My first article of the year is on the topic of health care revenue cycle and what consultants work on regarding those areas. In the past I touched upon 4 specific areas of revenue cycle and areas concerning revenue cycle. It might help some of you to go back and review those articles before reading the rest of this post. There are others of course, but these work best with this article.

Let's look at some of the biggest concerns that revenue cycle consultants run into when working with these areas. These aren't necessarily the biggest issues hospitals are having at the time they reach out to consultants, but the biggest issues consultants find and try to work with their clients on.

A. Admissions

1. Lowest paid employees

The people in admissions have become one of the most important assets to every hospital as it pertains to getting their money in quicker. Yet, in most cares these folks are the lowest paid in the revenue cycle area, let alone the rest of the hospital. Even though people aren't supposed to discuss their salaries, everyone has an idea of what someone else is making, and knowing you're being paid less than you believe you're worth never helps anyone.

2. Biggest opportunity for insurance fraud

This is mainly via the emergency room, but anyone with a little bit of intelligence can get free health care if they know how the process works. It's not uncommon for some people to give their insurance cards to someone else to use when they go for health care services, not realizing it's illegal, even if they know it's wrong. No matter whether you ask for identifying information or not, there's no way you can force someone to share it with you or prove that they might have it on their person.

3. Scheduling

One of the first questions I'll ask is whether there's been any charting of the registration patterns to see when it gets busy and when there's significant downtime. I've seen where a lot of hospitals schedule their employees based on tradition more than anything else, which could mean they're overstaffed, understaffed or just improperly staffed to handle the workload.

B. Charge Capture

1. Insufficient training

I find two things most often.

The first is learning that almost all the people who capture charges were taught by someone else who captures charges, who learned from someone else who captured charges, on and on. I've never found a single department that had any written procedures for how to capture charges.

The second is finding out that not only do directors of these departments often don't know how the charge capture process works, but some of them have never looked at their charge master to even see what they might be missing. One time I met with a director who owned up that he'd never seen the charge master. I showed him that one of his departments didn't have a single price on any of the services they were charging; I thought he was going to pass out, especially when he revealed that he'd only been in the job for 5 months but that the previous person had been in that position 4 1/2 years.

2. Little verification between charges captured by dept vs what the computer shows

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Yours truly!

The second part of #1 leads to this issue here. When I do a charge master review I often see services that a department should be doing a lot of with little activity and other services that shouldn't have much activity showing a lot. I'll usually ask general questions to see what the director and people who capture the charges say about these types of services before I show them what the revenue numbers reveal.

3. Sometimes a charge master has multiple confusing charges

Once I had an interim director ask me to come help him revamp his departments charges because they had multiple charges for the same services with different written descriptions. Each employee was picking what they'd originally been taught to use but only one charge on the charge master was still listed in the computer system for revenue capture.

C. Billing/Patient Accounting/Business Office

1. Insufficient training

I've walked into business offices where employees didn't know how to follow up on outstanding (unpaid) claims. At one hospital they weren't even allowed to, as the supervisory staff thought everything should go through them, which of course they didn't have the time to do. I've even met with directors who didn't know the billing rules of some of their most prominent insurance carriers. Yet, training is always on the back burner because of either the belief that it's too expensive or too time consuming.

2. Rules are always changing

With almost every insurance company, some of the rules change every year; Medicare seems to change some rules every couple of weeks. Because there are so many rules and so many insurance companies to deal with, and because often contract information isn't passed down to the billing department, I find that many claims that have to be written off because no one knew the rules and they're not liable for payment for one reason or another.

3. Way too many claims to manage properly

If there's one department that should never be understaffed it's the department hospitals count on to bring in the money. I sometimes walk into hospitals where each employee is expected to be able to properly work over 4,000 claims or more. Since no two claims are alike, it's an impossible situation to expect better of. Sometimes all it takes is proper training or a true look at revenue to see if there are things in the system that shouldn't be there, but initially it's hard to do because of a lack of personnel and, unfortunately, poorly trained directors.

D. Collections

1. Tough job asking people for money

If it's hard to ask someone to pay back $25, you can imagine how hard it can be to ask people to pay their hospital bills, which could be in the thousands. The biggest difference between health care and other industries is that most of the time health care asks for payment after services have been completed, sometimes after many months or even years. That kind of thing makes folks on both sides very cranky.

2. Need to balance the needs of the facility with the needs of patients

Understanding that health care is a business is one thing; making outrageous demands on patients to pay self pay claims is another. I've known hospitals that had policies saying that no matter the balance, if the patient didn't set up a payment plan to pay the bill within 6 months that they were going to send them to collection. How many of us can pay an unexpected $10,000 bill off in six months? Who do you think has to take the brunt of anger at this type of policy, written by a person who never has to talk to anyone on the phone?

3. Way too many claims to manage properly

If you think the number of claims billing personnel is high, you should take a look at how many claims collections people have. Most collections departments have way fewer employees trying to work on a lot more claims, and even with robo-calling (which has many restrictions) can't help them get to everything. Not only that, but because Medicare accounts can't be sent to collections until 120 days, it's another factor in keeping those numbers keep growing.

There's a lot more with each of these categories, yet it's a good thing to start with. You might not achieve Pareto principle types of numbers, but doing it on your own or working with a good consultant (like me lol) can improve your status a lot.