1. When – Or When Not – to
Outsource the Revenue Cycle
Michael Bernstein
Madison Healthcare Advisors
Providing Excellence in Financial Solutions
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2. Reasons for Partnering
• Inability to attract or retain appropriately skilled
employees
• High cost of billing and collections
• Declining reimbursements
• Denial management
• Clinical documentation improvement
• Large volume of aged receivables
• Growing number of self-pay accounts
• Consistently not collecting 100% of NPR
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3. Reasons for Partnering - continued
• Constantly changing payment protocols and processes
• Underutilized or outdated revenue cycle technology
• Lack of migration plan for new systems of system
conversions
• Regulatory issues: compliance, Patient Protection and
Affordable Care Act, HIPAA 5010, ICD-10
• Consumer expectations: cash pricing and bundled
payments
• Improved A/R = Improved operating income
• Hospital versus physician processes
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4. Common Myths
• Loss of control
• Admitting to failure
• The most important factor is selecting the lowest-priced
partner
• Only a few need to make the decision
• Expect a seamless transition
• Specific performance standards are not required
• Termination is an easy process
• The hospital/physician is indemnified against claims
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5. Solutions
• Onsite Projects
Health Full Revenue
– Cash recovery & Extended Patient Access
Information Cycle
A/R backlog Business Office Transformation
Management Transformation
– Computer
Conversions
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6. Expected Outcomes
• Improving and accelerating cash flow
• Sustainable results – best practices
• Avoid losses from aging receivables
• Reduction in bad debt and charity
• Reduced operating costs
• Access to enhanced technology
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7. Expected Outcomes - continued
• Access to management and staff with deep domain
expertise
• Ongoing training on best practices and regulatory
changes
• High-performing employees with incentive-based pay
systems
• Staff augmentation solutions
• Elimination of duplicate functions
• Improved customer satisfaction
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8. Revenue Cycle Experts
Dedicated to providing solutions that improve financial performance and
information management
Scheduling Preregistration Registration
• Appointment • Automated appointment • Patient check-in/kiosks PATIENT
coordination reminders • Referral authorization ACCESS
• Medical necessity • Eligibility verification confirmation
validation • Financial assistance • Scheduling
screening • Case management
HIM Revenue Quality Management CARE
• Clinical documentation • Contract management DELIVERY
Revenue Cycle
• Charge capture • Nurse audit
• Case management • Over/under payment detection
• Coding
• Transcription
• Claims submission • Payment prediction • Customer payment BILLING &
• Claims status • Automated dialer • Document management/ COLLECTION
• Denial management • Skip tracing workflow
• Payment/remit posting • Patient statements/
• Lockbox processing correspondence
• Insurance compliance
Budgeting
• Cost accounting DECISION
• Contract management SUPPORT/
• Clinical analytics PERFORMANC
• Physician practice analytics E ANALYTICS
• Key indicators
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9. Evaluation Process
• Study what a partnership means to your organization
• Ask yourself, “Is our current process achieving our
goals?”
• Understand your data
• COMMUNICATE – Board, executive management, and
middle management
• Identify potential partners
• Issue an RFI
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10. Evaluation Process- continued
• Conduct due diligence
• Don’t expect what you’re not willing to inspect
• Don’t rush the process
• Does the partner fit your organization’s culture?
• Don’t be afraid to succeed
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11. Performance Indicators
• There is no limit to what you should ask for
• Weight them as you deem appropriate to achieve your goals
• Administer incentives as well as penalties
• Examples:
• Cash collections
• DNFB
• Percent of A/R over 90 days
• Compliance
• Over-the-counter collections
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12. Contract Considerations
• Clearly define key performance indicators and scope of work
• Accuracy of metrics is critical
• Clearly delineate number of days that you receive the collections
for work in progress at transition
• Incentives and penalties: how much and settlement dates
• Consider your cash requirements when developing the incentive
calculation
• Third-party responsibility (i.e., underpayment recovery, silent PPO
recovery, denial and appeal recovery)
• Location of outsourced staff
• Collective bargaining considerations
• Whose technology will be utilized?
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13. Consider…
“What do we have to do today to be ready for an uncertain
tomorrow?”
“What futurity do we have to build into our present
thinking and doing, what time spans do we have to
consider, and how do we use this information to make a
rational decision now?”
Peter Drucker
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14. Questions?
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