David May: Thank you. Now we have a few housekeeping items to address before we proceed: Your phones will stay in listen-only mode during the entire webcast. However, listeners can send questions throughout the event. Our moderator will try to ask as many as possible before the hour is up. You can find the questions window on the right-hand side of your screen connected to the webcast dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, ModernHealthcare.com/webinars. Within a few days, all attendees will receive a follow-up email, including a link to that recording. All slides used during today's presentation will also be available online. And now, I'd like to turn the webcast over to Melanie Evans, Modern Healthcare's New York bureau chief and the moderator for today's webcast, and she will introduce our panelists. Melanie.
Melanie Evans: Good morning, everyone. Thank you for joining us, and I look forward to hearing from our speakers and taking your questions. Some of our listeners have submitted some excellent questions in advance, so we should have an interesting discussion today. Our first speaker is Vivian Boyd, vice president of revenue cycle for Iowa Health System. The system, which is based in Des Moines, owns and manages 23 hospitals in Iowa and Illinois and finished 2010 with a revenue of $2.2 billion and income of $165 million. Our second panelist is Sheila Kuenzle, network vice president of revenue cycle for SSM Health Care, St. Louis. SSM is based in St. Louis and owns 14 hospitals in four states. Its St. Louis operations include six hospitals including one children's hospital. With that, let's begin. Ms. Boyd, I'll turn it over to you.
Vivian Boyd: Thank you, Melanie, and good morning to everyone. We can move to the first slide. From our perspective, when we look at revenue cycle and why do we benchmark here at Iowa Health System? We look at just a very simple acronym. And it's really—benchmarks help us to position our system to be a top performer within the revenue-cycle arena. Transparency is essential for us throughout our system to share data, share metrics, share the performances throughout the hospitals, identifying our top performers, identifying our hospitals that are having lower performance so that we can deploy appropriate resources to help improve their overall revenue-cycle results. In addition to that, benchmarks help us to clearly point out where we have opportunities—if it is within our patient access arenas or within our health information management arenas—by having the appropriate key-performance indicators and benchmarks looking both internally and externally, we're easily able to identify where those opportunities are and then begin to prioritize where we're going to spend our resources. In addition for us, it drives ownership, so with the transparency, it's very clear within Iowa Health System to continue having those tough conversations with our finance executives or revenue-cycle leaders in addition to our central billing office, where we see accountability, and then begin holding our teams and our leaders accountable to produce improved results. Also for benchmarks for us, it really allows us to measure the overall performance trend, so we may have certain key performance indicators that are very cyclical throughout the year. We may have some that are impacted by volume or in specific areas within our state. So we're able to look at how we are trending—if we are improving internally with the key metrics or if we see some slippage in some areas, as well as looking at what's going on externally throughout the industry.
If we move to the next slide, this is just really sharing with you some of the metrics that we have adopted within Iowa Health System. We support and we utilize the HFMA map key metrics as well as our own internal operational metrics. When we look at our map keys, it's very easy for us to be able to see what other health systems are doing and then target certain key metrics that we really want to improve on or we want to see some increase in our cash flow or reduction in rework. And just sharing with you a couple of those metrics and what our results have been. Here within Iowa Health System, we launched a revenue-cycle initiative last year, so we just completed our first year and we're very pleased with some of the results that we have seen as we have begun measuring these key performance indicators throughout our system. If we look at our internal operational metrics, now these really for us are around eliminating the defects in our process, improving the efficiency as well as reducing rework. So our focus really is: How do we accelerate our cash flow, how do we eliminate any type of [unclear: 6:16 ?delay?] because we look at our gross day-to-day for us is about $12 million, so being able to see some movement in that area really helps us move our overall financial performance.
If you move to the next slide, now this just is sharing with you a sample with our overall benchmark score card and dashboard. Again, being very transparent with all of our hospitals and our leaders on the definition of the benchmarks that we are using, what are some of our internal targets. Also sharing with them the top performers, so which hospital is the leading performer with a specific metric at the end of last year, you know which hospital is leading in that particular metric year-to-date. For the purposes of this presentation, I have redacted the hospital name and replaced it with an H1 or an H2, but the score card that we publish actually has the hospital's name so that we're easily again able to say, ‘You know, we have hospital one that is a star performer. What are they doing that may be different than another one of our hospitals? And how can we easily scale or replicate that performance so that we can see the same results?' In addition, this just kind of summarizing our overall system, but this score card has a column for each hospital, and every hospital is able to see the performance of their peer hospitals. And we really use that as sort of peer pressure and a little bit of competition to see movement in those results.
If you move to the next slide. To talk a little bit about was our investment. Again, as I said, the revenue-cycle initiative was launched last year—2010—for Iowa Health System. And so our investment really was in three areas: human capital, technology as well as external resources or partnership. So from a human capital perspective, the organization felt it was very critical to have a system executive role that provided oversight or coordination of revenue-cycle functions throughout the system. Hence the addition of my role as vice president of revenue cycle. Since then we have added a project management office. That's where our process improvements, our Lean, our Six Sigma, our efforts are deployed from. We also have added a team of analytics, so that's where our data-mining, so that team really puts together a score card. [unclear: 8:57 ?It's real sound?] identifying what some of the root causes are—in addition to providing any type of ad hoc analysis that any of our revenue-cycle leaders or financial executives are screening throughout the system. Also we have a revenue-cycle governance council, so this was important to identify a revenue-cycle leader or CFO or executive director of finance that would set up on our governance council—this is a representative from each of our hospitals—and that really helps remove barriers within their hospitals to identify directions that we want to move in, help prioritize, elimination of barriers. So they're providing the oversight. We really do that in a collaborative manner within our system. From a technology standpoint, our organization identified that it was important for us to invest in a new practice management system. We're in the process of developing and implementing a new EHR as well—as well as eligibility verification throughout the revenue cycle. In addition to that partnership with external resources to really improve our clinical documentation and measuring the impact and the results from that program, reviewing Medicare underpayments, medical necessity compliance and standardizing our charge masters. So, if we look at for 2010 this was the investment that we made. Our goal, our target, was to see about a $20 million incremental improvement in that revenue, and for our first year, in 2010, we did exceed that target. So our performance was very strong.
If we transition to the next slide, which is actually my last slide, what are our next steps? So, again, a very new revenue-cycle initiative here. As we look at 2011, 2012, our focus is on stabilizing our metrics, so we've put events in place, we've had the initial buy-in. How do we have that continued buy-in and acceptance throughout all levels of each of our hospitals, making sure that we're fully utilizing the technology? How do we maximize that functionality so that we are able to, again, reduce any type of rework and defects that we have in our process? A continued communications strategy, keeping everybody informed, identifying which projects to take on, where do we see slippage, where do we need to deploy resources and how are we performing? We also want to continue to push and challenge the base performance so this is where our performance was at the end of the first quarter. Let's continue movement—whether it is across the system or it is within specific hospitals. Education and training strategy. We have identified certain key areas that we feel we need to improve in the education because we've been able to see some increases in our performance by simply creating a stronger, more deliberate education training program or plan around that. For us it's continued standardization around best practice whether we identify from an external hospital or health system or even internal, top-performing hospital being able to quickly replicate that best practice throughout the system. And then our continued effort around Six Sigma and Lean Process Improvement, so that's the discipline or the tool that we use when we've identified those opportunities to not only kind of patch the results but being able to identify that root cause so that we don't continue duplicating efforts or continue to revisit a certain defect that we have identified in the process. That's what the next step looks like for us. That's kind of what benchmarks mean to us from a revenue type of perspective, a couple other examples of key benchmarks that we've used. So with that, I'll just turn it back to you, Melanie.
Melanie Evans: Thank you so much. I wanted to follow up on one point that you made. You mentioned you achieved in your first year a $20 million improvement in net revenue or it sounded like you exceeded that target. Where did you see the most significant gain?
Vivian Boyd: I would say it was around our medical necessity identification of our impatient vs. observation. We also were able to improve in our controllable losses as well as our clinical documentation, so working with our physicians to improve their documentation so that our health information management and our coding specialist teams was able to capture that [unclear: 13:52] and we [unclear: 13:54] on the table.
Melanie Evans: Thank you so much. Now we'll turn to Ms. Kuenzle. I'll turn it over to you.
Sheila Kuenzle: Good morning. If you could go to the next slide, please. I thought that I would first give a slight overview of SSM and then talk about the alignment of our revenue-cycle goals with St. Louis regional goals and then with our [unclear: 14:18 ?exceptionals?] and how this works with measuring and monitoring our metrics and assessing the revenue-cycle operations through those metrics and then taking action based on what those metrics are telling us. And then showing some of the key wins that we have had within our metrics and operations. Next slide, please.
As Melanie mentioned, we're headquartered in St. Louis, Mo., and actually SSM began with five sisters from Germany in 1872. We were the first healthcare recipient of the Malcolm Baldrige Award, and we continue in all areas of quality. Our vision is, ‘Through our exceptional healthcare services we reveal the healing presence of God.' And this is very important because we want to carry that through all of our operations and in everything that we do including our revenue cycle. We have hospitals located in Wisconsin, Oklahoma, Illinois and Missouri. And our system has 23,000 employees and 5,800 physicians. St. Louis is the largest region within SSM Health Care, and I actually will be addressing the St. Louis region today. We have 11,200 employees in St. Louis, 2,500 physicians and had $1.3 billion in net patient revenue for 2010. Next slide, please.
As I mentioned, we wanted to align our revenue-cycle goals to the St. Louis network goals, which actually aligned to the system conceptually. So we wanted to make sure our metrics were aligned with patient-satisfaction, physician satisfaction, financial performance, growth, quality and employee satisfaction. We've always measured and have always had metrics, but in looking at our metrics, we knew that we needed to remove some, we needed to refine some, and we needed to add some new ones. Next slide, please.
So what were we hoping to obtain with our metrics? One: transparency. We wanted to be completely transparent within all the functional areas within revenue cycle. We wanted to be able to measure every function within the revenue cycle from the very beginning to the very end. We needed to be actionable by all levels, all areas and all functions within our organization. We needed these metrics to be understood by all levels in the organization. And we also want to provide clear expectations of staff and how they contribute to the well-being of the organization and can really be able to show them how they impact those metrics. We also wanted to compare ourselves to one another within our organization—hospital to hospital but also to our peers, so we could understand where we might be missing best practice and to incorporate best practice. Next slide, please.
So in looking at our metrics, as I said we wanted to start at the beginning and we looked at scheduling. And we said let's measure our call volume; our hold time; our voice mail; our abandoned call rate; our handle time; and the percents that are greater and less than some of those previous metrics [Unclear: 17:40 ?furnished in handle time?]. How many calls? What percentage are we handling less than 20 seconds or greater than 60 seconds? Now we knew that these were aligned to our physician and our employee—our physician satisfaction and our patient satisfaction—and also could contribute to growth. So we looked at our verification process, and in order to measure that we needed to look at our elective volume; our urgent volume; what did we secure at time of admission? If we weren't securing it, we knew we were leaving dollars on the table. We wanted to look at add-on procedures. How many add-ons were there, and, therefore, what prevented us from verifying accounts? And we also knew we needed to look at other reasons why we could not get accounts verified so that we could implement best practice. We also wanted to look at our urgent inpatient and outpatient due diligence complete. In our pre-reg process, we needed to look at the inflow. What was coming into our pre-reg, and then how were we handling it? What were the outcomes? Why could we not complete our pre-registration? We also wanted to know our collections at the point of pre-registration. And although I don't have registration listed, we do have some metrics that we look at for registration quality. We look at wait time. When that patient comes in, they sign in, what is the length of time before we are able to complete a registration? And we soon will be implementing how long it actually takes to complete that registration. And we also wanted to monitor the point-of-service collections at the point of registration. Financial clearance is becoming more and more important and until a couple of years ago, with the increasing volume of self-pay. We wanted to measure that; we continue to measure the volume that we might have the ability to qualify for Medicaid or other programs. We wanted to know why we weren't complete in that. Why we weren't attempting it. So what were our post-discharge statistics telling us for those patients that came in-house, that we were not able to get a financial app, why weren't we able to do that? And we just needed to monitor statistics and metrics regarding that. We want to measure our approval volume, our approval dollars and our conversion rate, how successful were we? In the CBO, as always, the accounts receivable aging with anything that we put in for best practice, what was happening with our accounts receivable? What was our cash doing period-over-period, by payer? And we wanted to implement a denial program and monitor the metrics from denials on the initial denials, the open, the closed and the recovery. We also needed to measure our follow-up activity. We were not measuring how many accounts were being worked on the backend. And I mention aging again by payer, by work group, by hospital. We monitor those metrics along with the days in A/R and the net days revenue credit balance. Then we have our all-revenue-cycle metrics. This is what everybody impacts, so everybody needs to be watching it, and it's the cash to net revenue, we look at discharge not final bill by functional error, our collections including point-of-service, delinquencies—why can we not get that account coded and out the door? We wanted to monitor our percent of increase in cash as well as late charges as a percent of total charges and our bad debt and charity. So we went about setting up some of these metrics, adding metrics and removing them. Next slide, please.
And once we did that, we assessed the current set situation using these metrics baseline data. And we knew we had opportunity in all of the areas that I just discussed. So we started with scheduling, and time into a goal of physician satisfaction growth. Our baseline metrics were showing us we really needed to improve in all order to get the goal that we had established. So we implemented a robust call tracking system. We implemented a full centralized scheduling function and what is called our North operating group. We have several hospitals in the North and several in the South. We have a decentralized process in the South, however, due to space restrictions of getting a full centralized process, we opened up a virtual centralization process for the South. We also eliminated redundant questions within our scheduling process by 14 questions that continue to occur at several points within our revenue cycle. On insurance verification, when we began to look at that, we knew we had areas of opportunity. And this goal was tied to physician and patient satisfaction as well as our financials. So we went about implementing an automated work-driver tool. We implemented automated reporting with reasons why we were not able to obtain the verification so we could improve those areas that were causing us not to be able to obtain these verifications. We also implemented a virtual centralization process. Our verification was occurring within each of our hospitals, and we wanted to make sure that if one staff is not able to get to their verification, that somebody at a different hospital could open up that work list and work them. The preregistration, looking at those metrics, we also had areas of opportunity. And this tied to our physician- and patient-satisfaction goals as well as our financial. We had outsourced part of our preregistration, and we brought it all in. We in-sourced the full amount. We actually centralized some of our preregistration, however, once again, [unclear: 23:57 ?to lack of space?], was able to centralize the entire function. So we did a virtual centralization allowing staff across the facilities to work—to preregister accounts no matter where they reside within our network. We also implemented an automated work driver. Next slide, please.
As I mentioned, financial clearance is very important because of the increasing self-pay population. We in-sourced all of our bedded patients. Previously they were outsourced. And we looked at the metrics based on that outsourcing, and determined that we probably could do a better job, and I will show you that that has occurred. So we in-sourced all those functions. We created work driver tools, and implemented automated reporting so we understood what was causing us not to be able to reach our bedded patients in order to have applications completed by the patient. In order to do this, we had to reorganize our financial counseling with our Medicaid eligibility staff, which we did a lot of training. However, it's worked quite well. Then we looked at our centralized business office, and the goals that were tied to this were patient, employee and financial. We did not have a robust automated work driver, so we implemented that. We also did not have a system for actually understanding our denials, so we implemented a system to capture all denials and, actually, we are now at 99% on our electronic remittances and our capture of all the denial reasons. We implemented a network denial team that crosses off functional areas ad involved all operations, so they understood—and understand—what the denials means and how they impact them and to process improve around those. And as I said, we implemented a robust denials tracking system, so everybody understands the opportunity there. And then all revenue cycle. There were things that we could do that impacted the entire revenue cycle that actually aligned with patient employee growth, financial and quality goals. And we implemented an automated failed bill and failed claim work-driver that works across the network. We implemented real-time productivity tracking. Historically it was done on a manual basis. And we standardized quality tracking across the entire revenue cycle. So knowing our baseline metrics, next slide please.
Knowing our baseline metrics, and being able to monitor them and measure them and then implement best practice— Next slide, please.
These are the results. Our average monthly cash collections in 2009—first quarter of 2009—were at $82 million. And first quarter of 2010, it increased to $88 million per month, and we are now looking at $91 million per month. We were able to decrease our denials in 2001 —October of 2009 when we started measuring the inflow of those denials, we were able to reduce open denials by 29%. And we were able to reduce our write-offs by 45%. Next slide, please.
Our base discharged amount billed, our baseline was at 4.1 days. As of April, we are 1.5 days on a goal of two days. We meet weekly with all the areas that impact the discharge not billed and we go over all of our metrics with the functional areas within our organization and we continue to work on process improvement. On the follow-up activity, when we began to measure this, we were looking at 5,469 accounts per week, and we are at 14,589 accounts per weeks on a goal of 12,000. Our scheduling wait times and remember are tied to our physician satisfaction and employee satisfaction and therefore growth. When we first started measuring this, we were at 53-second wait time. As of the first quarter of 2011, we are at 23 seconds with a goal of 30 seconds. And also on the abandonment rate, and once again the same goes for employee and for our physicians and patient satisfaction and therefore growth, we were abandoning 11% of our calls the first quarter of 2009. It is now 3.7% with a goal of 5%. Next slide, please.
Preregistrations, we were only completing 42% of our preregistrations, which, of course, was leading to denials, leading to lost self-pay revenue. We are now completing 89% of those on a goal of 90%. And our secure at admit, we were at a 74% and through the process improvements, we are now at 98% on a goal of 98%. The Medicaid in-house screenings, that is before the patient leaves. We were at a baseline of 73% between what we were doing internally and externally. And once in-sourcing it and having really good tracking systems, we now complete 95% of those on a goal of 90%. And our due diligence complete. We were at 73%. We are now at 99% on a goal of 98%. We continue to monitor all these metrics and process improve and we educate our clinical areas on how they are able to help us. And they've been closely aligned with us in all of our process improvements and continue to work with us. And so the next steps for St. Louis is to continue to improve, continue to work at standardization and consolidation where appropriate. And thank you.
Melanie Evans: Thank you, Ms. Kuenzle. You made some very interesting points. I wanted to ask about the investments that were required to achieve the results you outlined. Could you tell us which of the initiatives you undertook required perhaps the most significant investment, and what types of investment were required?
Sheila Kuenzle: We did have to invest in a good work-driver tool, so we did layer some software onto our main system, our foundational system. And that was a significant investment, however, we improved our net revenue by $12 million, so we definitely—it's more than paid for itself. We also reorganized however I will have to tell you, with the reorganization, we did not add staff. We just reorganized and refined management and so it didn't really cost us anything but really improved our operations. We did some things with our phone systems, but the costs were minimal and the metrics though are invaluable in working with the clinicians and the physicians in where we need to process improve.
Melanie Evans: Thank you so much. We'll now begin with our audience questions. I'll start with a question for Ms. Boyd. How did you determine which variables needed to be analyzed as you began your revenue-cycle process improvement?
Vivian Boyd: What we did is we quickly deployed our revenue-cycle analytics teams to pull data throughout the revenue cycle. It's very easy when you look at your accounts receivables to start there. It probably was there to be able to see what types of accounts are remaining in the A/R. What is the aging? Why are they still there? And then kind of begin moving upstream as a process so that we were able to identify if, ‘OK, we have an authorization issue or we are missing an opportunity with our diagnosis coding and medical necessity.' The same thing when we began looking at our cash flow on point-of-service collection. How much of our self-pay dollars are we collecting after discharge, and is there some opportunities or some low-hanging fruit or quick [unclear: 33:34 ?lens?] that we can deploy there? So I would say, from a data perspective, we really pulled metrics across the revenue cycle. We identified the ones that we felt would be quick ways for where the organization was within the first year. What would be easy to implement? What would be low-cost to implement? And we began tackling those as well as developing a plan to begin moving forward with some of the more challenging ones where we would require changes in the practice of hospitals or changes in how maybe the billing office had performed historically. But the data really allowed to quickly prioritize where we were going to start.
Melanie Evans: Thank you. Ms. Kuenzle, I've got a question for you as well. Did you identify an industry standard benchmark for denials and how did you go about benchmarking your denials in the revenue process?
Sheila Kuenzle: We did identify—actually it's interesting there are several standards out there—and we actually worked with a consulting firm to identify the standard to use. And we knew we had a lot of opportunity in denial, so what we had to do basically was not go for the gusto, but every year we're deciding to decrease that based on the process improvement. We don't want to discourage our clinicians or our staff by not getting to what I would call the best practice standard at this time.
Melanie Evans: Thank you. Which brings me to another question from our audience. Ms. Boyd, I'll ask you first, but I'll also then follow with Ms. Kuenzle. Ms. Boyd, what do you find are the perhaps best resources either for regional or national benchmarks?
Vivian Boyd: Actually that's a great question. When you begin doing the research, there are quote-unquote ‘best practices anywhere you look, and there's many consultants that provide a lot of information and/or may provide your benchmark data by region or by hospital size or by health system size, so there's a lot of available information out there. I think what we felt comfortable with was really looking at: Where are we at and then where do we want to be from an executive team? And for us, we really found that the information that we have received from HFMA was more aligned with where we wanted to go, what we wanted to accomplish and so it was through kind of collaboration and discussion with all of the forces with our executive team that we chose which metric we would use as our benchmark.
Melanie Evans: Thank you. I'll put the same question to you, Ms. Kuenzle. Do you have sort of top source for benchmark criteria?
Sheila Kuenzle: Well we utilize the advisory board, HFMA and several consultants. But like Vivian, we were more centered on where do we want to be and where do we want to go? And the reason for that is because the metrics are different depending on the source, and things could be entirely different provider to provider. What I mean by that is depending on managed-care contracts and how they are written, we might have some that are just percentage-based contracts where you might have another region that has very complicated managed-care contracts with many carve-ups and many stipulations. And so it's really hard to compare one tier to another. And so we worked with finance and looking at these external metrics and say this is where we want to be and we will continue as we improve to basically change our metrics so they're not in stone right now. We will continue to improve those metrics as we improve. But we continue to challenge ourselves also.
Melanie Evans: Thank you. That brings me to my next question. I'll begin with Ms. Boyd. In the process, over the year that you worked with your revenue-cycle improvement, has your, sort of, dashboard criteria for performance at all changed? And if so, how?
Vivian Boyd: For us, yes. Coming into the onset of the organization based on the initial data set, there were just some quick things that we wanted to measure. And we began working to improve those. We had Kaizen events, we had process-improvement events, and as we learned more about the organization and where kind of our opportunity pockets were, we were able to expand those benchmarks. And I would say over the course of this 12-month period, and also you have the buy-in of your executive team. So we have had a lot of dialog around this definition of the metrics. Should we include this? Why don't we include that? There's a lot of debate that has taken place in our organization, but where we are now is really growth over some of the 12-month period of ‘This is where I think we need to start.' As we've learned more and as we've drilled a little bit deeper through data-mining, we've found, ‘OK, there's some opportunities here. What are those appropriate metrics?' And also for us, we use a revenue-cycle metric as a part of the incentive program for many of our executives throughout the system, so having that volume, having that support, making sure that we have picked the metric that really will yield results that we want: reduction in rework, reduction in duplication, improving efficiencies, accelerating cash flow, so that if we're going to focus on it, we are going to see the outcome throughout the organization that we want to see.
Melanie Evans: Thank you. I'll direct the same question for you Ms. Kuenzle. Have your dashboard criteria for revenue cycle changed?
Sheila Kuenzle: Yes. They have changed, and in actuality, the dashboard previously was incorporated into the overall financial dashboard. And there really wasn't a whole lot of attention paid to it. We developed what we call ‘Help out the revenue cycle' report card, and it's an electronic dashboard that goes to all of our system management and it's by hospital but with a rollout to the overall network. And, they actually ask for it now. If we're delayed in sending it out, our management team actually asks to review that. And like I said at the beginning, some of our metrics that previously were part of the overall financial dashboard, we eliminated. We added new ones that were more significant to our processes and to our management team.
Melanie Evans: Thank you. Ms. Boyd, you mentioned that as you entered your second year, among your goals were efforts to stabilize some of your metrics and reduce slippage. Could you identify the metrics where you, perhaps, saw the most volatility or those metrics where you saw some slippage, and can you talk a little bit about maybe what you've learned?
Vivian Boyd: Sure. You know I can pull one metric. We were talking about denials earlier, and that's one that we can start with. The ability to measure your denials is only as good as your ability to capture 100% of your denials. And so as an organization, as we began culling that data very early in 2010, we clearly identified that we were not posting all of the denials, so the metric and the results was actually kind of a false positive. But that really allowed us to go back and understand the process, the electronic postings, the manual postings that we had and begin working to improve and ensure that we're capturing 100% of that denial volume so that we can accurately report that and measure it so that then we can begin working to improve on those results. So, if I look at some of— the quite a bit of the variation that we saw was many times we found it was because the practice or the process that was in place. May was yielding false positive or false results. So it really took us back to make those changes. We saw that metric significantly changed or go in the worst direction, but it was actually a correct measurement of our performance.
Melanie Evans: Thank you. Ms. Kuenzle, is there perhaps a metric that you have found to be more volatile? A metric where performance varies and what have you learned from perhaps taking a closer look?
Sheila Kuenzle: Well I promise Vivian and I did not talk before this call. However, I would also have to say it was our denials. When we started going down capturing our denials, what we found was there were periods— denials previously were only written off at the point of write-off, that's when they would be acknowledged. And some of them weren't even acknowledged. They would go to a contractual adjustment. So as we started capturing all of our denials, first of all by getting all of our remittances—electronic including our lock boxes—capturing all those CAS reason codes, we were able to really understand what our true denial opportunity was, and actually it causes a little bit of angst within the organization because previously they had only seen these numbers that were denial write-off numbers. So, once we captured everything, and we start looking at what our open denial opportunity was, it really gave people pause and our management team to say, ‘You know what? This really takes the entire organization in getting involved in our denials process.' And we've seen steady improvement. I will tell you when we first started capturing our open denials and putting into place the network denials team and process improvement teams, we actually saw a tick up in our open denials and our write-offs. However, that's because it was previous accounts before we started this whole team going and looking at the process improvements that had to occur. Since then, we don't have the tick up. It's actually continuing to tick down month after month.
Melanie Evans: Thank you. I'll put this question to Ms. Boyd. Have you developed any revenue-cycle benchmarks that are specific to a service line? We have one question from an audience member interested specifically in prosthetics and orthotics.
Vivian Boyd: I have not for that particular service line here. When we look at service line, one of our hot areas right now is our charge capture. So we do look at charge capture by service line, by location and really feed that back to those clinical leaders because our target is to be able to reduce [unclear: 46:04] days and to get charges into a timeline. So that's one of the main ones that we, as an organization, have really been pushing and partnering with our clinical directors to improve and maintain a consistent process for.
Melanie Evans: Thank you. Ms. Kuenzle, I'll put the same question to you. Have you looked at any specific revenue-cycle benchmarks by service line? And for our participant who was specifically interested in prosthetics and orthotics, I'm curious to know if you have looked at that service?
Sheila Kuenzle: We have started implementing ‘Help out the revenue cycle' report cards for our service lines. We actually have our oncology developed and our neuron surgery developed and our cardiac developed. Our goals are changing though. So, dependent on our goal on the specific metrics for aging, for cash, for Medicaid conversions, for denials, we are using those same goals for each of those service lines. However the reports look exactly like each hospital's report, which rolls up to the network report.
Melanie Evans: Thank you. Ms. Kuenzle, I'll put this question to you. We had one very specific question from a listener who asked you to please define CBO.
Sheila Kuenzle: Centralized billing office.
Melanie Evans: Thank you very much. My next question I'll put to Ms. Kuenzle, again. You discussed identifying and wait-appropriate enrolling patients in, for example, Medicaid. Can you talk a little bit about that process and the results that you've seen?
Sheila Kuenzle: Yes, I can. As I said, we actually had outsourced a portion of our self-pay population to be looked at by an external firm. When we knew that there was a huge area of opportunity, we went about trying to figure out how many FTEs we needs. We looked at our total FTEs for financial company, and what we found we had about four Medicaid eligibility staff, so we transitioned to where our financial counselors really were the ones that were going to meet with a patient after our Medicaid eligibility counselors would meet with the patient and find out whether or not they would qualify on the initial application. And so we downsized our financial counselors and upsized our Medicaid eligibility staff. We added approximately I was to say it's 10 Medicaid eligibility staff to the four that we had. We set up an individual to be team leader, and she is the go-to expert. So if our Medicaid eligibility counselors have any issues or questions, they know they can work directly with that individual. We set up automated—automatic—tracking that would just, when we have a per self-pay account, it goes in an automated fashion to a Medicaid counselor who then makes arrangements to see that patient and to get that application. And this is just [unclear: 49:41 ?set it?] patients whether inpatient or outpatient, the [unclear: 49:45 ?set it?] patient that they would meet with the family or the individual before that patient leaves. And, then, dependent on the results, they put the results of attempting to get the application into our system and continue the follow-up through the system. It triggers a follow-up date for the individual to work with either the state or the local offices or the patient if they need more information.
Melanie Evans: Thank you. Ms. Boyd, have you begun to identify any of the challenges to revenue cycle that might emerge under provisions from the Patient Protection and Affordable Care Act?
Vivian Boyd: Definitely. We have set up a team that closely—as far as our government relations area—in making sure we understand kind of the language. We are very involved in lobbying and helping write the policy and how various portions of that act will be carried out. So from our system, it really comes from our CEO is very pro-active in helping to shape what that looks like within each of our organizations. We work very closely in providing, from administrative challenges, how do we simplify implementation with some of those provisions that are presented? And providing those write-offs or submissions directly to our—to the finance and the tax teams as well as our representatives. So, very much involved with the topic. Now, on a weekly basis that we have here as we begin moving forward and understanding how that's going to impact us long-term.
Melanie Evans: Thank you. Ms. Kuenzle, I'll put the same question to you. Have you started to look at potential challenges or in any way tried to direct some projections for what might happen to revenue cycle under provisions of the health reform law?
Sheila Kuenzle: Yes. We have as an organization looked at the impact and it's not pretty, the financial impact. We also have individuals that specifically work with the government and try to mandate on our behalf. On a detail level and looking at the different things that have been implemented, we inform our patients, for instance, on the pre-existing conditions. When this was being rolled out, we actually looked at our database and sent a letter to all of our patients that potentially could have been impacted and on an ongoing basis as we have patients that are denied for pre-existing, we send them a letter on what they can do and how they can access the pre-existing plans at the state level. We also with our patients looked at those that might qualify for insurance under their patients' plan and also sent a letter before that was implemented to all of those patients and families so they knew what their rights were under the new law.
Melanie Evans: Thank you. This brings me to my final question for each of our panelists. I'll begin with Ms. Boyd. For anyone getting started or in sort of the early implementation of a revenue-cycle benchmarking process, do you have any tips or any suggested priorities?
Vivian Boyd: I would say what really has been significant for us to be able to move forward in the manner that we have has really been the support from our executive leadership. Iowa Health System has strong support from our board. They are fully supporting the improvement, the incremental revenue, the resources, pushing forth standardization. Our system CEO, our system CFO very much supportive. That at least gives us the momentum as we began being transparent because the challenge is after that, so we have the support, we have it from the top. We have our marching orders to move forward in this manner. And as we began getting kind of in the ground, that's where many of our challenges began is you will have pushback on the data, you will have pushback on how things unfold. Everyone will have their own justification or explanations for why their performance is what it is, so being able to get to that standardization and really being able to see significant change of movement, it really starts from the top of the organization. Making sure that you have that executive support; all of our hospital CEOs very much onboard in supporting what we're doing. So that at least makes it easier for us to have those discussions and be able to challenge the current state of performance. So that's really where I would start. Being able to pull the data, being able to clearly identify where your weaknesses are, where the opportunities are is kind of the easy part. The tough part is being able to get those changes implemented throughout a system such as our size.
Melanie Evans: Thank you. Ms. Kuenzle.
Sheila Kuenzle: Definitely the executive support is very important, and working with finance. Sometimes I think finance doesn't understand all the aspects of revenue cycle. So work closely with finance in establishing those metrics, communicating the metrics and get the buy-in of the executive team to make sure that the nonrevenue-cycle personnel have this as part of their goals that revenue cycle is important for them to understand, and they need to understand how they are paid and how they are denied and how they impact the revenue. And it's much more important to them to increase revenue because the alternative is that they need to decrease costs, and so that message being shared in a way that they understand and that they can react to is very helpful. The other thing I would say in establishing metrics is to steal shamelessly and to really talk to peers and to find out what they are doing—much like this presentation today—and then ask them for more information. We've shared many of our reports and our report cards, and are more than happy to do so.
Melanie Evans: Thank you so much. I'd like to thank both of our terrific panelists and to the audience for listening and for their excellent questions. We've had a thoughtful discussion today about why systems benchmark revenue performance and what it is that they can learn from that benchmarking. Dave May has a few closing remarks, so I'll turn it over to him. Dave.
David May: Thank you, Melanie. This concludes today's discussion on benchmarking the revenue cycle in healthcare. For those who want to view the webcast again, all attendees will receive a follow-up email with a link to this recording of this webcast available on ModernHealthcare.com/webinars. All slides presented during this webcast are also available at that address. We thank you.