Zen and the Art of Revenue Cycle Maintenance

Maintaining healthy revenue cycle operations is not easy. There are a million moving pieces and it is easy for routine maintenance items to fall to the bottom of the priority list. Left undone; however, a seemingly small chore can grow into a major problem, resulting in huge financial losses. Zen meditation is not enough to deal with these stressors!

To make your revenue cycle operations more Zen-like, you need to build a revenue cycle task calendar. This will help make order out of chaos, prevent the loss of institutional knowledge that comes with staff turnover, and allow you to focus on non-maintenance initiatives.

To build this maintenance calendar, determine and assign responsibility for each task completion. Then determine the frequency. Organize it into daily, weekly, monthly, quarterly, and yearly tasks. To get started on your task list, review the sample tasks below. Also, as you are building your calendar, talk to people in your organization to get cross-functional input. Consider color-coding your task list by people or department. Build a calendar with what you have now – you can always add things as you go.

The following samples of tasks can get you started.

Sample Daily tasks

• Use work task queues. What tools does your system offer to assist in daily work? Use queues or visit owner tools to track productivity. Organize your queues according to how your billing tasks are divided. For example, make a queue for following up on claims filed more than 30 days ago.  Some programs offer productivity reports based on task queues. You can use this to rebalance the workloads in your billing department.
• Resolve all payments. Payments entered into the billing system must be posted to patient accounts and not left outstanding. Otherwise, you have money posted to your system that is sitting out there unapplied and unassociated to a patient account. This will affect system closing, reports and outstanding balances on patient accounts. The longer unapplied funds sit around, the more difficult it becomes to post.
• Close daily batches. Batches are like cash registers for charges and payments. Close your register each day to make it easier to balance and for reporting purposes.
• Run daily reports. Which daily reports do you run? How do you benchmark and measure success? How do you balance financials? Run your daily reports (even if you save them to a PDF to save paper). Wish you had better reports to match your needs? Most systems have the option for you to request and purchase custom reports for a nominal fee.
• Balance income. Run a deposit slip report and balance the monies you entered into the system with what you physically have in front of you. Does the cash indicated on your deposit slip match the cash you are taking to the bank? Do your credit card slips all add up to your total on the deposit slip? Try balancing as soon as you can at the end of the day and allow yourself time to troubleshoot and backtrack to find and correct mistakes.
• Reconcile EMR charges and appointments. To prevent missing charges, audit the appointments on the schedule to ensure that the patient was seen. You may need to have a few days’ lag time between the appointment and the EMR charges to allow the providers’ time to enter the charges. If not done on a daily basis, this could turn into a major chore that can end up resulting in missed revenue and inaccurate documentation.
• Perform an EMR charge sweep. Depending on your system and setup, there may be opportunities to do a large sweep to retrieve EMR charges awaiting import. This is helpful because this allows you to bring over charges that were entered after the initial visit or charges that do not have a coordinating appointment. Left undone, you may have charges ready to come over from EMR but miss them because they fell through the cracks and were never brought over to billing. EMR charges left unbilled are a costly mistake.
• Adjust capitated insurance balances. If you have insurances that are capitated and the balances need to be adjusted off, do it on a daily basis so the outstanding amounts are not skewing your accounts receivable. Some systems allow you to setup the fee schedule to automatically adjust off the balance when the charge is posted. Whichever the method, get the charges adjusted off as soon as possible so that your accounts receivable is more accurate.
• File primary and secondary insurance claims. Regular claim filing will provide a steady stream of insurance payments or denials. File electronic and paper claims daily. 
• Resolve rejected insurance claims. Stay on top of rejections. The newer the rejection, the easier it will be to resolve. Contact your software support if you do not understand a rejection reason rather than refilling the claim or dropping it to paper. Clearinghouse and payor edits are known to change so contact support and fix the rejection correctly the first time around.
• Follow up on appeals and denials. Some claims take a little more elbow grease. Do not miss out on revenue due to lack of follow up. Track your appeals and denials and look for trends. Do not be afraid to reach out to your insurance representatives to discuss and resolve.
• Post insurance and patient payments. Payments should be posted daily as to allow for accurate reporting and to reflect the most current state of outstanding accounts. Aging performance measures include analyzing the number of days between posting charges and when the payment was collected and entered.
• Perform internal collections tasks. Collections for both insurance and patient balances are important to improve your accounts revenue cycle. The internal collections process can also include payment plans.
• Follow up with external collections. When you turn over accounts to external collection agencies, adjust off account balances with the appropriate adjustment type so they do not remain on your current A/R. When the payment is received, adjust the amount back on with the appropriate adjustment type. Tracking what you write off compared to what is received is helpful in monitoring the collection agency’s productivity. Also, using the appropriate adjustment types will provide an accurate picture of why amounts are adjusted.

Sample Weekly Maintenance Tasks

• Send out patient statements. If this is not already in place on a daily basis, ensure that it is a weekly task. Sending out weekly, rather than monthly, statements will aid in leveling out the amount of payments and phone calls received. If you send out monthly statements, you may get a rush of payments to post and calls from patients with questions.  
• Close out credit balances. Credits and refunds are often overlooked. Left untouched, these will skew your financial reports. Review the balances and find the reasons for the credits. Does a patient owe a balance on another date of service but have a credit on others? Did the patient pay a copay by mistake and the amount needs to be refunded? Get the credit balances off of your A/R.
• Go through returned mail. It is a waste of time and money to continue to send outstanding patient balances to bad addresses. In addition, you are helping to provide quality patient care by facilitating the correct mailing address for important medical care such as test or lab result notifications sent by mail.
• Audit “unsigned” items in EMR. There is a common gap between EMR systems and billing processes. If charges are entered in EMR and then imported to billing, you must check in EMR too for all charges that should already be on your “to do” list. Audit unsigned items in EMR, including documents, flags/notifications, orders, referrals, etc. Review your provider and clinic staff desktops on a weekly basis.  Unsigned documents and clinical list changes can interfere with routine patient care and can hold up the billing for the patient visit.  It is all too common to find EMR desktops with hundreds of unsigned documents and changes. Implement a policy for signing off clinical items in a timely manner and enforce the policy when users are not compliant.

Sample Monthly Tasks

• Review top payor rejections. Often overlooked, a regular audit of payor rejection reasons can help identify and correct issues on the front end. What tools does your clearinghouse or system offer for this analytical reporting?
• Review top payor denials. Different from rejected claims, what are the reasons payors are not paying on claims? Review EOBs by payor and identify trends. Is there a back-end denial that can be prevented by adjusting the workflow at the front desk or when the patient is with the provider?  See what you can do to prevent denials and get paid.
• Reconcile and compare monthly reports. Which monthly reports do you run? Monthly reports are important for balancing, trending, and benchmarking. These reports give you a high-level dynamic picture of the financial health of your organization. In addition, reconciling monthly reports will ease end of year closing. 
• Hard close batches. All financial transactions for payments and charges should be logged in batches. If you do not hard-close batches, the financial data can fluctuate because soft-closed batches can be overridden and the data can be edited. Hard closing batches on a monthly basis permanently locks down the financial data, which allows for accurate reports and benchmarking. If a change needs to be made after the hard-close, the visit can be reversed and recreated with the accurate information.
• Audit all unpaid visits. Keeping tabs on where your outstanding balances exist in the revenue cycle can help you pinpoint breakdowns and stay on top of problems. It is a healthy practice to audit all outstanding patient visits and break them down by provider, insurance carrier, or financial class. 
• Audit average A/R days. How long is it taking from charge entry to payment posting? Understanding the life of a patient visit through the insurance and patient collections process can help you identify barriers to speedy payment. Start with examining your current A/R days for your biggest insurance payors. Once you know where you are, you can set a realistic target goal. For patient accounts, examine the workload distribution within your patient accounting department. Review documentation within the visits and queues to ensure that these accounts are worked and followed up on in a timely manner.
• Audit charge lag time. How long is it between the patient visit and charge entry? This is an often overlooked task that could end up costing plenty of lost revenue. It can also help identify workflow breakdowns or learning opportunities. 

Sample Quarterly Tasks

• Clean up custom lists. Many systems allow users to create their own “favorites” lists including diagnosis codes. Some are not automatically removed during regular software service updates.  Expired problem codes should be removed from these lists promptly. Review and edit clinical lists to add or remove relevant immunizations, lab codes, modifiers, order sets, or reference tables. If you are sending charges over from your EMR, audit those lists because the system could be sending outdated information to billing. Cleaning the front-end in your database will aid in preventing back-end insurance denials and ensure that the patient’s treatment plan and document is up to date.
• Install system updates. Most system vendors release quarterly updates. Read the release notes first, print a security report, and then install the system updates on a regular basis. The service updates typically include important patches or fixes to known issues. Some even include advanced features and functionality. Remember to update all the components to your system, including plug-ins or peripheral software. Read the release notes on these updates. Sometimes they include changes to the back-end of the system that may require action in the billing or EDI setup.
• Review insurance carriers. In most systems, adding an insurance carrier takes a bit of time, as you have to find the electronic payor IT and make all the correct settings for the EDI transmissions. For some, it is easier and faster to set it up to file on paper. Review all of your carriers to ensure that they are going electronic when possible. This will provide a better audit trail for claims filing, allow an additional scrub due to going electronic, and will also promote a faster turnaround time on adjudication.
• Audit coding and compliance. Perform a quarterly billing audit. Take a few visits from each provider and audit the chart for documentation, audit the CPT codes used and the insurance submission process. Are your providers billing the most appropriate level of service possible? Is your billing staff constantly correcting codes manually on claims but not on the EMR side? Does the billing and EMR office visit match if you were to be audited?
• Shadow a patient. Observe and shadow a couple of patient appointments from beginning to end. You will see the patient flowing through the office and it is a good time to identify bottlenecks, training opportunities, or workflow optimization opportunities. You will also gain an understanding of routine tasks on the front-end that trickle down to billing.
• Sweep up inactive users. Does your system still contain users who have not been with your company for some time now? Sweep them up and inactivate users who are no longer with your organization. Doing so will keep your data nice and neat and will remove unnecessary clutter for active users. This includes billable providers who have left your organization.

Sample Annual Tasks

• Update fee schedules. Fee schedules not only store your prices, but also payor allowed amounts. Knowledge is power. Make a copy of your existing fee schedule and update each year.  Most systems allow this task to be done in advance. Use a fee schedule importer solution to save time. Include the year in the fee schedule name. Doing this will allow you to accurately compare financial data and will provide better reports. Look at the data on your fee schedules and follow up with the allowed stored versus the actual allowed amounts paid by insurance payors. Follow up with your insurance representative if the actual amounts paid do not agree with what you expected. Use your software features to store and report this information. This can give you leverage when negotiating contracts.
• Clean up schedule templates. How long has it been since your scheduling system was implemented in your office? Does your system have old templates for doctors and resources cluttering up the system? Your office workflow is determined upon how your schedule is designed and how cohesive it is to patient and clinical flow. Your schedule template affects the amount of patients you see and how often, the number of claims sent as a result of the visits, and the volume of visits spent in A/R and collections. Setting a strategic schedule template will ensure smooth patient traffic and a consistent workflow and billing cycle. Make a fresh start, get rid of the old templates, and replace them with organized and clean ones.
• Run yearly reports. If you run your monthly reports, reconciling and comparing to your yearly reports should be a breeze. Unsure of what to run? Ask your vendor for suggestions or collaborate with other users of your software or specialty.
• Hard close. If you are not hard closing monthly or quarterly, you should definitely hard close on a yearly basis. 
• Review system downtime plan. What is your plan if the system goes down or your power goes out? Preparation here is key. All departments review downtime policy and ensure all paper documents are up to date and available in the event of an emergency or if the PM/EMR goes down. Test your plan with a “fire drill” and see how prepared your office is. Review your policy on a yearly basis at a minimum. Make sure that your downtime plan includes a clear process for getting charges entered in billing in a timely manner.

Optimize your software

Investing in your people and examining your processes will lead to big returns on your investment. Your software likely offers several options for building and customizing its structure as to accommodate your individual practice and specialty. Because of this variability, features are designed to maximize the software’s performance in many environments. During the initial software implementation, users are in “survival mode” learning how to use the basic functions of the software in order to perform their job.  They tend to be overwhelmed with information overload or not really recognize how all the components will work together in the big picture.

Also considering staff turnover, industry changes, software updates, lack of training, and changes in technology, it is easy to see how data can build up and new features not utilized. The optimization process is key to maximizing the use of the software and to increase staff productivity and satisfaction. Take a regular look at your workflows, review your system setup, find opportunities for education. Engage your staff in all departments and encourage feedback for process improvement. Implement a communication plan and monitor change management when new workflows or changes are made. Reevaluate yearly or even more often on a regular basis for continuous improvement.

Is it Zen yet?

Maintaining revenue cycle operations takes patience, focus and insight, just like Zen meditation. So, when the going gets tough, take a deep breath and be grateful that you have built a structure in which the right people are in the right places doing the right tasks. Ahhhh, breathe out.

Angela Hunsberger is a senior healthcare consultant at Hayes Management Consulting.

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