'Revenue managers' improve dialogue between physician clinics, billing office

Goal is resolving issues that could result in decreased income

A newly formed team of "revenue managers" is working to link billing and clinical departments, providers, access personnel, and insurance payers and help resolve issues that otherwise could result in decreased income at the University of Arkansas for Medical Sciences (UAMS).

The initiative came out of the timely convergence of feedback from an internal survey and a benchmarking study by the University Hospital Consortium (UHC), says Beth Wheeler, director of operations for the UAMS faculty group practice (FGP) billing office.

"We have 21 clinical departments, each of which has a clinical administrator," she adds. "We decided in spring 2005 to survey the Group on Business Affairs [GBA], which is made up of all those administrators, to find out how the billing office was doing."

Part of the feedback from that survey, Wheeler explains, was that administrators wanted more communication between the clinical departments and her office, which does the billing and collections for UAMS physicians and other clinical professionals, such as nurse practitioners and licensed social workers.

About the same time, UHC did its own survey, to benchmark academic billing offices. "They used the data to identify the top 10 performers, and each of the 10 wrote a case study on why they were successful."

Those case studies revealed that several of the hospitals involved had individuals functioning as liaisons between billing offices and clinical departments, Wheeler says.

As the UAMS survey already had identified the need for more communication between those two entities, the solution presented by the UHC study seemed tailor-made, she adds. To begin developing the idea, Wheeler says, the clinical executive GBA — a subset of the clinical administrator GBA made up of six clinical administrators and herself — broke into smaller groups and began contacting individuals at the successful UHC facilities to pick their brains.

"We wanted to find out what had worked for them, what hadn't worked, and what they would do if they had it to do over again," she says. "We got job descriptions and all kinds of material. It was very valuable."

The clinical executive GBA put together a proposal and a budget and presented it to the college of medicine, which gave its approval, Wheeler adds. "From the time we did the survey in the spring of 2005, it took about a year to hire the first person."

One of the conclusions reached early on was that the revenue manager initiative was too big to just add on to someone's existing responsibilities, she notes. "We needed an individual to be in charge of this program."

That person turned out to be Nicki Morris, whose title is assistant director of operations for the FGP billing office. "Her function is to get the program up and running and maintain it, to be the key person in hiring personnel. We felt that we had done the outline, but we wanted someone to get in there and work on the details."

Start small, get it right

With a strategy of "start small and get it right," the decision was made to hire three revenue managers to work with three of the 21 departments, she says. "We decided to use those represented by the [administrators] in the executive GBA group — medicine, pathology and obstetrics-gynecology."

One of the expectations for the revenue managers, notes Morris, is that they will work closely with the Revenue Integrity Specialist Team (RIST), which is the primary resource for access personnel at UAMS, to identify obstacles at registration.

While RIST members focus on resolving front-end issues that can interfere with the ability to get paid, revenue managers will look at problems that occur on the back end, after the billing process has been initiated, she says. "We're all here to generate revenue and make money for the physicians and the hospital."

The goal of the revenue managers, Morris adds, "is to communicate areas that need improvement, whether on the billing side or on the physician side in the clinics."

One example of how her staff will work with RIST, she says, has to do with VoiCert, an automated, telephonic tool that combines multiple pre-certification requests into one phone call and provides documentation of authorization history, Hiryak adds.

As revenue managers began meeting with the clinical departments being targeted in the initial phase of the program, Morris says, "we noticed that a lot of their denials are because the patient isn't really eligible because of an identification or name mismatch."

"We started asking whether they verify insurance when the patient walks in the door, and they said no," she adds. While VoiCert has been rolled out to the clinics, employees are not using it, Morris says. "They said it's kind of cumbersome and made various excuses, such as not having time."

Revenue managers are getting a demonstration of the product from the RIST team to determine whether, in fact, it can be used efficiently in the clinics, she says.

"We also can go back [to RIST] and say, 'This clinic has a high rate of denials due to registration issues. Can you work with them?'"

RIST members do periodic audits in the clinics, Morris points out, "but what they audit may not catch some things we might catch from looking on the back end after the billing process has been initiated."

Dealing with denials

"We look at all the denials and the denial reasons — lack of preauthorization, or a patient not being eligible for that insurance because of a name or number mismatch," she adds. "Say the name [on the account] is Betty Smith, but it really should be Betty Z. Smith."

Two people from the physician billing office at Massachusetts General Hospital — which had "incredible results" with a similar program — spent a couple of days meeting with UAMS revenue managers, billing office directors, and the chief operating officer, as well as the GBA and the clinical executive GBA, Wheeler says. The senior manager for the professional billing office of Mass General's physician organization gave the kickoff presentation for the UAMS program.

In addition, she says, Morris visited Mass General to get a feel for its program.

One of the successes attributed to a Mass General billing manager, as that facility's revenue manager counterparts are known, had to do with a CPT code for which Blue Cross Blue Shield had a technical but no professional component, Wheeler notes.

The billing manager met with a Blue Cross representative, she says, and made a convincing argument that there was in fact a significant professional component to the procedure. The payer is now reimbursing a physician component for that charge nationwide, Wheeler adds.

Program gaining visibility

At UAMS, the assistant director and all three revenue managers spent four days in each of the three departments being targeted by the program, she says. "They all went [to each of the areas] because they wanted to see what was being done the same way and what was being done differently, [thinking], 'Maybe I can translate that to my department.'

"Now they are visible, people know their faces and names, so they're ready to start digging in," Wheeler says. "I'm not sure at this point at what rate we will roll out [to the remaining departments]. We want to make sure as many wrinkles are ironed out as possible."

Before the revenue manager position was created, Wheeler was the point person for questions that came from all 21 clinical departments, she notes. Having the revenue managers in place will allow more time to work proactively on billing issues, rather than simply responding to problems, Wheeler adds.

"Usually when they call it's because collections are down, or they're getting a lot of denials, so we want to concentrate on that," she says. "There are also [concerns about] coding issues and charge capture: Are people actually billing for all the services provided? So [revenue managers] will look at encounter forms, billing documents."

A recent e-mail from the cardiology department had to do with a diagnostic test with a particular code that one carrier is always denying, Wheeler adds. "We feel we can convince [the carrier] that it should be paid."

Her personal take on the mission of her department is that it's about "the three Cs — collections, communication, and confidence."

"We're a centralized billing office, we're off campus, so most of the people that work out here billing and collecting the physicians' money are invisible to them," Wheeler points out. "[Physicians] take care of patients, mark a box on a form, and then don't know what happens to it, but they have lots of questions."

Many of the providers think like they did when they were in private practice, when they knew exactly what they received for each patient and which insurer was paying what, she says. "A lot of them miss that.

"We send reports back to the departments, but they may or may not filter down to the individual providers," Wheeler adds. "If they do, the [physician] may not have time to look at them, or know how to interpret them."

In an effort to fill in those gaps, the reporting function will be a big part of the new program, she says. "[Revenue managers] will take data to the departments and the administrators and will sit down with them at regular monthly meetings.

"They will explain things and identify problems before they become enormous," Wheeler says. "We're revamping the entire reporting structure so we can do a good job of making it understandable."

Much of the inspiration for that has come from the leadership at Massachusetts General, where an "unacceptable" collection rate has been replaced by "spectacular results," she notes. "The chief operating officer told me, 'We used to provide data, now we provide information.'"

Drawing from material provided by that organization, her office has developed a list of service standards for revenue managers. (See list below.)

"We have a fairly standardized schedule that each [revenue manager] can follow," Wheeler explains. "We want the departments to feel that they are getting a consistent level of service: [For example], this week the revenue manager is in the office working on reports, this week she is making presentations, this week she is trouble-shooting."

That kind of arrangement was recommended by several of the billing offices that have successful programs, she adds.

To get a realistic look at the programs at other facilities, Wheeler says, the clinical executive GBA group made it a point to talk with the person in her position, with a department administrator, and with an actual revenue manager.

"We wanted to get a full picture, not a skewed [perspective]," she says. "One thing we heard fairly consistently is 70-30: About 70% of the time the revenue managers are all doing the same thing, and about 30% of the time they're doing things that are unique to that department."

Of the three revenue managers, two came from the billing office, and the other had been a billing manager for a clinical department, Wheeler says. "We felt our first [hires] should have a strong background in the billing area."

That differs from the approach at Massachusetts General, she notes, which has been to look first for people who can think on their feet and have great communication skills, with the idea that they can be trained for the billing-specific duties.

"If you do that, you have to have a great training program," Wheeler points out. "Since we are brand new, we didn't want to start with employees who don't know what we do."

(Editor's note: Beth Wheeler may be reached at WheelerElizabethL@uams.edu. Nicki Morris may be reached at nmmorris@uams.edu.)