How to Mitigate Revenue Cycle Risk During an EHR Implementation
Vice President of Revenue Integrity and Centralized Coding, Change Healthcare
Elaine Dunn has more than 20 years of experience in clinical operations, revenue cycle performance improvement, revenue integrity, and coding operations.
Onboarding an electronic health record (EHR) is one of the most complex and disruptive implementations a healthcare organization can undertake. This type of initiative impacts, and in many cases, fundamentally changes every aspect of your clinical and financial operations.
Given the size and scope of these projects, it’s not surprising that the revenue cycle implications are vast, and an unsuccessful implementation can pose significant financial risks to your organization. According to a report by the credit rating firm, Moody’s, hospitals experiencing implementation problems can see operating losses, lower patient volumes, and more receivables write-offs, as well as other operational and financial disruptions.
To reduce potential risks, organizations should approach an EHR initiative holistically, proactively considering how the project’s clinical and financial elements interweave. Going a step further, organizations must intentionally work to optimize the features of both the new EHR and the revenue cycle management (RCM) solution while mitigating the risk of revenue loss during the transition. By embracing this kind of strategy, you not only can avoid negative financial outcomes but can seize opportunities to improve RCM performance.
Although pursuing a holistic approach may seem daunting, the following best practices can serve as a guide, helping organizations keep RCM top-of-mind and lay the foundation for a financially successful initiative.
Establish an RCM-Focused Team
Most EHR implementations are driven by the IT department with revenue cycle representing one of many project stakeholders. Without a concerted effort to have the RCM perspective heard, the department’s needs, requirements, and perspectives can get lost.
One way to mitigate this risk is to create a revenue cycle steering committee. This group should be actively engaged in providing EHR project direction and take charge of any strategic RCM assessments. They should weigh in on essential decisions, such as how to map the flow of data between systems, which technology will manage each part of the revenue cycle, and what scenarios should be tested prior to go-live.
Assigning a project manager who can serve as a liaison between the steering committee and the IT department is also valuable. Since this individual will be more involved in day-to-day tasks, they will be well-positioned to share useful insights with both groups.
Revenue cycle subject matter experts should also be present at any system build or sub-committee meetings because there will be decisions regarding charging and revenue that require RCM-specific expertise and direction. This includes involving revenue integrity perspectives in all clinical documentation and charge discussions.
To make sure your team is available throughout the different system implementation phases and is engaged at the various levels described above, take time to plan for and allocate resources accordingly.
Conduct a Full Revenue Cycle Assessment
Since a new EHR fundamentally changes most revenue cycle processes, health systems that try to keep current RCM workflows intact while onboarding a new EHR often run into problems. Before embarking on the implementation journey, consider conducting a comprehensive revenue cycle assessment in which you evaluate current workflows, pinpoint risk, and identify opportunities to improve process efficiencies and collection yields. This enables a more intelligent and intentional design and build and allows you to execute needed changes prior to the system conversion.
The assessment should cover the entire revenue cycle continuum. On the front-end, you should review patient access functions, including prior authorization, registration, and patient collections. Efficient, patient-centric workflows in these areas are critical to maintaining patient satisfaction during and after the conversion.
For the mid-cycle, examine everything that happens from the point of service through billing, with a special focus on clinical documentation and charge capture. Look for issues and opportunities in these areas that could be addressed in a new system build. For example, new EHRs may allow you to move charge edits further up into the workflow to the point of charge generation, which streamlines the process by putting certain edits in the hands of revenue owners as opposed to accruing back-end edits that require multiple touches. Think through whether shifting charge edits in this manner is appropriate for your organization and what the effects of that decision would be.
As part of a mid-cycle review, be sure to evaluate billing and claim edits as well. Assess whether your current edits are still valid, and if they are, how they will be reproduced in a new system. Often, organizations build edits and then don’t go back and revisit them. A new system implementation presents an ideal opportunity for such a review.
Back-end assessments should examine processes that happen once the claim is submitted to the payer, including accounts receivables management, expected-versus-actual payment analysis, and denials management. Note that your organization may choose to work A/R inventory that exists at go-live within the legacy system while managing new inventory in the new system. As part of a back-end assessment, consider what this might mean for productivity and inventory management and create a burn down plan that enables efficiency and minimizes risk.
Make Sure Your Chargemaster (CDM) Is Ready
As the EHR initiative gets underway, you should check that your critical systems, such as the CDM, are ready for the move. Typically, building a CDM in a new EHR involves copying over the current CDM information and reformatting it for the new system. However, you shouldn’t just copy the CDM blindly. Instead, take time to verify that existing codes are active and not duplicative, and validate that what you are currently charging is complete and compliant for all services provided. This is also the time to identify where the legacy CDM needs to be redesigned to fit into the established guiding principles and the new EHR’s technical structure.
If your project involves moving to a common database for all sites, the EHR platform will typically require one common CDM across all sites while still allowing certain pricing variations. This will most likely force you to standardize data attributes and charge methodologies. If you don’t have an existing revenue integrity program in place to drive the work, create guiding principles that address compliance and revenue optimization considerations. Some key things to think through include charge methodologies by service line, how statistical charges should be handled, when services need to be duplicated versus consolidated, and how to tackle payer-specific claim requirements. Also, be sure to standardize revenue codes and descriptions and how you charge for services across all sites.
Reconciling the clinical system with the CDM system is also important. This process systematically links each clinical order to the CDM to identify where there are missing or incorrect links. To be most effective, you should completely validate all links versus using a sampling method. By fully reconciling, you can not only catch errors but also identify additional clinical build modifications that may not have been identified to date.
Shore up Clinical Documentation Processes
With a new EHR, the documentation workflow for clinicians will change, especially as physicians use more templates. Although templates can create documentation efficiencies, they can also generate systemic errors if they aren’t specific enough or unintentionally promote inaccuracy. To help you see where documentation process changes are negatively impacting coding, conduct parallel documentation reviews prior to and during golive. It can be beneficial to have additional clinical documentation improvement (CDI) support tackle these reviews and manage increased query volumes as providers acclimate to the new system.
It’s also critical to understand how documentation workflow impacts charges. In many of the newer EHRs, clinical documentation drives charges. So if you’re going to be using more templates, make sure you understand how that affects charge capture and whether the system is correctly picking up charges or if there are areas you need to tweak.
Be Involved During Testing
Once a system is designed and built, the testing work begins. This is the time to check that RCM processes will function as they should within the new system. Efforts should focus on charge testing, parallel testing, and then full integrated testing to proactively identify possible issues. Testing should encompass all processes from pre-access through charge capture to claims generation, validating that each outcome meets the acceptable criteria for a clean, complete, and compliant claim. Before you consider testing complete, make sure you have the revenue cycle steering committee sign off. In fact, their approval should be mandatory before your organization moves to the next phase of implementation.
Plan for Inevitable Slowdowns
Prior to go-live, you should try to work down as many outstanding items as possible. For example, clear coding backlogs and check that discharge not final billed (DNFB) is current and accurate.
Since staff are learning new documentation practices and system functionalities, it is important to anticipate and plan for coding productivity issues as well. Health information management (HIM) resources will often get pulled into situations that require immediate attention. Be sure they have the time available to handle these problems without having to fit the work between other priorities.
As mentioned before, it is essential to think through how to stratify your workforce to manage A/R in two different systems, tackling outstanding inventory in the legacy system while addressing new inventory in the new system. This is especially important if accounts are not being converted to the new system.
Having staff work in multiple programs at the same time can create convoluted, ineffective processes that result in increased A/R days and subsequently decreased cash collections. Conversely, a stratified approach yields more efficient workflow, and it can minimize the likelihood of errors. Depending on your resources, you may want to bring in outside support temporarily to handle the legacy volume. While your team focuses on the new system, an outsourced team can manage the old accounts receivable and help you preserve cash flow. Outsourcing your receivables during this time can help your staff stay focused on implementation and training in time to confidently go live on the new system.
Monitor. Monitor. Monitor.
Continuous performance monitoring is a key project success factor. Not only does it help you return to revenue neutrality as quickly as possible, but it ensures you are getting to target revenue in the right way. Effective monitoring involves comparing post-go-live performance to preproject levels, looking for concerning patterns that need to be addressed.
Prime areas to watch include
- Service-to-payment velocity. It’s always wise to understand how fast you are getting paid and whether that has changed. A/R days is the industry standard metric for this analysis. It is normal to see an initial increase in A/R days, but you should return to pre-implementation levels relatively quickly.
- Discharged Not Final Billed (DNFB). This illustrates how long it takes to get a claim out the door. Spikes in DNFB could indicate process or people problems that warrant attention.
- Charge-to-cash conversion. This metric compares outgoing dollars to net income and is a function of gross charges. If this metric is substantially higher post-implementation, you need to see if you’re actually collecting more on each dollar because you’ve got better collection policies or practices in the new system or if it’s because you have potential issues with your pricing methodologies.
- Payer mix. By checking payer mix, you are verifying whether you set your plan codes up properly. If you haven’t correctly captured your payer mix in the new system, then it will affect how you’re reporting revenue. For instance, if you have a Medicare Advantage plan, and you’ve got it categorized as a commercial plan, it will skew how you report your payer mix, bad debt, and charity care. If payers have different requirements for claims, a misclassified payer can also lead to an increase in denials and negatively impact reimbursement.
- Coding and documentation. By comparing current charts to pre-conversion ones, you can spot changes in coding, charging, and documentation patterns that can have a negative effect on revenue and compliance. Some trends may not immediately be apparent post go-live, so it’s important to review charts regularly for several months.
- Charge trends. Watch for any charge delays to pinpoint which departments may not be submitting charges as quickly as before. Clinical departments should be engaged in the charge monitoring process, and charge reconciliation should occur daily as a standard practice. To ensure clinical involvement, create charge reconciliation policies and procedures and offer educational workshops with each cost center’s primary and secondary revenue owner prior to go-live, providing hands-on education on how they should capture and reconcile charges in the new system. Even though this type of training is not standard curriculum in most EHR implementation plans, it is critical to achieve rapid revenue neutrality.
In addition to training, conduct charge audits that trace charges from the point of order through to the bill to validate charge capture and verify compliant reporting. Also monitor unresolved charge rejections and pricing errors. Note that it may be helpful to use a neutral third party to maintain objectivity.
- Underpayments and denials. If you see big differences in underpayments and denials, it could indicate you have process or build issues that are creating claims that aren’t getting adjudicated correctly. When you spot an anomaly, try to identify root causes as quickly as possible. This helps reestablish processes that may be knocked out of alignment during a system change.
- Overall revenue. When monitoring revenue, look beyond just the cost center level. Also compare revenue and utilization patterns at a service or procedure level. This can help you spot significant net revenue or compliance impacts.
To stay on top of the monitoring effort right from the start, task specific resources to identify variances, conduct root cause analyses, and drive corrective actions—whether those are related to systems, processes, or people. As you start to generate data, set up a daily meeting with revenue owners to review variances and assign corrective actions. This will establish accountability for the work and keep everyone focused on improvement.
Keep your eye on the prize
Making sure your RCM and EHR technologies work well together is critical to ensuring solid long-term financial performance after an EHR implementation. By following best practices that keep RCM front and center throughout the initiative, you can not only mitigate risk but seize improvement opportunities. While good planning can go a long way, so can the right resources. Check that you have the correct levels of people, processes, and technology to support a smooth and financially lucrative implementation.
For more information on how Change Healthcare can help ensure RCM success during an EHR implementation, go to changehealthcare.com/solutions/revenue-cycle-management.