Revenue cycle gets make-over with technology

When Irving, TX-based Christus Health set out to improve its revenue cycle operations, it turned to technology and training in equal parts.

As a large health system with 40 acute care facilities, revenue cycle operations varied tremendously across regions. "As a result, our financial performance reflected the same degree of variation," says Sandi Green, CHAM, system director of patient access/revenue cycle services. "We needed to revisit the revenue cycle operations from a system-level approach."

Green says that in tackling this, "Our biggest challenge was resistance to change, and especially standardization. Every facility believes they are unique and has a need to be different. This was indeed our biggest task," says Green.

First, a corporate revenue cycle services (RCS) department was created to provide leadership and oversight of revenue cycle operations across the system, and standardize communications and best practices.

The RCS department consists of director-level positions for revenue cycle areas of admitting, medical records, and patient financial services. Each of the system directors developed resource teams made up of the key leadership associates over these departments in all the facilities. The RCS directors offer onsite support for all revenue cycle functions in all facilities.

"This has tremendously changed our ability to make process changes and implement standard procedures in an organized and timely fashion," says Green. "We have created very positive working relationships with these leaders. We have come a long way in working together to find system-wide solutions to our issues and challenges."

Program improves staff skills

"One of our key focus areas was on patient access, the birth of the revenue cycle," says Green. A program was developed and implemented to promote and enhance the skill level and performance of front-end staff.

"This was a very comprehensive program that provided many hours of additional education to our staff," says Green.

The hospital contracted with an education vendor to obtain an extensive revenue cycle course curriculum. The "Excellence at the Front End" program was developed by the RCS department after a year of internal research on various issues affecting patient access areas across the system.

"The obvious issues that the industry suffers were no different to us — high turnover; changing demands and skill sets; lack of training and technology; and, more and more, responsibility of the outcomes," says Green. "Our program addressed all of these."

The team rewrote job descriptions to address outcomes and built a career ladder that promoted associates based on their demonstrated skill competency. Positions are no longer task-specific, such as insurance verifier or registrar. Instead, they're based on levels of skill competency.

Associates are also eligible to be promoted and compensated by obtaining Certified Healthcare Access Associate (CHAA) certification. "Although the certification is not mandated, it is required for promotion up the career ladder," says Green.

Multiple competency assessments are done for all new hire applicants to assess their basic skills in math, reading comprehension, and data entry. "We no longer consider registration an entry-level position and have modified our pay scale accordingly," says Green.

Green says that in her opinion, "this has by far been one of our most successful accomplishments in our organization. It has taken many years for folks to realize how the job has changed for patient access. It is very comprehensive and has so many opportunities for failed outcomes on the customer, financial, and regulatory side."

Although several hundred patient access associates have obtained CHAA certification, the process also has resulted in some turnover. "Not everyone is cut out to do this job," says Green. "It takes special people to do what they do accurately, be friendly, and of course, be fast."

Technology also key

Simultaneous with the educational program for staff, two new standardized technology solutions were implemented. First, an integrated application with the hospital's registration system allows for eligibility verification and data validation during the registration screen flow. "This eliminated the multiple web sites that were being used to obtain and verify payer data," says Green. Another application performs charity qualifying screenings.

In addition, an automated system was implemented to provide registration data element audits prior to bill drop. "This has moved the edits for successful billing to occur promptly after the registration so corrections can be made and our bills are clean when they drop," says Green.

In less than one year of implementation, some facilities reached the standard of 94% accuracy, and other facilities are very close to achieving this standard as well.

"The improvements in the patient access department are clearly reflected in improved patient financial services performance metrics related to A/R," says Green.

Previously, staff contended with long lists of telephone numbers, web sites, and faxed forms to obtain benefits. "We literally had many process maps, depending on the payer," says Green. "Some staff used these resources well, and others did not use them at all. Therefore, there was no consistency in the verification process." Since obtaining eligibility was such a time-consuming task, it often was never done on many accounts.

With automated eligibility verification, staff are alerted when there is a discrepancy between the information on the account and the payer database, which allows the account to be updated.

"It also validates that we have selected the correct insurance assignment based on the plan information," says Green. "This was especially good for the managed Medicare and Medicaid plans."

It also helped ensure that in patient financial services, the proper contractuals are posted to the revenue. "This has saved us tremendous rework on the back end to correct and recalculate the adjustments," says Green. "In addition, we can validate the guarantor address with the USPS, which helps reduce return mail form simple data entry mistakes."

The system confirms that all the necessary steps are taken, and if they are not, this is reported with a daily list of every account by associate. "This level of performance detail has produced the consistency we were looking for," says Green.

[For more information, contact:

• Sandi Green, CHAM, System Director, Patient Access/Revenue Cycle Services, Christus Health, Irving, TX. Phone: (713) 277-2254. E-mail:]