The document discusses strategies for improving revenue cycle performance that were employed by hospitals that won HFMA's MAP Award for High Performance in Revenue Cycle. It outlines seven key strategies used by the award-winning hospitals: 1) Create dedicated teams for revenue cycle improvement 2) Use metrics to conduct root cause analysis 3) Create shared accountability for performance 4) Collaborate across departments 5) Develop comprehensive uncompensated care approaches 6) Enhance customer service 7) Focus on improving the total patient experience. The strategies helped increase cash collections, reduce days in accounts receivable, lower bad debt, and improve patient satisfaction scores.

1. strategiesforimproving
valueintherevenuecycle
byjeniwilliams
MAPPING
OUT
Winners of HFMA’s MAP Award
for High Performance in Revenue
Cycle share seven key practices for
improving quality and performance in
hospital revenue cycle operations—and
enhancing the patient experience.
byjeniwilliams
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2. The ability to effectively track revenue cycle performance at
each stage of the revenue cycle, compare results with those of
peer groups and the industry, and identify proven strategies to
achieve revenue cycle excellence will be critical in an era
of reform. Winners of HFMA’s 2011 MAP Award for High
Performance in Revenue Cycle have developed innovative
ways to achieve excellence in revenue cycle operations—with
outstanding results.
“Now more than ever, achieving value in revenue cycle
operations—through high-quality performance and cost con-
tainment—is key to a hospital’s success,” says Suzanne Lestina,
FHFMA, CPC, director of revenue cycle/MAP for HFMA.
“This year’s MAP Award winners demonstrate an ability to col-
laborate and communicate effectively to drive improvements in
revenue cycle performance—and the lessons they’ve learned,
such as how to successfully use metrics to conduct root-cause
analysis, could help other organizations learn how to perform
to the highest standards of revenue cycle excellence.”
In 2009, HFMA created the MAP Award for High
Performance in Revenue Cycle to honor hospitals that achieve
revenue cycle excellence. MAP Award winners excel in
meeting key benchmarks for success, as established through
HFMA’s MAP initiative (see the sidebar at left), while adhering
to the principles outlined by HFMA’s PATIENTFRIENDLY
BILLING®
project. The award is sponsored by 3M Health
Information Systems.
Here, three MAP Award-winning hospitals share strategies
and tactics that made their organizations high performers—
and offer insights into what your organization can do to
enhance revenue cycle performance.
A new tool that enables hospitals to
track revenue cycle performance using
industry-standard metrics, compare
their results with those of custom-
ized peer groups, connect with other
revenue cycle leaders, and access best
practices, expert commentary, and
unique HFMA analysis. The MAP App
also offers tips on evolving best prac-
tices and includes a community discus-
sion forum for airing common concerns.
More information, including previews of
the MAP App prototype and a detailed
explanation of its features, is available at
www.hfma.org/mapapp.
An annual award recognizing health-
care organizations that achieve excel-
lence in the revenue cycle. Applications
for the fourth-annual award will be
available in late 2011.
An event where evidence-based
lessons from leaders in revenue cycle
performance are shared with providers.
MAP Events bring together the best
ideas on how to improve revenue cycle
performance. During HFMA’s 2011
MAP Event, to be held Oct. 26-28 at
the Doral Resort in Miami, discover
what it takes to build your team, instill
proven practices, extend accountability,
and reward high performance. For more
information, including a list of sessions,
visit www.hfma.org/mapevent.
Defining key indicators of revenue
cycle performance. Using MAP Keys,
healthcare finance professionals can im-
prove business intelligence, strengthen
revenue cycle management, and
decide—based on industry-created met-
rics—where to focus for improvement.
To date, the Association has released
25 MAP Keys (see the sidebar on page
seven for a complete listing).
The MAP initiative
features the following
components.
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3. Legacy Good Samaritan
Medical Center in Portland,
Ore., developed a revenue
cycle project team four years
ago that provides support
and project management
for revenue cycle initiatives.
“The project team allows our
managers to concentrate on
their day-to-day work while
enabling our system to be innovative in our approach to revenue
cycle improvement,” says Mary Kjemperud, vice president, revenue
cycle, Legacy Health. Team members include a project coordinator
and a project analyst.
Within the revenue cycle at St. Catherine Hospital in Houston—
part of CHRISTUS Health—high-performance work teams have
redesigned revenue cycle workflows to increase efficiency. When
CHRISTUS Health’s revenue cycle departments converted to a
new IT platform—a move that affected several facilities—these high-
performance work teams facilitated the switch to the new system
and ensured rapid stabilization. “When we converted our systems,
although we experienced a slight blip in A/R [accounts receivable]
days, we recovered in less than 60 days. That’s an outstanding
achievement, especially considering there were some chargemaster
issues that held up billing for the first 30 days after the platform went
live,” says Cassandra Hogans, systems director, patient financial
services, CHRISTUS Health.
The use of metrics to conduct
root cause analysis was a key
to success for all MAP Award
winners. For example, in addition
to reviewing traditional metrics
for revenue cycle performance,
Legacy Health also reviews top
10 claim edits and top 10 charge
work edits, “So we’re actually
looking at the front end as well as the billing—what’s going out the
door,” says Terrie Handy, director of patient business services for the
health system. Through a careful, continuous review of key metrics
and root cause analysis, Legacy Health’s percentage of secured
accounts has increased to 99 percent at time of service, and the
system has achieved a net cash increase of nearly $20 million,
Handy says.
At St. Catherine Hospital, metrics are all web-based. “This pro-
vides us with an apples-to-apples-like comparison, plus it allows our
organization to have easy access to the data,” Hogans says. “We also
provide all of our managers, team leads, and supervisors with our
revenue cycle academy training, which includes root-cause analysis
as well as training in outcome action planning that relates to the root
cause analyses.”
St. Catherine Hospital uses “kaizen events”—five-day intensive
events “that allow us to redefine the process, implement metrics, and
implement team shift briefings as well as work management tools”—
to eliminate errors and enhance work flow within the revenue cycle,
Hogans says. “Our root-cause analysis is a significant part of that
process,” she says. Using root-cause analysis, St. Catherine Hospi-
tal’s net-to-cash conversion has increased from 88 percent to
95 percent, and many other CHRISTUS Health facilities have
achieved the same level of excellence. “Our success comes from
having well-designed, standard processes and tools,” Hogans
says. “That 7 percent difference can be multiplied by hospital net
revenues to determine our true cash benefit.”
At Concord Hospital, Concord, N.H, where the emergency
department (ED) is the busiest in the state, a process improvement
workgroup was initiated to assess the coding and charging process
for ED accounts. The workgroup was composed of ED physicians
Strategy No.2Use metrics to conduct root
cause analysis to facilitate
systemic change.
Strategy No.1Create teams dedicated
to revenue cycle
improvement.
At St. Catherine Hospital, high-per-
formance work teams enable each
cell to function as a mini-business
unit. Among the improvements
St. Catherine has experienced is an
increase in net-to-cash conversion
from 88 percent to 95 percent.
MAP Award-Winning
Strategies for Success
Seven specific strategies for revenue cycle
success came to light during interviews
with recipients of this year’s MAP Award.
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4. and nurses, the hospital’s coding manager, the ED director, the
patient access director, and the director of revenue management.
The group’s goal was to develop ways to decrease discharged-not-
final-billed (DNFB) days from 28 days to a sustainable standard.
Through a root-cause analysis, the hospital discovered that charging
and coding processes were separate functions performed by
various staff—creating unnecessary handoffs and delays, says Tom
Antinerella, director of patient access, Concord Hospital..
Implementation of a web-based application that generated
charges based on activities within the abstract/coding processor, as
well as the creation of rules and edits that each account must fulfill
before it is forwarded to the hospital’s billing system as a charge,
resulted in a 50 percent reduction in data entry time. As a result,
DNFB days for the ED have dropped, with only 18 percent of ac-
counts waiting for coding more than 10 days post-discharge by the
end of FY10. One lesson learned: “Don’t assume anything about a
process until you go and observe it,” Antinerella says.
Legacy Good Samaritan Medical
Center sends out a weekly dash-
board to the organization’s revenue
cycle leaders and to health system
office leaders to ensure that the
organization as a whole understands
how its revenue cycle is perform-
ing and leaders take responsibility
for the revenue cycle success of
the hospital and the health system.
Additionally, the organization has formed teams to address issues
such as billing delays and chargemaster challenges and has monthly
meetings with non-revenue departments, such as utilization review,
to address revenue cycle issues. “We have created a supportive
environment, and that is key,” Handy says. “It’s an environment that
is transparent and open, so that leaders can really bring those prob-
lems to the table and know that we will collaborate on a resolution.”
At St. Catherine Hospital, revenue cycle employees are trained
in Lean Six Sigma principles and are engaged in redefining revenue
cycle processes. The organization also has a pay-for-performance
program for revenue cycle associates, with incentives of $200 to
$400 per person for achieving predetermined individual levels of
performance as well as the potential for an additional $100 bonus
for meeting team performance goals. “I can truly say that our (rev-
enue cycle) associates own their processes. They are fully engaged.
They own the metrics,” Hogans says.
This year’s MAP Award winners
demonstrate an ability to look
outside the box in develop-
ing ways to build a culture of
collaboration. Legacy Health
developed a SWOT (strengths,
weaknesses, opportunities and
threats) team—a systemwide
operations team—with execu-
tive team support to investigate
and mitigate “silo issues” that impede performance improvement,
including clinical department operations that impact revenue cycle
improvement. The health system’s revenue integrity and patient busi-
ness services team also reaches out to hospital departments to iden-
tify and resolve issues that delay billing and payment. “For example,
our goal is not to have any accounts held up in Care Management
for patient status review, delaying billing,” Kjemperud says. “We work
together with Care Management staff to ensure that we’re on track
with that goal. We also hold a monthly forum where revenue cycle
and non-revenue cycle representatives discuss successes and issues
that require action, and work one-on-one with departments weekly
and daily, as needed. Teamwork and communication are the founda-
tion for our success.”
Concord Hospital developed
proactive measures to identify
patients in need of financial
counseling or services—and has
decreased bad debt as a per-
centage of uncompensated care
by 36 percent (bad debt ex-
penses were 41 percent of total
uncompensated care in FY10).
Strategy No. 4Step up efforts to collaborate
with other departments to
enhance revenue cycle
performance.
Strategy No.5Develop a comprehensive
approach to tackling
uncompensated care.
Strategy No.3Create a shared sense of
accountability for revenue
cycle performance.
Between 2003 and 2010, Concord Hospital’s level of bad
debt as a percentage of uncompensated care dropped from
77 percent to 41 percent, and charity care as a percentage of
uncompensated care rose from 23 percent to 59 percent.
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5. Strategy No.6Look for innovative ways to
enhance customer service.
“In 2005, we revamped our charity care policy and expanded the
number of financial counselors from two employees to seven,” says
Kevin Hunt, who recently retired from his position as senior director,
revenue management, Concord Hospital. “We also developed
an in-house Medicaid Advocacy Program, leveraged technology
to build prompts that would identify the need for intervention as
early as possible, and, in 2010, created a defined copay structure
for patients who receive financial assistance.” Concord Hospital’s
approach to uncompensated care reflects its culture of continual
process improvement. It’s also among many initiatives that have led
to patient satisfaction scores in the 94th percentile.
St. Catherine Hospital’s single-
call resolution policy ensures that
patients need only make one call
to the hospital or other facilities in
the CHRISTUS Health network
for their concern to be resolved.
“If our patients are calling with
a question or concern, there
shouldn’t be a need for the patient
to make additional calls to resolve
the issue,” Hogans says. “When there is a need for contact with an-
other department, we facilitate that contact and make sure that the
patient is being taken care of rather than giving the patient another
phone number to call. We also stay with the patient to ensure that
the patient’s concern has been handled and resolved.”
The health system has a centralized customer service center
that supports 11 hospitals. Requests for assistance are monitored,
and turnaround time is tracked to ensure that the health system’s
policy of resolving patient concerns within two working days is
adhered to. The health system closes the loop with a follow-up call
to patients. Formerly, the health system received 10 to 15 patient
complaints a day; now, they are a rarity. “I can’t recall when we last
received a complaint. It’s been in excess of two weeks, at least,”
Hogans says.
As part of its customer service
initiative, Concord Hospital has
worked to reduce the number of
times patients are asked for the
same information at its facili-
ties (about 50 facilities total). “It
certainly has enhanced the patient
experience,” Antinerella says, but
he adds that the initiative requires
staff to trust that information that
has already been recorded by another department or facility is
accurate. “It took time for departments to have trust with each other.
We still have issues with this,” he says.
Additionally, to speed registration times, some of the health
system’s physician offices have received the “gold stamp” to book
their own CT scans, MRIs, and other radiology imaging studies
through Concord’s registration system. “We’ve really pushed the
envelope here,” Antinerella says. The change has much delighted
both physicians and patients. “Our Press Ganey scores for speed of
registration have greatly improved,” he says.
One key to revenue cycle patient satisfaction at Legacy Good
Samaritan Medical Center: online bill pay, which has led to fewer
patient phone calls and statements, Handy says. Online payments
more than tripled from May 2009 to May 2011, increasing from
$41,000 to $142,000. Additionally, the hospital’s focus on customer
service has resulted in decreased call hold times.
Strategy No. 7Focus on improving the total
patient experience
Keeping Close Tabs on
Cost to Collect
Although cost-to-collect ratios were not evaluated as part of
the MAP Award for High Performance in Revenue Cycle, all
of this year’s MAP Award-winning organizations focused on
cost to collect as a measure of their success. The following
are a sample of cost-to-collect percentages maintained by
MAP Award winners:
l
Legacy Good Samaritan Medical Center: 1.6 percent
l
Texas Health Presbyterian Hospital Plano: 0.9 percent
l
Princeton Baptist Medical Center: Less than 3 percent
l
Baylor Medical Center at Irving (central business only):
0.8 percent
Legacy Good Samaritan Medical Center’s focus
on improving customer service has decreased
caller hold times, more than tripled the number
of online payments, increased point-of-service
collections by 40 percent in one year, and more
than doubled real-time eligibility transactions
over the course of a year.
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6. “The more that a hospital can automate its
processes, the more it can lift the burden
from its staff.” —Suzanne Lestina, HFMA
director of revenue cycle/MAP
Days
in A/R
Cash
Collection
POS Cash
Collection
Aged A/R
90 Days
DNFB FBNS DNSP Bad Debt Charity
Care
Mean 41.5 98% 23% 23% 6.4 1.3 7.3 3% 4%
Median 40.3 100% 20% 24% 5.7 0.9 6.7 2% 3%
Minimum 23.4 44% 1% 2% 2.1 0 3.6 1% 1%
Maximum 70.5 115% 65% 44% 17.4 9.0 19.7 37% 25%
Percentiles
10th 31.6 105% 53% 10% 3.7 0.1 4.7 1% 1%
25th 35.6 102% 36% 16% 4.6 0.4 5.7 1% 2%
50th 40.3 100% 20% 24% 5.7 0.9 6.7 2% 3%
75th 46.6 96% 7% 28% 7.0 1.5 8.4 3% 5%
90th 54.0 91% 5% 35% 10.0 2.4 10.2 6% 7%
Data were collected from nearly 150 applicants for HFMA’s 2011 MAP Award for High Performance in Revenue Cycle.
POS = Point of Service
DNFB = Discharged Not Final Billed
FBNS = Days in Final Billed Not Submitted to Payer
DNSP = Days in Total Discharged Not Submitted to Payer
At a Glance
Revenue Cycle Statistics from 2011 MAP Award Applicants
Patient-Would-Recommend Scores,
2011 MAP Award-Winning Organizations
Texas Health 81 percent
Lynchburg General Hospital 80 percent
Geisinger Medical Center 79 percent
CHRISTUS Health—St. Catherine Hospital 75 percent
Princeton Baptist Medical Center 78 percent
Saint Francis Hospital 75 percent
Sharp Grossmont Hospital 75 percent
Baylor Medical Center at Irving 77 percent
Legacy Good Samaritan Medical Center 80 percent
Spectrum Health Grand Rapids Hospital 78 percent
Baptist Hospital of Miami 79 percent
Concord Hospital 81 percent
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7. Key Performance Indicators for
Tracking Performance
HFMA has developed a common set of revenue cycle key perfor-
mance indicators (KPIs) known as MAP Keys in collaboration
with multiple stakeholders. The MAP Keys promote the consistent
reporting practices and peer-to-peer comparisons needed to
achieve significant revenue cycle performance improvement.
Embracing the MAP Keys for tracking revenue cycle performance
can help hospitals identify revenue cycle performance trends and
proactively prioritize and address areas in need of attention.
The following 25 KPIs constitute the MAP Keys:
Patient Access
Point-of-Service Cash Collections
Charity Care
Preregistration Rate
Insurance Verification Rate
Service Authorization Rate
Conversion Rate of Uninsured Inpatient to Payer Source
Revenue Integrity
Days in Total Discharged Not Final Billed (DNFB)
Days in Total Discharged Not Submitted to Payer (DNSP)
Late Charges as a Percentage of Total Charges
Net Days Revenue in Credit Balance
Denial Write-Offs as a Percentage of Net Revenue
Claims Adjudication
Aged A/R as a Percentage of Billed A/R by Payer Group
Days in Final Billed Not Submitted to Payer
Initial Denial Rate—Zero Pay
Initial Denial Rate—Partial Pay
Denials Overturned by Appeal
UB04 (837I) Clean Claim Rate
Management
Aged A/R as a Percentage of Billed A/R
Net Days in Accounts Receivable
Cost to Collect
Cash Collection as a Percentage of Adjusted Net
Patient Services Revenue
Bad Debt
Charity as a Percentage of Uncompensated Care
Case Mix Index
Cost to Collect by Functional Area
Communication Integral
to High Performance
One key attribute stands out among this
year’s MAP Award winners: effective com-
munication both within all areas of revenue
cycle operations and with departments
that are key to revenue cycle success.
Hospitals seeking to achieve high levels of revenue cycle per-
formance should begin by relaying the importance of revenue cycle
initiatives to the organization as a whole, and obtaining buy-in from
the top down.
“It’s important that hospital leaders—and in particular, healthcare
finance professionals—consider how to effectively communicate
risk and the importance of solving an issue that relates to revenue
cycle performance, because it’s only through that communication
that they are going to be able to get people to say, ‘We need to fix
this. We need to be working on this right now,’”says Suzanne Lestina,
FHFMA, CPC, director of revenue cycle/MAP for HFMA.
“For example, denials are not just a revenue cycle issue. If an
organization’s denials are clinical in nature, then the organization
will need to obtain clinical buy-in to be able to fix this issue, because
the revenue cycle department cannot solve this problem on its own,”
Lestina says. “So key stakeholders should be involved not only in
communicating the revenue cycle challenges the organization is
facing, but also in resolving those challenges.”
Effective communication between revenue cycle staff and other
departments that shape a hospital’s revenue cycle success also is
key to enhancing processes related to eligibility, Lestina adds.
Another important collaboration involves revenue cycle leader-
ship and the hospital’s IT department. “Developing a relationship
with IT that underscores the importance of the revenue cycle is
essential—so that when the IT department reviews its work order
requests, revenue cycle requests are elevated toward the top of
the pile based on the importance of the outcome,” Lestina says.
“The more that a hospital can automate its processes, the more it
can lift the burden from its staff,” she says.
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8. For more information,
or to register, visit
hfma.org/mapevent
Learn Strategies for Transforming Your
Hospital’s Revenue Cycle Performance
Celebrating Success
Upon learning they had won HFMA’s MAP Award for High Performance in Revenue
Cycle, the organizations described in this report shared the news of the achievement
quickly. “When we received the phone call informing us that we’d won the MAP Award,
we literally stopped in our tracks to take a moment to celebrate this achievement with
our team,” says Terrie Handy of Legacy Health. “We all felt not only excitement, but also
renewed energy, pride, and enthusiasm for our role in our organization’s revenue cycle
performance—and that enthusiasm will carry us through the next year.”
It’s important to celebrate revenue cycle achievements with the rev-
enue cycle team, MAP Award winners agree. “We’re thinking about
treating the MAP Award plaque like the Stanley Cup and passing it
from desk to desk,” Concord Hospital’s Tom Antinerella told attend-
ees of HFMA’s ANI: The Healthcare Finance Conference in June.
St. Catherine Hospital held a social in July to celebrate the award
not only with the revenue cycle team at St. Catherine’s, but also with
revenue cycle staff from throughout the health system, while Legacy
Good Samaritan’s MAP Award traveled from revenue cycle depart-
ment to department, even making a stop in the system’s C-suite
office to be shared with the organization’s leaders.
Recognizing the efforts of other departments in the organization
that contribute to the organization’s revenue cycle success also is
key. “The MAP Award is an organizational achievement. Our suc-
cesses in revenue cycle performance are not based on the efforts of
our revenue cycle staff alone; there are many other staff throughout
the hospital who have contributed to this success,” Antinerella says.
Move your organization’s revenue cycle performance to the next level at HFMA’s MAP Event, to be
held Oct. 26-28 at the Doral Resort in Miami. During the event, HFMA’s MAP Award winners will
share strategies to decrease net days in A/R, improve cash collections, reduce cost to collect, build a
cohesive leadership team, and more.
Best practice sessions that will be taught by MAP Award-winning organizations include the following:
l
OhioHealth: Aligning People, Processes, and Technology to Increase Collections, Reduce Bad
Debt, and Decrease Net Days in A/R
l
Henry County Health Center: Enhancing the Total Patient Experience
l
Lynchburg General Hospital: Leveraging Technology and Departmental
Collaboration to Improve Revenue Cycle Performance
The event also will feature a tour of MAP Award-winning Baptist Hospital of Miami.
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