able to take a greater role in their own healthcare, but it’s also taking some of the burden of these processes off your own staff members and improving your internal efficiency. Appointment text reminders are the most common patient self-service option you all are offering, about 66.7% of you are offering this. Followed by billing text reminders, paperless billing, online scheduling, all the way down to patient feedback app at bottom.


Compared to when we asked this in 2019, appointment text reminders stayed the most popular option. It was at the top of the list last year, about 61% of respondents offered it. So, a little bit more of you are offering it this year, but it’s still number one. Billing text reminders boomed, they really moved up the list. Last year only about 23% of you were offering those, and now it’s up to 64%, which isn’t surprising, since appointment text reminders have stayed the most common. This is obviously a proven and effective strategy that’s now being expanded into other areas.


This also speaks to the importance of meeting patients where they are in order to collect. You can see that paperless billing is also very common. There’s a large appetite for online bill pay. Mobile billing is relatively prevalent, 42% of you are offering this, and then self-service payment plans, about 38% if you are offering this as well.


Compared to 2019, a couple of things have stayed the same. Live-chat adoption is still pretty low, interest is growing a little bit. Last year only 8% offered live chat. Now it’s up to about 18%, but you can see it’s still low on the list. Same with patient feedback apps. A few more of you last year offered this. It’s dropped down a bit, 20% compared to 14.5%. But the adoption of a lot of self-service features stayed really stable. Compared to last year adoption was pretty flat for paperless billing, online scheduling, online pre-reg, some of those self-service functions that are a lot more established in the revenue cycle at this point.


Now we’re going to take a look at some of the industry pressures that we asked about during the state of the industry survey. First, I’ll point your attention toward the organizations adjusting eligibility parameters for financial assistance in the past two years. You can see that half of you actually expanded your eligibility parameters, and a few of you, 3.3%, tightened. The remaining roughly 47% did not adjust your parameters at all in that two-year period.


And we were not surprised to see the eligibility parameters were expanded. The Kaiser Family Foundation in its 2019 employer health benefits survey found that the average deductible for covered workers has doubled in the past 10 years. About 28% of covered workers now owe a deductible of at least $2,000. Similarly, about 66% also owe coinsurance. Among workers who have an out-of-pocket maximum included in their plan, 20% have a maximum of at least $6,000. So as the portion that patients are being asked to pay for their healthcare grows, it’s not surprising to see that we’re making it easier for patients to access their financial assistance and expanding the eligibility parameters for doing so.


We also asked about non-fee-for-service contracts and the prevalence of those. So, the percentage of organizations contracts that are value-, quality-, or risk-based, you can see that the majority, about 38%, have 5% or less of their contracts in a non-fee-for-service structure. About 24% have 6% to 15% of their contracts in non-fee-for-service, 27.8% have about 16% to 30%, and 10% roughly of you have more than 50% of your contracts in a non-fee-for-service structure.


This is really interesting because we asked the exact same question last year with the exact same response options. This shows that there’s been the most growth in the category of 16% to 30% of contracts being fee-for-service. That one segment increased more than 100% over last year. The percentage of you all having more than 50% of your contracts be non-fee-for-service also increased significantly. That one is up by 66%. And the categories for 0% to 5%, and 6% to 15%, those contracted. So, this is showing that in the past year, the percentage of your contracts that are based on non-fee-for-service structures have really grown.


But in talking with revenue cycle execs over the past couple of months, it seems that value-based care is still a bit of an unproven quantity in the industry. They’re saying that some of the revenue cycle costs have actually increased in order to comply. Maybe they’re having to hire new coders and staff up in order to be able to track more quality metrics. And the promised increase in quality, while it has ticked up a bit, the perspective that has been shared with us from some revenue cycle executives is that it has not yet delivered on the promises that were made for value-based care.


Taking a look now at organizations’ perspectives on whether the entry of payers and retail companies into the healthcare provider market has affected reimbursement, and here we’re talking about things like Amazon, Aetna, and CVS beginning to also offer healthcare to their employees, 4.8% of you say that this has affected reimbursement, but a lot of you are unsure. That also mirrors what we’re hearing from execs during some of our Q&As in the past year. They were split on whether these industry entries will have staying power, and they’re unsure how they should adapt knowing that these players could just as easily exit the market.


Also taking a look at your perspectives on whether the availability of competing telemedicine options have reduced primary care patient retention, a very slim sliver of you said yes, 2.6%, but nearly half of you were unsure. And as we’ll look to the next slide, this is especially interesting because telehealth is the area that you all are expanding into the most, about 30% of you have added telehealth in the past year. Your expansions into the market are also driven by patient demand and needing to compete with those non-traditional providers, such as shifting to outpatient. You can see that urgent care, retail clinics, free-standing imaging, and free-standing EDs were all pretty popular options for expansion.


And there’s another trend driving expansion here as well, and I link that back to the aging population. MedPAC predicted that Medicare enrollment would increase about 62% from 2013 to 2030. By 2030, we’ll have 81 million Medicare enrollees. In the short-term, those Medicare enrollees will be a little bit younger than Medicare enrollees have been lately, as that Boomer cohort is aging, more of those Medicare patients are going to fall into the 65- to 74-year-old range rather than older. Now you can see that home health, hospice, and durable medical equipment are all areas that are being targeted for revenue cycle expansion as well.


We’ll just take a quick look through these next few slides. We also asked about vendor usage in the state of the industry survey. We get a lot of questions from you all on which vendors your peers are using, and while HBI does not endorse or support any particular vendor or project, we are aware that interest is always high and we do want to give you some insight into A, who is using vendors, and B, which vendors they’re using. One interesting caveat that I’ll note right up front is that for most of these vendors that we were asking about, one of the potential responses was to indicate it was the same as your EHR. And we found in analyzing that, that it’s very common for Epic users to stay within the Epic universe rather than using other vendor products. That could mean that they’re using an Epic bolt-on for some of these services, or it could just indicate that the existing Epic suite right now is sufficient to meet their needs in these areas.


So, looking quickly through these results, about 98% of organizations use a real-time eligibility vendor. Experian is the most common vendor, followed by Passport and Change Healthcare. About 89% use a vendor for estimation. Epic is the most common, followed by Experian. 73% of organizations use a vendor for pre-auths, Epic again is the most common, followed by Experian and Recondo. Very split on presumptive charity, exactly 50% use a vendor, 50% do not. Among those using a presumptive charity vendor, Experian the most common, followed by Epic. 51.5% of organizations use a propensity-to-pay vendor. Experian is the most common, followed by Epic and then TransUnion. 90.9% of organizations use a billing vendor. Epic is the most common, followed by Change Healthcare and nThrive.


84.8% of organizations use a collections vendor. Many organizations reported that it was the same as their EHR vendor, so you can see Epic is the most common. If a non-EHR vendor were listed, the responses were varied. 68.6% of organizations use a patient financing vendor. Epic is the most common, followed by a local bank. 81.1% use a denial management vendor. Epic again the most common, followed by nThrive and Cerner. 100% of organizations use a statement vendor. Epic is the most common, followed by RevSpring, and then Apex and Change Healthcare were tied. 87.9% of organizations use a charge capture vendor. Epic is the most common, followed by Cerner and 3M. 54.4% use a chargemaster maintenance vendor. Craneware is the most common, followed by Epic and nThrive.


93.5% of organizations use an encoding vendor. The most common vendors were 3M and Optum360. 68.4% use a population health vendor. Again, many organizations reported it was the same as their EHR. Epic was the most common, followed by Cerner. 86.2% use a CDI vendor. 3M is the most common, followed by Optum360. And 96.9% use a patient engagement vendor, but you can see here that it’s mostly limited to surveying. Press Ganey is by far the most common, 80.6% of organizations using a patient engagement vendor use Press Ganey. And NRC Picker is the next most common.


But we can see on the next slide that 22% of you intend to use a non-Press Ganey survey in 2020 as one of your ways to improve the non-clinical patient experience, to improve patient engagement. There’s also an emphasis on staff training. You can see that point-of-service collections training and other revenue cycle training are the most common here. There’s a double benefit there, because if you’re investing in your staff, you’re building their skills and their confidence, you’re improving your staff satisfaction, while also improving the patient experience. And as we remember, staff satisfaction was the second most important priority for you all in the coming year.


There’s also an emphasis here on getting information from patients directly and actually seeing the experience through the patient perspective. Call monitoring is a very common area of focus for you in the next year, and you’re also looking to conduct more surveys, social listening, and secret shopping.


Next, we’re going to take a look at some initial denial trends from another HBI analysis that we’ve gone through. We worked with our analytics team here at HBI to analyze their real-world data set. We look at roughly 747 million remits, which represented more than 1.6 billion charge lines from 2017 and 2018 to reveal initial denial trends. This data is really just looking at initial denials. We’re not looking at anything that was appealed and denied again. We’re looking at things that were just first remit, that the payer has denied. This includes all payers. And we also use a proprietary mapping to CARCs to organize root cause categories and I’ll show you that on the next slide in just a moment.


What I want to show you here on this side first is the initially denied line items by place of service. In 2017 and 2018, we found that about 11% of billed line items were denied. And again, we’re looking at just denial CARCs. We’re not looking at patient responsibility. We’re not looking at contractual allowances. We are just looking at actual denial root causes. We also split that by place of service. We looked at office and hospital outpatient, we looked at hospital inpatient, and we looked at ED. In both years we found that the ED is the most common area to have an initial denial. Number 2 was hospital inpatient for both years, number 3 office and hospital outpatient.


Here’s the CARC mapping that I promised. What we’re looking at here is the name of our internal denial root cause category, as well as the most common CARC in each of those categories so that you can get a sense of how you compare. We have billing error, coding error, coordination of benefits, credentialing, documentation needed, eligibility, level of care, medical necessity, non-covered, pre-authorization, registration, timely filing, and other. And here are our results. Here we’re looking at just the initial denial universe. Of all the actual initial denials we found in that data set, here’s how they break down into each of those categories.


All of those numbers you see for ED, those are going to add up to 100% because it’s 100% of those initial denials. We found that across the board non-covered was the most common initial denial category. Documentation needed was also very prevalent, followed by billing error. I’ll give you just a minute to look this over, look for that root cause category that’s most important at your organization.


Now on the next slide, we’re going to take a look at how these trends have changed year over year. So, anything where you see a red up arrow, that means that the prevalence increased. A green down arrow, the prevalence decreased. Looking at the same initial denial universe here, now we’re looking at both 2018 and 2017. We’re looking at the same service setting. Some of the trends that I’ll pull out for you here. The positive trend, medical necessity, level of care, coordination of benefits, and timely filing denials decreased in all service settings, which is really great to see. Because we know from the AA questions that you’ve been asking us over the past year, all those ad hoc research requests you’ve been sending in, those have been really strong areas of focus for you. And this shows that the work you’ve been doing is paying off.


Next, I’ll point out the downward trend in registration errors. This looks like really strong performance. But I do want to point out that the sample for registration category was so small to begin with, any fluctuation was going to appear dramatic. It’s not really a statistically relevant result.


Next, I’ll point out that documentation needed and non-covered initial denials increase in all categories. So, we’re trending in a negative direction here. Jerica is going to give some more information later in the presentation about the most common areas for AI in 2020, but I’ll just point out now that pre-authorizations are one area that AI is being explored for in 2020, about 25% of you are looking at pre-auths as an opportunity for AI. About 19% of you are looking at CDI as an opportunity. Both of those could help reduce this trend of increasing documentation needed and non-covered denials.  So, it looks like you’re already aware of this, suspecting that this is a trend, and looking for ways to combat it.


Last, I’ll point out a couple of interesting points for inpatient hospital. You can see that inpatient coding increased pretty significantly compared to the other areas. That went up almost 33%. Inpatient hospital denials in the “other” category also increased significantly, about 59%. And I’ll highlight these just to show that you always want to have the opportunity for deeper analysis. If we were looking at one hospital’s denials here, and we found these trends, we would absolutely dive into the processes in place, what CARCs are being mapped into that “other” category, whether there are certain payers that are involved in driving these trends, for coding whether there are certain procedures, maybe new service lines, and really try to narrow in on what is driving those initial denials.


But we’re going to stay pretty high level here today and we’ll take a look at some of the risks and common factors of increasing initial denials. Anytime you see your initial denials increase, you’re risking a higher cost to collect, and it’s actually a double effect, because as your costs go up and your collections go down, that’s going to doubly effect your cost to collect. You’re also risking increased denial write-offs, patient dissatisfaction due to billing delays, waiting for that self-pay bill to drop, and of course increased A/R days and aging.


If your initial denials are increasing, some possible driving factors could be improperly loaded contracts in your contract management system. You might look to payer relations issues, even just relations with individual representatives. Perhaps there was a really helpful representative at one payer who’s moved on, and your staff are no longer sure exactly who to reach out to. You would want to look for gaps in clinical documentation, unnecessary admissions, missing or incorrect pre-auth, coordination of benefits errors, ineffective insurance verification processes, and any late or missing charges that could be resulting in timely filing issues.


You might also want to take a look at your training and turnover. You can see that clinical and technical denials from 2017 to 2018, clinical initial denials became more prevalent from one year to the next. And we find that about 22% of initial denials in 2018 came from patient access focused areas. So that technical area is still just as important, even though it shrunk a little bit. Selby is going to show you a little bit more data on patient access turnover later in the presentation, and the churn that we’re seeing there does make it very hard to prevent these technical denials.


I won’t go into a lot of detail in this slide. These are some of the areas that we can provide case studies and resources to you. These are some strategies for acting on the initial denial trends that we pointed out. A lot of them do focus on the front end to prevent those technical denials, and if you’re interested in more detail, we have a full report diving into all of this information and the link is there for you to access it.


And at this point, I’m going to hand it over to Selby.


Selby Rodriguez: Thank you, Beth. I’m going to start my section with a question for everyone on the line today. Why is staff satisfaction and why is staff development such a priority, and such a priority right now? The reasons for this are going to, of course, vary depending on your individual healthcare organization, but I really wanted to emphasize what turnover means for revenue cycle, and what it means for the greater healthcare organization.


If you look at the annual revenue cycle turnover data on this slide, and compare it to the average monthly turnover across all industries reported by ADP, you might think that revenue cycle isn’t doing too poorly when it comes to engaging staff. However, as we all know, healthcare is complicated and when a hospital is operating on a 2% profit margin, the cost of finding, hiring, and training a replacement can quickly add up. How much money and how much time can an organization use to replace its revenue cycle team members? And how much cash flow is going to be impacted by having a short-staffed team? These are all things that we need to contend with in the revenue cycle.


You might also see on the graph here that patient access is having a little bit of a harder time holding down its staff. These staff are often your patients’ first interaction with the healthcare organization, meaning you want to make sure that you have people there who know what they’re doing and who can deliver a high degree of customer service in that role. Staff engagement is going to be a key piece in keeping your most valuable talent at the organization, and for patient access specifically, it means that your patients are interacting with your best talent as well.


Given today’s time limit, I wanted to break down strategies into two camps. That is, training your front-line staff, and educating your managers. If you think about it holistically, staff engagement all comes down to your culture. And unfortunately, the revenue cycle’s culture has not always been one that fosters a true sense of loyalty among its front-line team members, and this culture seemed to be a challenge for many of you in the HBI membership community last year. Some questions that we received were how to engage staff in ongoing training and development, how to structure separate revenue cycle training departments, both in terms of staffing and processes, how to reinvigorate quality audit processes. My personal favorite is how to engage millennials, and also how to engage older generations of staff. And then of course, we need to prove the ROI of all of these.


Let’s move on to some best practices for just training your front-line staff. Another question here, I’m big on questions. These are all rhetorical, but please bear with me, think about them. This question is, what percentage of your front-line staff do you think could explain every piece of the revenue cycle? And what percentage of your staff could explain their role in that revenue cycle, and how that role impacts others downstream? If that percentage is on the lower end, there is a problem and that problem is what the first best practice on this slide—holistic revenue cycle education—is all about.


This can take a variety of forms. We’ve seen leaders coordinate field trips for staff to physically visit every single revenue cycle department. It should also be part of any new hire onboarding orientation, so that you’re not just showing staff how to do their job, but why they’re doing their job. HBI additionally has some training here as well. It’s really important to just show staff their overall importance.


The next best practice then is soft skills training, or really customer service training. Here you want to emphasize your patients, and how much your staff impacts patients. Adding in a component of how to interact with colleagues can also go a long way toward building a better work environment overall. Performance transparency is a little more self-explanatory. It’s all about providing staff feedback on their quality, their productivity, and other needed coaching on a regular basis, rather than storing that information for an annual review. The closer to real time that that feedback can be provided, the better.


I saved gamification for last then, because while it is one of the more exciting strategies for staff, our surveys indicate that it’s still not common for gamification to be part of training at many organizations, and that really is a shame. When I say gamification, what I’m referring to is taking elements of typical board games, online or TV shows like “Jeopardy!”, and applying those concepts to different things that you want your staff to learn. That could be as simple as creating a trivia game about KPIs or your current performance to convince staff to keep track of dashboards, and then giving them points for every correct question. We’ve also seen it get as big as kind of like a video game, where staff had an avatar, their collections were shown on a TV in the business office, and they were able to compete with each other in real time as they continue collections and performing other actions.


Let’s switch over to management. I wanted to start this piece with a quote for everyone and that quote is, “Leadership isn’t about demanding control anymore; those days are over. It’s about unpacking the personal motivations of your individual employees.” Now if anyone has seen me speak on this before, you’ve seen this before I love this quote. I include it in everything, and I think that it gets right to the core of what revenue cycle managers need to start thinking about when they’re thinking about how to develop their staff and how to create a culture where employees want to stay long term.


Technical or hard skills have been the emphasis for revenue cycle in the past and they’re still a very important piece of the puzzle, but staff need to see how the organization is invested in them, how the organization is invested in their progress, and how they will have a career if they stay at that organization. Managers are a direct reflection of the organization in this respect. They’re part of the leadership team, but they’re also a face that staff are seeing day in and day out.


That’s why I found the results at the bottom of this slide so interesting. HBI asked members to identify the top three most important qualities in a leader at their organizations back in 2018. Three of the top five qualities spoke more to those soft skills required to motivate workforces in today’s day and age. So, it is starting to take hold.


Thinking back to the quote on the other side, though. How many leaders today could tell me what the personal motivations of all the employees that report into you are? I’m guessing you know this for some, but it’s going to be important to encourage or maybe even require your front-line managers to know this for all of their staff. And one way to do that is to just tell them to talk to team members. Set up one-on-ones on a regular basis and use those one-on-ones as an opportunity to ask staff about their satisfaction and about their career aspirations.


That sounds small, but this small, simple thing is not happening at many businesses across the U.S., not just in hospitals. After holding these conversations, the manager should then look for ways that they can engage that employee. They could find shadowing opportunities. They could find committees for the employee to be part of. Or really anything else offered at the organization that speaks to that individual’s specific goals.


Following up after these conversations with actions demonstrates how much the organization is interested in its staff, how it wants their staff to be happy. It helps put the organization’s money where its mouth is for lack of better words. Personality assessments, soft skill workshops, and other training that emphasizes different communication styles or preferences can additionally go a long way toward broadening your manager skill sets, or even just how they choose to approach certain situations, again contributing to that culture.


And then, of course, emphasizing these softer skills and career ladders, leadership programs, and succession planning can be beneficial to getting everyone in the organization bought in and on board to furthering their emotional intelligence.


We’re actually going to pause really quickly here for a brief poll. Jerica is going to introduce that for you all.


Jerica Hopkins: Thank you, Selby. We’d like to share the results from our previous in-conference poll first. And as a reminder that question was, “Does your organization also have a project management team or department centralized under the revenue cycle?” 51% of attendees said yes, they do have a dedicated centralized project management team or department under the revenue cycle. 38% said no, 3% of attendees said they plan to have one in 2020, and 8% of attendees that they were unsure.


Our next polling question for today asks, “Does your organization specifically provide training on basic managerial skills for staff transitioning into leadership roles?” The options are yes, no, plan to within 12 months, and unsure. And as you fill out those answers, Selby will finish up her section.


Selby Rodriguez: Thank you, Jerica. I know that I’m kind of throwing a lot at everyone in a very short period of time, and I’m not actually even touching everything that there is to be included in training programs. For anyone on the line wondering how you might be able to design or deliver new training for your staff and management team, I really just want to emphasize that you don’t have to reinvent the wheel alone. We are here to help, and we can help you in a variety of ways.


You might notice that there is a photograph on the slide. That is not me. That is Noelle Wysocki, one of our very talented team members on the HBI Learning team. Noelle and her colleagues have actually been traveling the U.S. for the past 12 to 18 months to deliver training workshops geared toward addressing many of the challenges I touched on today, as well as others that HBI members have submitted to us in the form of questions. These workshops include one that is geared toward point-of-service collections that is meant to give staff confidence and really empower them to hold empathetic financial discussions with patients. Financial care is just as important as clinical care when it comes to the patient experience, and this workshop helps drive that concept home for your staff. Staff typically walk away from these workshops with more soft skills, and organizations typically see accelerated cash. That’s a nice plus.


We also have a customer service or a patient experience workshop. In order to deliver an excellent patient experience, you must deliver an exceptional employee experience. That’s the main point of everything that I just spoke about. You really cannot have one without the other and this workshop is about both. It provides staff the skills to further their own emotional intelligence, as well as gives them the tools to manage their roles and deliver great customer service during times of stress, high patient volumes, and more.


Our train the trainer workshop is then for trainers, managers, or individuals who are responsible for delivering education in healthcare organizations. It’s not uncommon for these individuals to have not been taught how to deliver impactful education with adult learning principles in mind. Rather, they’re just kind of thrown into the midst of it, as I feel like a lot of us on the line can identify. But just like all the other staff that we’ve been talking about today, trainers need to be given the right tools in order to be successful in their roles, and to make education in an organization effective, engaging, and measurable.


And then last but certainly not least, as part of the revenue cycle community you have direct access to Beth, myself, the other speakers today, and additional analysts here at HBI. You’ve likely seen our reports or articles come across your inbox, but you also have the ability to contact us directly and ask us questions. We love it when you do it. So, please take advantage of that offering.


That’s about everything I wanted to cover today, Jerica, so I’m going to go ahead and transition it over to you.


Jerica Hopkins: Thank you, Selby. And as she and Beth alluded to earlier, AI and automation have been one of the top areas of inquiry and innovation both in 2019 and for 2020. And this does actually feed into staff development and engagement, which you might not all think at first, but I’ll get into that a little bit more throughout my section.


On the next slide, we’ll go ahead and open the next poll and share the results of the poll that we did with Selby. As a reminder, that previous in-webinar poll was, “Does your organization specifically provide training on basic managerial skills for staff transitioning into leadership roles?” About 62% of attendees said yes, 22% of attendees said no, 4% of attendees said they plan to in the next 12 months, and 12% of the attendees said they were unsure.


Our next polling question asks, related to my section, “What barriers has your organization faced in implementing artificial intelligence solutions within the revenue cycle?” And here this is a select all that apply, so it’s not just one option. But if you run into any of these go ahead and click those. The answers here are: cost, trust in vendor technology, unclear return on investment, existing systems or IT limitations, lack of internal expertise, concerns about the effect on staff, or resistance from external partners, like vendors or payers. And, of course, an “other” option.


Let’s go ahead and share, while you’re filling out those responses, the prevalence of these technologies that we’re seeing. Artificial intelligence we’ve defined as the use of machine learning, natural language processing, statistical modeling, or a similar technology that can mimic human cognition and learn from past errors. Really overall, it’s not been increasing all that much from year to year in terms of the application in the revenue cycle. You can see that there’s a slightly bigger jump in 2020 than there was from 2018 to 2019.


There are a few reasons why AI might not have quite taken off yet. It’s a bit immature or unproven, most AI vendors are not really revenue cycle specific at this point, though it does seem as though they’re starting to partner with hospitals more and more. By and large leaders are holding out for their peers to show a road map or a return. Cost is obviously a factor here, with some leaders that we’ve spoken to getting quotes in the six figures, and we’ve heard leaders note that it doesn’t really feel that much more advanced than what robotic process automation offers now.


Vendors and payers, if not hospital operation leaders, are still resistant. Your organizations may be worried about the implications on staff, and some vendors have actually voiced opposition to AI for that very reason. Payers also have shown a reluctance to allow things like artificial screen scraping or portal access. Organizations that are piloting this now are running into issues with their current systems. There are sometimes interoperability issues, integration issues, security concerns. I would say that based on the organizations we’ve talked to, it does seem like they’re figuring them out. But often that’s with some external help.


Many organizations, for a lot of these reasons, are turning first to automation and using that as a way to optimize technology, get their feet wet, test out some new vendor relationships, and use this as a stepping stone for potential AI in the future. And as you can see here, there is some overlap in terms of what people are automating and implementing or planning to apply AI to. In terms of automation, the top three functions are insurance verification or eligibility at 54.5% of organizations. Payment posting came in second at 50.9%, and claims submission is a close third at 50% even.


Already implemented AI is in basically those same areas, and the percentages here are about as we expected, fairly low compared to the other categories, but 12.7% was the highest percentage here, and that was AI for insurance follow-up. 11.8% of organizations have been applying AI for claim statusing, and at about 9% each there’s a tie for third among AI in coding and CDI separately.


Now the percentages for planning AI in 2020 are much higher, so perhaps this will be a big year for these technologies. So far, we’re seeing that 26.4% of you are planning to apply AI to price estimation, 24.5% are planning AI for pre-authorizations, and productivity monitoring came in second at 20.9%, with presumptive charity on its heels with an even 20%.


As I mentioned, the general consensus is that it makes more sense to advance automation before employing AI, and there are some quotes here from leaders that we’ve spoken to about this. Overall the sentiment is that RPA, robotic process automation, is more cost-effective, it’s easier to implement, and it’s a way to walk before you run. It’s a way to build stuff culture around technology, a way to develop governance and protocols around technological innovation, build some knowledge and expertise, and it should help you go through the process of identifying where these technologies can and should be applied, and prioritize them.


An interesting quote at the bottom here I wanted to pull out, “Management is more fearful of this than staff are.” Ultimately, management is going to be beholden to the cost spent and the return realized for one, but there may be a fear in what staff will think. Of the organizations implementing technologies like AI and RPA, the general advice that they give is, as long as you communicate early and well, your staff are actually going to love this. If they understand that it will take the extremely mundane, repetitive manual tasks off their plate so they can either build more expertise or better utilize their expertise elsewhere, their role is going to grow more enriched. They will not only be on board, but they’ll be advocates in helping you find the next place for implementation.


So, what are some of the use cases?  We have several, and in all cases the goal has not been to actually reduce FTEs—as in, see those employees to the door—but reduce FTEs spent on meaningless touches, and reallocate their time to learning a new payer, or handling a new service line, or a new task. What’s keeping leaders up at night is that they’re continuing to be asked to do more. There are more functions. There are more service lines. There’s more volume that’s coming under your revenue cycle, but you’re not exactly able to add new positions.


Here are some examples of some of the results we’ve seen, and once you receive these slides you’ll be able to click to see the bigger case studies and the details with those. In using robotic process automation for claims statusing, OhioHealth saved the time of six FTEs on the hospital side and was slated to save 10 more in other settings. Ultimately work queues were reduced by about 25% on the hospital side.


Michigan Medicine is starting simple and working through a process where RPA can identify where there is a secondary EOB claim that needs to be printed and mailed. They have one person who has been doing this manually on the hospital side, and as many as three FTEs on the physician side of the business.


As far as AI, INTEGRIS Health uses machine learning to evaluate charts before CDI specialists. It reviews elements of what’s been documented in the medical record. It determines what a live person should review based on the opportunity and dollar impact, and it prioritizes worklists as such. It was actually able to increase its team impact by nearly $3 million.


So, as you think about where to implement advanced automation and eventually AI in your own organizations, I wanted to share some key considerations. Starting with RPA first, one of the organizations I mentioned on the previous slide did a revenue cycle-wide engagement where all department directors got in a room and they were educated on what RPA is, how it works, and were asked to brainstorm possible applications. This was done with the VP of revenue cycle and led by project managers both on the operations and IT side. This group then worked on narrowing down suggestions based on their ease of implementation, expected results or savings, and other factors. Directors will be asked to visually outline the process steps of the narrowed down tasks, and from this they will move forward on the top three proof of concepts.


This organization was not alone and emphasized again that it communicated with staff about the organization’s intentions to further automate processes. They knew someone would tell someone else, and there would be rumors and that would breed the “am I going to lose my job?” anxiety. So they made a point to explain their goals surrounding it, which was that they knew staff are being asked to continually do more, that worklists are growing longer, the organization is absorbing more services and facilities, and this is what RPA is and how it will benefit you, and it’s going to really help you apply your skills and expertise to more meaningful work.


Other than that, again, start simple, but build incrementally. It’s important to start with a process that is based on simple options. If X, then Y. If not X, then Z. Even then you’ll have to consider a variety of potential exceptions that your own brain may be processing almost too quickly to recognize. An organization automating claim statusing started with the solution simply checking whether the status changed to paid or not. If it’s paid, it can fall off the work queue and staff don’t have to look at it. The idea here is, again, work on implementing the foundation that you can expand on later and then look to step 2, and step 3. Step 2 for them is marking anything that is still in process. Overall, one academic leader noted that the name of the game here is really, is this helping you ultimately get claims out or cash in faster, cheaper, more accurately, and with less inherent risk?


I think a bigger question here, and I know some of you have asked about this, but maybe some of you haven’t really had the opportunity to think about this, but how do I govern this? Does this live with IT, with revenue cycle? And of course, the answer is probably a little bit of both, but we all know that both of those teams already have full plates. So here are some examples.


The first organization here, they initially wanted to purchase the licensing to a software application, and then develop the functionality and have full autonomy internally. As they started down that path, they realized even with RPA this is just going to be too expensive. So, they went with what they call hosted model, and they purchase programming hours in blocks through an external service. They also have a maintenance agreement for any reprogramming, because you’re going to have to do reprogramming. And the revenue cycle gets approvals through an IT committee, but the revenue cycle directs the vendor on what to do.


The second organization here ultimately decided to have a consulting-type partnership where they will come in and make recommendations about how to build an internal center of excellence around automation and AI. In the meantime, a revenue cycle-based project manager is working with an IT project manager, and they report into a dual reporting revenue cycle/IT role, and together they’re going to build out the proof of concepts.


Finally, an East Coast health system has purchased external software and programming for AI, but it’s been investing in an innovation and analytics group to which it plans to add software coders and programmers. It’s also setting up a multidisciplinary charter group to hopefully include clinical, revenue cycle, managed care, finance, possibly to a certain extent HR, and that group will help to approve applications, expenditures, etc.


Another organization not listed here, but who we’ve spoken with, has been very lucky in that it has a revenue cycle operations leader that has crossed over from the IT world, and he’s leading the charge, but he also is using vendor systems as a starting point. He said he envisions there being no other way but dedicating a team or department to these efforts in the near future, and he also has plans to have its vendor work on a claim statusing solution while its internal team works on a very similar process for authorization status, and he wants to see which team is going to be more successful.


Really the key takeaway here is that no one’s doing this alone, at least not at first. You’ll likely need to hire some help while also dedicating some internal resources. So, as you think about where to implement advanced automation and eventually AI at your own organizations, I wanted to share some key considerations.


Starting with RPA first, one of the organizations I mentioned on the previous slide…I think we’ve made this part clear throughout the presentation, but this is not about reducing head count. So, you should have a plan in place for, if I do save myself X hours, here is where I will rededicate that time. AI should not be the immediate answer, so always identify the root cause first. There is a chance your current systems could automate it without needing the cost and complication of AI or even RPA. It might even be staff behavior that would cause problems somewhere else in the process, or perhaps a protocol or policy that’s outdated, or not being followed.


Make sure you get the right people in the same room and on the same page. You’ll need a subject matter expert that knows the IT side, but separately one that knows the process in and out. These two need to work together. You also need to involve external partners if they are part of the process, and you don’t want to plan and start an implementation only to be told that your vendor or payer won’t allow it, which can happen. And that ties nicely into the fact that vendors and payers still remain resistant. So, start with one payer or vendor first, get their blessing, and expand it out from there. Designate the bot to show up as a bot so payers can monitor it too. Communicate that it will function the same as a live person, but it will be quicker. And give them a point of contact that if they do see your run into any issues, it can be turned off. In taking steps like these, OhioHealth noted that it didn’t have any challenges with its 10 major payers that it went live with this claim statusing solution.


Vendors in these spaces, RPA especially, are pretty much at this point in an arms race and they’re very similar and what they offer, so really think about the cost efficient option for you, but also consider who can promise you AI later on, who is working with the Epics and Cerners of the world to improve integration, and who can actually support you in analyzing what processes would be best to automate or apply AI to.


Last point here, be sure you set goals with your vendors. Set controls so that you can identify success but also failure. If we hit X, we know we can call this successful. But if we don’t even hit Y, we’re going to turn this off. A nice example there is from OhioHealth, it told its vendor that it would need to save the time of at least five FTEs to reach success. And that if the automated claim status interface did not reduce a payer’s work queue by at least 10%, it was going to turn it off for that payer.


That concludes my section, and I’m going to actually turn it over to Kelli, who is our expert with price transparency. Kelli, take it away.


Kelli Jenkins: Thank you, Jerica. Just on these last couple of slides I’m going to give a brief regulatory update, and then some high-level strategies for furthering transparency.


Although healthcare providers have been working to increase transparency for some time, now the push for this grew immensely over the past year as the federal government became involved. As many of you are aware, CMS finalized its price transparency rule in November of 2019, expanding the cost information hospitals have to make public by January 1, 2021. And as a reminder, CMS expanded the definition of standard charges within this final rule so that hospitals will need to make their negotiated rates for specific payers and plans public, in addition to gross charges.


It also requires hospitals to provide standard charges for 300 shoppable services. Complying with these requirements may create a great deal of administrative burden for some providers. However, if your organization currently has an online price estimator, you may be exempt from posting the 300 shoppable services, provided your estimator meets certain requirements. So that would definitely be worth looking into if you have an estimator currently.


CMS has also included provisions for penalizing hospitals that do not comply with these rules at up to $300 per day. Although this will be primarily enforced through reactive monitoring that relies on complaints from patients and other entities, this could still negatively impact many organizations, especially smaller hospitals and critical access facilities, where the $300 per day will be felt harder.


Concerns around the legality of the rule, the burden and cost of compliance, and of the confusion this information might cause patients has led four major hospital associations and three individual hospitals to file a joint lawsuit against the Department of Health and Human Services. Although the outcome of this lawsuit is yet to be determined, HHS remains firm in defending the rule. Meanwhile a separate proposed rule specific to payers awaits finalization. No matter how these different factors play out and whether or not the price transparency rule remains as is or changes, one thing that is for sure is that consumers are continuing to demand greater transparency, and this will not change no matter the outcome. Evidence of this is the fact that 57% of organizations HBI surveyed in 2019 noted an increase in estimate requests and price shopping.


Providing estimates alone might not be enough to meet the needs of consumers. More than anything, patients want information about the cost of care that is meaningful and actionable. After all, an estimate is only a good as a patient’s ability to understand it. Those patients and price shoppers who actively seek this information out are not the only ones who want it either. They are simply the ones who know to ask. For this reason, it would be beneficial to work toward providing cost information to patients more proactively, perhaps by generating estimates in advance for all scheduled services.


At the same time, patients want options in how they access and obtain price information. Offering self-service estimators or clearly laying out all the ways a patient can obtain price information could go a long way toward fulfilling this need. Some providers are going beyond these strategies and pairing price estimation with a strong financial clearance process where staff, including financial counselors, actively reach out to patients and educate them on what the different parts of an estimate mean, and help them navigate how they will pay for care.


All of this points to the need for providers to take a more holistic approach to providing transparency. These concepts and more are explored further in HBI’s 2019 price transparency report, which looks at the groundbreaking strategies that organizations are using to move the needle on transparency and go beyond compliance. It also takes a little closer look at the regulatory environment and patients’ perceptions about their financial experience. It contains a plethora of data from recent HBI surveys that can help inform your organization’s strategy. If you’re interested in learning more, we’ve included a link to the report at the bottom of the slide, and please don’t hesitate to reach out to the team with any questions you might have.


Back to you, Jerica.


Jerica Hopkins: Thank you, Kelli. With that we’re going to be closing, but as you sign off for the day, I’d like to share the results of our last poll, a little bit of information on our next webinar. But as we’ve mentioned throughout the presentation, please reach out. You can call 888.700.5223 to reach our client services team and they can get you in touch with the right person. Or email one of us directly through the emails listed here on the slide. Again, please don’t hesitate to get in touch, ask us questions, whether based on this, any other questions, you might have, initiatives that you’re undertaking. That’s what our team is for. We’re here to support you, help you get the information and resources that you need to be successful.


With that I’d like to share those results from our previous and last in-conference poll. As a reminder, that question was, “What barriers has your organization faced in implementing artificial intelligence solutions within the revenue cycle?” And that was a select all that apply. So, 53% of organizations say that cost is a major barrier, 35% said trust in vendors or technology at this point in time, 46% said unclear ROI, 50% said existing system/IT limitations, 40% said lack of internal expertise, 15% noted concerns about the effect on staff, 9% resistance from external partners, and “other” 15%.


You can see a lot of these are really tying and competing, so a lot of these are barriers all at the same time. We’re going a little bit over time, so I just want to go ahead and thank my team for speaking and sharing your research and insights and also to our attendees for joining us today. To everyone on the line, I wish you all a successful and productive 2020. Again, let us know how we can help you. We will be meeting with you again in just a few weeks. Our March webinar will feature Renown Health and how they were able to utilize existing technology to automate charge capture for their organization. So that’s a very timely topic that feeds well off of this one.


Thank you for attending Mitigating Denials, Engaging Staff, and Advancing Automation – An Overview of Revenue Cycle Leaders’ Top Focuses for 2020. As always, we’re available for further questions on the materials or anything else, and please do get in touch, take advantage of the Analyst Advisory or ad hoc research request service included with your membership. And as always, please join us next time.

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