HFM Redesigned

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hfm SEPTEMBER 2019 | healthcare financial management association




CFO OF THE FUTURE How finance leaders like Advocate Aurora’s Dominic Nakis are adapting to relentless change


contents SEPTEMBER 2019 ISSUE

news 14 16

HFMA'S News Quick hits: Top news stories of the month CHAPTER NEWS HFMA recognizes lifetime member status JENNIFER NOVOSELETSKY


NEWS WATCH 3 ways the public option could endanger more than half of U.S. rural hospitals RICH DALY


RESEARCH HIGHLIGHT Hospitals, health systems prepare to take on more risk ERIKA GROTTO


IN THIS EDITION 10 From the chair: Share the Dare. Michael M. Alllen FHFMA, CPA 62 From the president: Improving the patient financial experience starts with us. Joseph J. Fifer, FHFMA, CPA INSIDE HFMA 12 Announcing the winners of HFM Best Article award for 2018. Eric Reese

EYE ON WASHINGTON Do presidential Dem. candidates see a role for private insurance? GAIL R WILENSKY, PHD


columns 50

LEADERSHIP Why prioritizing workplace integrity matters JILL GEISLER

Bundle Up: How one organization uses analytics to optimize EHR Stephen Morgan and Nick Hut discuss the process. hfma.podbean.com

Inside this section: 50 Leadership / 56 Podcast


hfm SEPTEMBER 2019 | healthcare financial management association




CFO of the Future How finance leaders like Advocate Aurora’s Dominic Nakis are adapting to relentless change

On the cover Dominic Nakis Cover Photograph Bill Konway

Expert Reviewed  Feature Stories in hfm® bear the Expert Reviewed stamp, which indicates that content has been evaluated by an independent panel of healthcare professionals who have the expertise to ensure accuracy, credibility, and usefulness of information. Disclaimer Material published in hfm is provided solely for the information and education of hfm readers. The Healthcare Financial Management Association (HFMA) does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions in articles and columns in hfm are those of the authors and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear in such articles or columns do not constitute endorsements by HFMA.

hfm® (ISSN 0735-0732) is published and distributed monthly by the Healthcare Financial Management Association (HFMA), Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. Subscription Rates/Orders: Subscriptions within the United States are $260 per year. Outside the United States, North American subscriptions are $270 per year. Other foreign subscriptions are $280 per year. Institutional subscriptions are $150 per year. Postmaster: Periodicals postage paid at Bellwood, IL 60104, and additional mailing offices. Send address changes to HFMA, Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. Copyright 2019, Healthcare Financial Management Association. All rights reserved. Printed in the U.S.A. Volume 73/Number 7.



contents AUGUST 2019 ISSUE

features 32


COVER STORY Dominic Nakis: The healthcare CFO of the Future LAURA RAMOS HEGWER AND NICK HUT


FEATURE STORY How an Iowa hospital earned 2MAP Awards for excellence in revenue cycle performance ERIKA GROTTO


CASE STUDY 4 strategies for an AI-driven approach to improve revenue cycle performance ERIK NILSSON


EXPERT REVIEW 5 lessons on launching a provider-sponsored health plan

8 Business Profile Ontario Systems: Helping healthcare organizations realize the benefits of accountable collections team 54 Business Profile Enjoin: Enabling Holistic Clinical Documentation Improvement 35 Peer Review Spotlight 62 Carrer Opportunities



How providers should adapt to demands of consumer-driven healthcare system


COMMENTARY How primary care physicians can navigate business intelligence challenges under risk models THERESA HUSH

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2019-20 Officers Chair: Michael M. Allen, FHFMA, CPA, CFO, OSF Healthcare System, Peoria, Ill. Chair-Elect: Tammie L. Galindez, CHFP, associate vice president, value based care, Conifer Health Solutions, Frisco, Texas Secretary/Treasurer: Aaron R. Crane, FHFMA, CFO and Vice President, Seattle Cancer Care Alliance, Seattle President and CEO: Joseph J. Fifer, FHFMA, CPA, Healthcare Financial Management Association, Westchester, Ill. 2019-20 Directors Abby Birch, CRCR, regional director, business development, Revint Solutions, Fort Lauderdale, Fla. Dennis Dahlen, CPA, CFO, Mayo Clinic, Rochester, Minn. James L. Heffernan, FHFMA, senior vice president of finance and treasurer, Massachusetts General Physicians Organization, Boston Jeffrey T. O’Malley, vice president, partnership integration, Dignity Health, Phoenix Cindy Price, FHFMA, CEO, Houston Shared Services Center, Parallon Business Performance Group, Houston Marc B. Scher, CPA, partner-in-charge, U.S. and Global Audit Healthcare Practice, KPMG LLP, Orange County, Calif. Margaret L. Schuler, MBA, system vice president, revenue cycle, OhioHealth, Columbus, Ohio Mimi Taylor, CIO and corporate vice president of information technology, Baptist Health South Florida, Coral Gables, Fla. T. Carley Williams, CPA, partner, BKD LLP, Tulsa, Okla.

hfm® is published monthly by HFMA. Editorial Mission hfm® supports the mission of the Healthcare Financial Management Association by serving as a key resource for individuals involved in the financial management of health care. Editorial Position hfm® is written and edited principally for finance professionals in health service organizations all along the continuum of care, including hospitals and health systems, managed care and accountable care organizations, physician organizations, outpatient service centers, and post-acute care providers. It also is directed to professionals in law firms, accounting firms, banks, and consulting firms that have an interest in healthcare finance. hfm® covers the full range of topics related to healthcare finance. Key topic areas include strategic planning, hospital-physician alignment, payment, revenue cycle, patient financial services, enterprise risk, business intelligence, information systems, network development, accounting practices, leadership development, management issues, legislative and regulatory issues, capital finance, cost management, consolidation and affiliation, and emerging financial trends. About HFMA The Healthcare Financial Management Association (HFMA) provides the resources healthcare organizations need to achieve sound fiscal health in order to provide excellent patient care. With more than 38,000 members in 66 chapters, HFMA is the nation’s leading membership organization of healthcare finance executives and leaders. Membership in HFMA provides opportunities to attend educational seminars and conferences, to access technical and management information, to obtain professional certification, to interact and network with colleagues, and to gain other professional benefits. For information about annual membership dues, which include a $30 allocation to hfm magazine, contact Member Services at (800) 252-HFMA, ext. 2.



offering(s) help address these needs?

mbedded technology helps providers get more done with less by utomating aspects of the collections process. It supports greater Ontario Systems empowers healthcare organizations to maximize ADVERTISEMENT roductivity and accountability for each collection contributor their technology and talent to reduce costs while increasing produc— including those working insurance claims, denials, appeals or tivity and cash flow. Our technology and solutions help providers alances from patients — and enables supervisors and leaders to track maximize labor investment and reduce turnover by increasing rogress and outcomes so contributors can perform at optimal levels. productivity through our embedded data strategy and supporting We recognize that providers have complex ecosystems of servers, and incentivizing staff through on-screen gadgets and dashboards echnology solutions, electronic health records (EHRs) and data. Our SPONSORED BYprogress ONTARIO that illustrate andSYSTEMS promote accountability. roduct family can serve as an aggregation point for this disparate data, tandardize it and then funnel it through workflow, ultimately driving We enable providers to address challenges related to shrinking reimburseositive business outcomes. ments and growing patient out-of-pocket responsibility by maximizing a collector’s time and effort, automating processes whenever possible so staff can focus on the exceptions that require their attention. ADVERTISEMENT

business profile

Helping healthcare organizations realize the benefits of accountable collections team

What are some of the biggest challenges you see affecting healthcare organizations?

weeping regulatory changes, rising healthcare costs, constricted ayer reimbursement and increasing patient responsibility are compliating providers’ collection strategies and shrinking already narrow perating margins. With margins often below 2%, there’s not much oom to operate profitably. These challenges are exacerbated when an rganization wants to grow to meet changing demands of its community. ike any business, a provider either has to “sell” more services or be more intentional about costs to increase its operating margin.

inding ways to maximize large investments, such as the EHR and abor, also poses challenges to the healthcare finance community. September 2019

Moreover, our technology can help reduce wasted payer hold time on calls by leveraging data and analytics, so collectors can work multiple claims on the current payer call. While the next prioritized payer call is automatically launched, the IVR is automatically navigated and payer collector.awaiting By working right number oftime claims perthe payer call and hold time is consumed thethe target-connect with

performance through data. Wit obtaining significantly more payer connects through the day, produccoach their collectors to be mor tivity significantly increases. Providers should seek out techn this Businesstechnology Profile, Steve Scibetta, vice president OurIncloud-based is quick to deploy, integrates with an certain aspects of collections. F What are some ofOntario the biggest challenges and general manager at Systems, discusses organization’s existing EHR/ecosystem and promotes accountability, consume payer hold time while productivity and quality assurance by allowing leaders to monitor staff reduce downtime from five, ten strategies foraffecting optimizing the revenue cycle through you see healthcare organizations? andsupportive implement accounts interventions for process improvement. This maximizes their useful time receivable technology and With the right Sweeping regulatory changes, rising healthcare data, providers accurately assess performance building an can accountable collections team. and identify and training opportunities. costs, constricted payer reimbursement and increasSTEVE SCIBETTA coaching

What advice would

Vice President, General Manager © 2019 Healthcare Financialat Management Association Ontario Systems

ing patient responsibility are compli-cating pro- leaders when choo What are some key considerations for hfma.org already viders’ collection strategies and shrinking Ideally, vendors should be innov healthcare leaders when choosing this narrow operating margins. With margins often be- industry, a strong install base an typelow of2%, product Are there profitably.new technologies. Their service there’s or notservice? much room to operate diverse to meet various business keyThese product/service features that people challenges are exacerbated when an organizaand capable of meeting non-bu should about? tion know wants to grow to meet changing demands of itsthe cloud. When choosing a ven partners well and offers contem To accelerate reimbursement and self-pay collections, a providereither has How do you help healthcare organizations? community. Like any business, a provider should build an accountable collections team comprised of individuals Ontario Systems is a 35-year-old company that to focused “sell” on more services or be more intentional aboutAs healthcare orga who are generating reimbursement, including those working with insurance, denials, and self-pay collections. continues to innovate in our industries, bringing costs to increase itsappeals operating margin. use of your produc When looking for a solution to facilitate and support staff in these roles, new solutions forward to the markets we serve. We the system Finding todata maximize investments, shouldways leverage to identify large the associate’s priorities such day-to-day operati upon their skill and set and the day’s assignment. should provide accounts receivable and revenue cycle man- basedas the EHR labor, also poses Providers challenges to the you offer so they ca look for solutions that generate a toolset and dashboard for employees age-ment technology, software and solutions to help so theyhealthcare finance community. can facilitate calls knowledgably, take concise action and move up for success? next priority. Technologyare should also besignificant data-embedded, While organizations making investhealthcare providers address their biggest business on to the When implementing one of our which flags exception-based issues for the employee’s intervention mentstheir in time EHRs and onboarding talented people, the the organization to revisit, rewo challenges. With increasing out-of-pocket expenses to maximize and effort. technology offered by the industry is often insufficientWe highly recommend creating for patients and reductions in payer reimbursements, An effective solution should present tips and tricks to staff in order to committee that helps assure im to support and optimize these resources. This impactsproject’s pace are on track. In a today’s hospitals and health systems yearn to improve efficiently guide them through their day. For example, a system should to identify whenemployee an employeesatisfaction can work through multiple productivity, and turnover risk,organization should also engag productivity, increase collections and reduce costs. be able claims on a single call and automatically present that information, their goals so that we can then r which are costly to the organization. The growing usethe products in a way that will fu Our data- and analytics-embedded technology helps in priority order, to the collector. Features like this help the collector comply policy and training, in additionposes to beinganother as efficientrelated and ofwith work-at-home collectors chalproviders get more done with less by automating productive as possible. lenge in that providers need the right technology and Are there any educ aspects of the collections process. It supports greater Providers should also look for technology and solutions that enable data manage monitor remote workers.would like to share productivity and accountability for each collection them to listentotosupport, calls in real time or afterand the fact via recording, allowing them to intervene and improve productivity, quality or compliance. contributor — including those working insurance providers in these e This feature isn’t about getting staff into trouble. It’s about accountability How does or service claims, denials, appeals or balances from patients — and incentivizing For more information about On staffyour to riseproduct to the next level of performance. Many visit www.ontariosystems.com. are launching intentional qualitythese assurance programs, meeting offering(s) help address needs? and enables supervisors and leaders to track progress providers podcasts, webinars and blog ar with associates on a periodic basis and assessing quality and Ontario Systems empowers healthcare organizationsAccountable Collector, please and outcomes so contributors can perform at optimal to maximize their technology and talent to reduce levels. We recognize that providers have complex ecosystems of servers, technology solutions, electronOntario Systems is a leading provider of enterprise revenue cycle managem ic health records (EHRs) and data. Our product family accounts receivable management, and government markets. Established in Ind., Ontario Systems offers a full portfolio of leading software platforms, inc can serve as an aggregation point for this disparate Contact Savvy®, and RevQ®. Ontario Systems’ industry-leading customers data, standardize it and then funnel it through worknetworks who actively manage over $40 billion in receivables collectively, a companies and more than 100 federal, state and municipal government clie flow, ultimately driving positive business outcomes. Ontario Systems is a leading provider of enterprise revenue

This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accu management software the healthcare, accounts those ofcycle the participants and not those of HFMA. Referencesto to commercial manufacturers, vendors, products, or services that may appear do not

receivable management, and government markets.



costs while increasing produc-tivity and cash

generate a toolset and dashboard for employees so

flow. Our technology and solutions help providers

they can facilitate calls knowledgably, take concise

maximize labor investment and reduce turnover

action and move on to the next priority. Technology

by increasing productivity through our embedded

should also be data-embedded, which flags excep-

data strategy and supporting and incentivizing staff

tion-based issues for the employee’s intervention

through on-screen gadgets and dashboards that

to maximize their time and effort.

illustrate progress and promote accountability.

An effective solution should present tips and tricks

We enable providers to address challenges related

to staff in order to efficiently guide them through

to shrinking reimburse-ments and growing patient

their day. For example, a system should be able to

out-of-pocket responsibility by maximizing a collec-

identify when an employee can work through multi-

tor’s time and effort, automating processes whenev-

ple claims on a single call and automatically present

er possible so staff can focus on the exceptions that

that information, in priority order, to the collector.

require their attention.

Features like this help the collector comply with

Moreover, our technology can help reduce wasted

policy and training, in addition to being as efficient

payer hold time on calls by leveraging data and ana-

and productive as possible.

lytics, so collectors can work multiple claims on the

Providers should also look for technology and

current payer call. While the next prioritized payer

solutions that enable them to listen to calls in real

call is automatically launched, the IVR is automat-

time or after the fact via recording, allowing them

ically navigated and payer hold time is consumed

to intervene and improve productivity, quality or

awaiting the target-connect time with the collector.

compliance. This feature isn’t about getting staff

By working the right number of claims per payer

into trouble. It’s about accountability and incentiv-

call and obtaining significantly more payer con-

izing staff to rise to the next level of performance.

nects through the day, produc-tivity significantly

Many providers are launching intentional quality


assurance programs, meeting with associates on

Our cloud-based technology is quick to deploy,

a periodic basis and assessing quality and perfor-

integrates with an organization’s existing EHR/

mance through data. With these types of tools,

ecosystem and promotes accountability, produc-

providers can help coach their collectors to be more

tivity and quality assurance by allowing leaders

productive, efficient and successful.

to monitor staff and implement interventions for

Providers should seek out technology and solutions

process improvement. With the right data, provid-

that help automate certain aspects of collections.

ers can accurately assess performance and identify

For instance, technology that can consume payer

coaching and training opportunities.

hold time while a collector is conducting other calls can reduce downtime from five, ten or fifteen min-

What are some key considerations for healthcare leaders when choosing this type of product or service? Are there key product/service features that people should know about? To accelerate reimbursement and self-pay collections, a provider should build an accountable collections team comprised of individuals who are focused on generating reimbursement, including those working with insurance, denials, appeals and self-pay collections. When looking for a solution to facilitate and support staff in these roles, the system should leverage data to identify the associate’s priorities based upon their skill set and the day’s assignment. Providers should look for solutions that

utes per call to seconds. This maximizes their useful time and boosts productivity.

What advice would you offer to healthcare leaders when choosing among vendors? Ideally, vendors should be innovative and have tenured experience in the industry, a strong install base and be continually evaluating and adopting new technologies. Their service offerings should be mature, evolving and diverse to meet various business needs. Vendors should also be agile and capable of meeting non-business needs as well, such as moving to the cloud. When choosing a vendor, providers should look for one that partners well and offers contemporary pricing/bundling strategies. ❚



inside HFMA





‘Share the Dare’ challenges everyone to do bold things MICHAEL M. ALLEN FHFMA, CPA Chair, HFMA @Allen0777 Instagram @michaelallen9185


Dares in my first column here in June and during my presentation at the HFMA Annual Conference in Orlando. I also talk about it when I’m out speaking with chapters and regions across the country about my Dare You 2 Move (DY2M) theme. DY2M is all about breaking out of what’s comfortable, easy and familiar and daring yourself to do something bold. The HFMA 1000 Dares Project adds an element to that idea: It says there are no disposable moments and that no action is too small or insignificant when you move to make a difference, take the dare or leave the safety of the familiar. So let’s do bold things at work, at home and as we serve others in HFMA and elsewhere. And as you meet that challenge, use the hashtag and the “Share the Dare” page on LinkedIn, and share your stories. I want to see 1,000 bold stories shared. When I was talking to a group of finance leaders at OSF HealthCare recently, a woman raised her hand and said she was 40 years old before she found the courage to jump on a trampoline for the first time. That’s a great story! Everybody’s moments are different. I started the thread with my own DY2M moment. You can read

it on the project web page, but many more stories have rolled in since mine. I want to highlight a few of them here. Jennifer told us about her daughter, a 16-yearold cancer survivor who was diagnosed with a form of leukemia at age four and had a bone marrow transplant as part of her treatment. For her DY2M moment, Jennifer is going to register to be a bone marrow donor. Not a small commitment but one that someday may save a life. Camie changed roles from working in the C-suite of a health system to become the CFO of her state’s department of health and human services — a completely different type of organization and job. This move brings a new scope, new accountabilities and a chance to make a difference across the state for people who have great needs. And Heather set a goal to serve 1,000 people in need over the next year. What a great heart to serve and a great commitment. She ends her dare by challenging others with, “What you got?” What great stories and dares! There’s never a better time to step up. Get your dare together and post it at hfma.org/HFMA1000DaresProject. What’s your trampoline moment? ❚

View HFMA’s DY2M Your Alabama Chapter awaits alabamahfma.org


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inside HFMA Announcing HFM Best Article award winners for the year Three works honored with Helen Yerger/L. Vann Seawell Best Article Award for outstanding editorial achievement for 2018-19




Michael Rovinksky

he award-winning articles were selected by a panel of five leaders in the healthcare industry who review each expert-reviewed article published in hfm. Articles are judged on the writers' demonstration of technical quality and writing skills and contributions to the literature of healthcare finance professionals. The following three articles are the F19 recipients of HFMA’s Best Article Award.

Sean Looby


Charles Brown

“7 considerations in the financial modeling of value-based payment arrangements” Jim Ryan, MBA, and Charles Brown, MBA October 2018 hfm

Laura Zacchigna

“The shift to outpatient TKA: What’s the big deal?” Michael Rovinsky, MBA, Sean Looby, MHA, and Laura Zacchigna July 2018 hfm This article addresses the impact of change in Medicare policy that opened the door to a shift in total knee arthroplasty (TKA) procedures from inpatient to outpatient settings. TKA has long been an important revenue source for hospitals, so such a shift could place hospitals at risk of severe revenue declines from loss of inpatient TKA procedures to outpatient competitors. The authors describe how modeling possible scenarios can help hospitals begin to prepare and develop effective strategies for not only retaining but also building market share for TKA procedures.

Jim Ryan

Stephen Sibbett

The August issue of HFM. File

Lawrence Martinelli

“Empowering physicians to become stewards” Stephen Sibbitt, MD, and Lawrence Martinelli, MD, FACP, FIDSA July 2018 hfm

t thestatement time ncial nts toimpact avoid analysis in s in designed ating king lease-vs.-buy decisions. The set and lease liability on About the authors . The l be based ounting standard applies only to ugh it certainly will be nly to rrowing Bill Hanlon Jenna Magan ser—but to discuss with their Jenna Magan one year in length or longer—but it it Leong is principal, H2c,Mayling San Diego (bhanlon@ ng is a partner, Orrick, Sacramento is a partner, Orrick, Sacramento edthe to evaluate at industrythe will see an influx of is senior associate, Orrick, Sacramento nflux of h2c.com). (vcmagan@orrick.com). make (vcmagan@orrick.com). on and the structure of all to avoid (mleong@orrick.com). ereagreements designed avoid he new accounting e lease ility on asset and lease liability on erating ctors, both quantitative eet. Although it certainly will be will be stclarifies be analyzed. SpecificalKathleen Thomas Louis Bill Hanlon Jay Miele Jenna Magan their borrowers to discuss with their Jay Miele when eal estate portfolios, Masiulis Schaich Mayling Leong Katie Proux Rossiter Mayling Leong is managing director, H2c, New York sers the need to evaluate semust also consider the theis senior associate,is Orrick, Sacramentosenior Diego associate, Orrick, Sacramento (jmiele@h2c.com).an associate, H2c,isSan ureregulatory of all compliance buy decision and the structure of all (mleong@orrick.com). (kproux@h2c.com).(mleong@orrick.com). nd “New approaches and technologies fo ng sis in ofofboth ntages ontext theoptions. new accounting improving cost performance in health care” titative s. The ny other factors, both quantitative Kathleen Masiulis, Thomas Schaich, Louis pecificaldisclosure to investors. For nly to must e, also be analyzed. SpecificalJenna Magan Rossiter and Jemmy Thomas, January 2019 ios, can estate promote Mayling Katie ger—but Katie Proux tanizations to theiritreal portfolios, is a partner, Orrick, Sacramento Katie Proux Meong Preox hfm der theof nflux is(vcmagan@orrick.com). anthe associate, H2c, San Diego anizations must also consider is an associate, H2c, San Diego mpliance avoid “Bottom-line(kproux@h2c.com). implications of new This case study recounts how a seven-hos(kproux@h2c.com). rational and regulatory compliance tions.on bility lease accounting standards: pital system in New York was able to reduce d disadvantages of both options.

will be What healthcare leaders should know” readmissions while lowering costs and imtheir tors. For Bill Hanlon, Jay Miele, Jenna Magan, proving care by tackling the issue of inpatient Mayling Leong parency in disclosure to investors. For he romote is senior Orrick, Sacramento Mayling Leong andassociate, Katie Proux, overstays (i.e., lengths of stay two or more thcare can promote copyright 2018 management Association, ture oforganizations all by Healthcare Financial (mleong@orrick.com). December 2018 hfm online days longer than expected for the patient’s Westchester, IL 60154-5732. For more information, call 800-252-HFmA or visit hfma.org. ing A lease accounting standard, issued by the condition). By strategically targeting certain ntitative FASB in 2016 and effective in 2019, changed patient groups and investigating reasons pecificalthe way healthcare organizations are to report for overstays, the health system was able to lios, Katie Proux leases on their balance sheets. This article improve patients’ outcomes and experiences ider the is an associate, H2c, San Diego describes how the new accounting standard while also improving the bottom line. ❚ (kproux@h2c.com). mpliance lthcare Financial management Association, couldcall significantly affect healthcare organizaptions. 5732. For more information, 800-252-HFmA or visit hfma.org. rom hfma.org. copyright 2018 by Healthcare Financial management Association, tions’ILfinancial calculations under or visit hfma.org. er, Suite 600, Westchester, 60154-5732.covenant For more information, call 800-252-HFmA stors. For their borrowing agreements, as well as the promote structure of their future borrowing agreements and their choice of financing product.

althcare Financial management Association, 5732. For more information, call 800-252-HFmA or visit hfma.org.


Deidre Baggot

“Preparing for BPCI-A: Avoiding the common mistakes providers make when implementing new payment models" Deirdre Baggot, PhD, MBA, RN October 2018 hfm

About the author Eric C. Reese, PhD, is a content manager, HFMA, Westchester, Ill. ereese@hfma.org



Chapters HFMA recognizes lifetime member status

Paul D. Garrett, CPA, Mississippi Chapter Virginia M. Goldbach, FHFMA, CPA, Western Pennsylvania Chapter Greg A. Gombar, CPA, North Carolina Chapter


Martha B. Hemphill, Mississippi Chapter

etired Members in good standing who have shown outstanding Chapter accomplishments are eligible to become Chapter Life Members of HFMA. Following approval by the Chapter’s Board, the Chapter President sends HFMA a letter affirming those conditions have been met. The Chapter then pays the member's annual dues for five years, after which all further dues are waived. HFMA's Regional Executive Council and Board of Directors have approved 31 members for this status for FY19.

William D. Keckan, CPA, Northeast Ohio Chapter Gary R. Kijanka, Western Pennsylvania Chapter Thomas Lenkowski, New Hampshire-Vermont Chapter Bruce K. Liebel, FHFMA, Western New York Chapter

JENNIFER NOVOSELETSKY jnovoseletsky@hfma.org JNovo

Maria S. Abrahamsen, Eastern Michigan Chapter

Sharon M. Lucian, FHFMA, Hudson Valley NY Chapter

Roxann L. Arnold, Georgia Chapter Robert H. Lux, FHFMA, CPA, Jeffrey G. Blumengold, FHFMA, CPA

Metropolitan Philadelphia Chapter

Metropolitan New York Chapter Gail A. Miesner, FHFMA, Southern Illinois Chapter Mary Kay Boudewyns, FHFMA, New Hampshire-Vermont Chapter

Stephen M. Moore, CPA, North Carolina Chapter

Elizabeth Carnevale, Metropolitan New York Chapter

Marsha L. Morien, FHFMA, Nebraska Chapter

Peggy J. Cary, FHFMA, CPA, South Texas Chapter

James W. Petty, FHFMA, Metropolitan New York Chapter

Dianna L. Cesa, West Virginia Chapter Ronald A. Snyder, FHFMA, Dennis J. Coffey, FHFMA, CPA,

McMahon-Illini Chapter

South Carolina Chapter Christoph Stauder, FHFMA, CPA Joseph F. Corfits, FHFMA, Iowa Chapter

Oregon Chapter

Herbert F. Crum, FHFMA, CPA, Arkansas Chapter

Roger W. Stroud, North Carolina Chapter

Susan S. Cunningham, West Virginia Chapter About the author

Margaret A. Deming, FHFMA, CPA, South Texas Chapter


Jennifer Novoseletsky is a social media manager, HFMA, Westchester, Ill




Quick hits: Top news stories of the month HEALTH AND TREND POLICY OF OUR COMMUNITY

Enrollment of large-company workers in HDHPs reaches historic high


The share of covered workers enrolled in high-deductible health plans (HDHPs) at large employers reached 47% in 2019. HDHP enrollment increased from 35% of such workers in 2018 and 28% in 2017, according to annual tracking survey data from the National Business Group on Health (NBGH), which queries large employers annually on healthcare trends. In recent years, employers increasingly have expressed skepticism that such plans benefit their employees, after many companies embraced them as a cost-saving strategy. The exposure to large deductibles did not drive the type of shopping and consumer behavior that employers had anticipated and instead often led employees to skimp on both needed and unneeded care. Hospitals have raised concerns that HDHPs leave more patients unable to cover their out-of-pocket costs, leading to an increase in hospital bad debt. ❚

Hospital industry sheds jobs for the first time in 20 months

Small FY20 Medicare payment increases for post-acute care

Concerns raised over the proposed release of negotiated charges


Hospitals cut a net 2,000 positions in July, marking the first time in 2019 they lost jobs as a sector. The decline in seasonally adjusted hospital positions was the first since November 2017, when hospitals shed 2,400 positions, according to data from the U.S. Bureau of Labor Statistics. The hospital job losses came amid otherwise strong growth in healthcare jobs in July, with a net gain of 30,400. No other category or subcategory of healthcare lost jobs. Nearly all those gains (28,900) came in ambulatory care. Within that category, the biggest job gainer was home healthcare services, which added 10,700 positions. ❚


CMS recently issued final rules with FY20 rates for skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs) and hospices.Payment change details include increasing SNF payments in FY20 by a net 2.4%, increasing IRF payments by 2.5% and increasing hospice payments by 2.6%. ❚


The requirement in the Medicare Outpatient Prospective Payment System CY20 proposed rule that all nonfederal hospitals post online their gross charges and payer-specific negotiated charges has raised concerns among national hospital advocacy groups. “While we support transparency, today’s proposal misses the mark, exceeds the Administration’s legal authority and should be abandoned,” says Rick Pollack, president and CEO of the American Hospital Association, in a written statement.  ❚

See news updated daily: hfma.org/news


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3 ways the public option could endanger more than half of U.S. rural hospitals RICH DALY rdaly@hfma.org RichDaly

Creation of a public-option government insurance plan could endanger the solvency of more than 1,000 rural hospitals, according to an August 7 Navigant analysis. The consultancy analyzed the financial impact of incorporating a government insurance program in the individual-insurance market, where providers would be paid at Medicare rates, as is proposed in the four leading bills that have been advanced in Congress. Some of the proposals offer the possibility that rates would increase under various scenarios. The analysis points to three possible outcomes from passage of any of these bills:


As many as 55% of rural hospitals, or 1,037 hospitals across 46 states, would be at high risk of closure if a public option were implemented.

2 3

The closures could cost 420,000 jobs.

Rural hospitals not at high risk of closure could be forced to eliminate some services and reduce clinical and administrative staff. ❚


Del Bigtree is one of the most visible members of the growing anti-vaxxer movement. Photo: Marckus / AFP





Medicare For All would cost $200B annually Although a slice of hospitals might financially benefit from a single-payer model based on Medicare rates, 90% would face cuts totaling $200 billion each year, according to a July 16 Crowe analysis of its transaction database for more than 1,000 hospitals. If all hospital payments switched to Medicare rates, the report found, financial impacts would include:

$143 (21.9%) Average per-case

• • • •

An average per-case outpatient payment cut for hospital-based services of $143 (21.9%) An average per-patient inpatient payment cut of less than 1% A cut in net revenue for 90.2% of the hospitals studied A decrease in payment across all hospitals of $200 billion ❚

outpatient payment cut for hospitalbased services

Medicare OPPS proposed rule to bring many hospital financial challenges ADAM ROGERS arogers@hfma.org AdamRogers

The long-awaited Medicare proposed rule for hospital outpatient payments includes a high-profile mandate on hospitals to release rates negotiated with commercial health plans, among other regulations that could pose financial challenges. For CY20, the Medicare Outpatient Prospective Payment System (OPPS) would increase payments by 2.7% after factoring several mandated cuts into the 3.2% initial rate increase, according to the proposed rule. That would increase OPPS payments by $6 billion, to $79 billion. Major provisions include: A requirement that hospitals make public a list of their standard charges, defined as both gross charges and payer-specific negotiated charges (with compliance costing each hospital an estimated $1,000 annually) Creation of a civil monetary penalty of up to $300 per day for noncompliance with the

charge-posting requirement Removal of total hip arthroplasty from the inpatient-only list Addition of total knee arthroplasty, knee mosaicplasty and coronary intervention procedures to the ambulatory surgical center (ASC) covered procedures list Continued payment of the average sales price minus 22.5% for 340B-acquired drugs (amid ongoing legal challenge) A 2.7% payment increase for ASCs that meet quality-reporting requirements ❚

OPPS payments would increase by







7 details on final Medicare IPPS rule The Centers for Medicare & Medicaid Services (CMS) issued an FY20 final rule for Medicare’s inpatient prospective payment system (IPPS) and the long-term care hospital (LTCH) PPS, affecting about 3,300 acute-care hospitals and 390 LTCHs. Key provisions in the rule include: A 3.1% increase in the IPPS operating payment rates for general acute-care hospitals that meet requirements of the Hospital Inpatient Quality Reporting program and criteria for electronic health record (EHR) meaningful use A four-year area wage index increase (AWI) for hospitals with wage index value below the 25th percentile An end to the plan to fund the AWI shift to rural hospitals with a cut to the highest AWI hospitals, and replacement of that plan with


2 3

At a glance The final rule includes key provisions such as a 3.1% increase in the IPPS operating payment rates for general acutecare hospitals and the creation of an alternative pathway for any medical device that receives FDA marketing authorization.

payment cuts across all IPPS hospitals A requirement for higher wage index values for urban hospitals than for rural hospitals in the same state, known as the rural floor Creation of an alternative pathway for new-technology add-on payments for any medical device that receives FDA marketing authorization and is part of the Breakthrough Devices Program Use by CMS of worksheet S-10 of the Medicare cost report FY15 data to distribute uncompensated care funds Permission granted to hospitals in the Medicare and Medicaid EHR Incentive Programs (now known as the Promoting Interoperability Programs) to report data for any continuous 90day period in CY21 ❚

4 5 6 7

Mandatory models among 6 newly proposed Medicare demos Mandatory models for kidney care and oncology were among six new Medicare payment models proposed in mid-July. The End-Stage Renal Disease Treatment Choices (ETC) model would be mandatory for certain areas of the country, as would a radiation oncology (RO) bundled payment model. Four other kidney care models would be voluntary.

At a glance Demo model types include a voluntary model that would use one- or two-sided risk to incentivize provider

Details of the model types include: A mandatory bundled payment model for radiation oncology that would enroll group

adoption of care plans that help patient stave off the need for dialysis


practices, hospital outpatient departments and freestanding radiation centers in randomly selected regions A mandatory model for end-stage renal disease (ESRD) under which enrolled provider participants would be treating about half of all Medicare ESRD beneficiaries Four voluntary models that would use oneor two-sided risk to incentivize provider adoption of care plans that help patients stave off the need for dialysis and encourage kidney transplantation ❚

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Verma points to hospitals as largest driver of healthcare costs Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), told insurers in July that hospitals are the leading cause of rising healthcare costs. In a keynote address, Verma told attendees at 2019 BMA Medicare Advantage Summit in Washington, D.C. — hosted by Better Medicare Alliance, which represents many Medicare Advantage plans — that Medicare pays more for services performed in hospital settings. “This has led to a surplus of hospital beds in the country; and hospital spending is the largest driver of healthcare costs,” Verma said. Verma, who criticized Medicare’s “hospi-

Verma About Verma: Seema Verma is administrator of the Centers for Medicare & Medicaid

tal-centric payment model,” highlighted several ongoing Trump administration initiatives aimed at curtailing hospital spending. The initiatives include efforts to: Expand site-neutral payments to disincentivize hospital purchases of physician practices Allow more procedures to move from hospitals to ambulatory surgical centers Cut Medicare payments under the 340B discount drug program Reduce Medicare paperwork requirements on independent physicians to eliminate incentives for them to become employed by health systems ❚

Services (CMS)

‘Digital transformation’ will create both opportunities and challenges for hospitals A new report from Moody’s describes four opportunities that not-for-profit and for-profit hospitals and healthcare stakeholders will gain from proliferating digital technologies: Telemedicine will provide rural hospitals with access to clinicians. Technology that aids in data collection and predictive analytics will facilitate a shift to outcome-based payments. Use of data analytics and artificial intelligence will help hospitals identify medical histories and examine demographic trends to prevent admissions penalties and uncompensated care cost. Cutting-edge analytics that can detect illness or predict outcomes will boost efficiency.


Proliferating digital technologies will introduce opportunities, challenges. Foto: AFP

The report also points to three challenges hospitals will face from these same technologies: Increased up-front investments will be required in systems, personnel and cybersecurity. Revenue will be reduced as nontraditional telemedicine competitors increase their appeal to patients. The required upfront investments in digital technologies may be significant enough to hurt hospitals’ credit quality. ❚





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* “U.S. Hospital Transformation,” Economist Intelligence Unit and Prudential (3/2017). © 2017 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, the Rock symbol and Bring Your Challenges are service marks of Prudential Financial, Inc., and its related entities, registered in many jurisdictions worldwide. Retirement products and services are provided by Prudential Retirement Insurance and Annuity Company (PRIAC), Hartford, CT or its affiliates. PRIAC is a Prudential Financial company. 0312853-00001-00 HFM MAGAZINE | SEPTEMBER 2019 | 23




Hospitals, health systems prepare to assume more risk Discussions about emerging payment models have flourished in recent years, however many providers are still rooted in conventional fee-for-service options.


lthough hospitals and health systems have acknowledged industrywide emphasis on quality-based reimburse-ment, it has been somewhat unclear how willing and ready they are to move away from traditional payment models and take on higher degrees of risk. To learn more about providers’ interest in and capabilities for assuming risk, the Healthcare Financial Management Association (HFMA) surveyed a group of HFMA members about the topic. The survey was in the field for two weeks during May 2019 and involved 170 hospital and health system senior financial executives. This HFMA Research Highlight, sponsored by Navigant, discusses key takeaways from the survey. PROVIDERS ARE POISED TO ACT

Nearly three out of four healthcare executives (72%) believe their organizations have the necessary capabilities to support increased levels of risk and plan to take on additional risk in the next one to three years. Health system leaders were more certain of their organization’s abilities, with 81% of them expressing confidence versus 68% of leaders in stand-alone hospitals. “The Affordable Care Act left many providers assuming that risk-based models would be the new normal, but the transition has not been as successful or widespread as anticipated,” says Richard Bajner, Navigant managing director



and healthcare value transformation practice leader. “With most health system leadership teams anticipating continued downward pressure on margins, accepting risk can represent a lever for revenue growth, as long as providers commit enough of their revenue and resources to risk-based models. The results of this survey show the value-based movement may be coming full circle, and this time providers will benefit from previous experiences in designing their approaches.” Despite the general willingness to pursue value-based options, there are still organizations that are hesitant to move in this direction: Fully 28% of respondents indicated they had no plans to take on more risk. Of these individuals, more than half (56%) cited a lack of local-market demand as the reason. “Making the switch to outcomes-driven reimbursement requires a substantial, organizationwide commitment in terms of infrastructure, resources and the overall strategy,” says Chad Mulvany, director of healthcare finance policy, strategy and development for HFMA. “If there isn’t the market demand from employers, individual market plans, or government payers, or it’s difficult to negotiate mutually-agreeable terms, then it’s easy to see why an organization may refrain from making significant investments.” POTENTIAL PARTNERS RUN THE GAMUT

Respondents cited commercial payers as the most likely partners for risk-based arrangements in the future with 64% of survey participants predicting commercial-payer contracting models. Government plans were also potential partners with 57% of those surveyed anticipating Medicare Fee-for-Service risk arrangements and 51% anticipating Medicare Advantage (MA). “It is rather surprising that people listed Medicare Advantage programs last,” says Mulvany. “MA models typically don’t have the issues with attribution that Medicare FFS models have, and there is flexibility to negotiate arrangements just like in commercial plans. Plus, the MA plans have a greater incentive to enter into risk-based deals with providers relative to the Administrative Ser-


Q: Does your organization have the capabilities needed to support increased levels of risk?





Q: Through which model(s) is your organization planning to assume additional risk in the next 1-3 years? (Select all that apply.)

64% Commercial payer value-based contracting

56% Medicare value-based contracting

50% Medicare Advantage

vice Only (ASO) programs running ERISA plans.” The fact that providers are bullish on partnering with commercial payers is also unexpected, especially as 75% of health system execu-tives predict an increase in this type of arrangement. “The response may be a little overly optimistic,” says Mulvany. “Oftentimes, providers find roadblocks to commercial risk-based arrangements, including when plans and employers want a steep per-unit price cut or aren’t willing to narrow the network or use creative-benefit design to prevent leakage. In some cases, organizations find the shared savings percentage to be insufficient, and there can be concerns about attribution models if it is an open-network alternative payment model. Also, if the provider perceives that a payer is disinclined or unable to share the necessary data to manage the population in a timely matter, it can derail efforts before they get started.” The lack of progress with commercial programs is not all one-sided. “Commercial payers sometimes feel that providers want to keep too much of the savings or demand unnecessary carve-outs or exclusions,” continues Mulvany. “There is also a perception

that providers want to narrow a network beyond what the market will bear, or they may want a base-rate increase to participate. There’s a bit of truth in both perspectives. It will be interesting to watch how organizations make headway with these plans going forward.”

What to know A not-for-profit pediatric hospital


Health care facilities.


nonsequas ex expero

In addition to working with commercial and government payers, 25% of respondents say their organizations are already part of a provider-sponsored health plan, and nearly 20% plan to launch one in the future. This means that almost half (44%) are turning to this type of program to facilitate their value-based care efforts. “Standing up a provider-sponsored plan requires a strong balance sheet, analytical capabilities and technical skills that aren’t native in most health systems,” says Mulvany. “And once you’ve launched one, you have to manage the inherent tension between the plan and provider businesses. However, if you can overcome these barriers, it creates the best opportunity for value-based alignment and produces an opportu-nity to increase market share if you can offer a competitive product. So, it’s understandable why health systems are pursuing a provider-sponsored plan strategy to accelerate the transition.”

et pos solore quam, torest, solorpos magnis molorepta dem ut occumet aut peligendita vewligen tectem atentia. Health insurance and accessibility. Parchiciminte nonsequas ex expero et pos solore quam, torest, solorpos magnis molorepta dem ut occumet aut peligendita veligen tectem atentia.


To enable greater collaboration between providers and payers and foster a smoother shift to risk-based models, survey participants

25% of respondents say their organizations are already a part of a provider-sponsored health plan, and nearly 20% plan to launch one in the future. NEXT PAGE







Hospitals and health systems can drive revenue and margin growth in both FFS and value-based worlds through strategies focused on engaging physicians on clinical standardization, targeted cost-of-care reductions in areas such as post-acute care and building tight provider network relationships.

Look at A not-for-profit pediatric hospital Health care facilities. nonsequas ex expero et pos solore quam,

indicated the need to shore up their infrastructures. When asked where they were planning to increase investments, more than 60% said they would devote resources to improving information technology capabili-ties. More integrated and advanced systems will allow for seamless information exchange across the continuum and better access to critical data to support more proactive and informed decision-making. Physician and patient engagement were also cited as critical areas of focus. The more patients and providers are committed to and involved in a risk-based program, the more successful an organization will be at improving patient outcomes while keeping costs in check. “Even with their increased risk-assumption interest, providers will inevitably continue to operate in a market primarily driven by feefor-service payments,” says Kai Tsai, managing director, Navigant. “But the path forward does not have to be an either-or scenario. Hospitals and health systems can drive revenue and margin growth in both FFS and value-based worlds through strategies focused on engaging physicians on clinical standardization, targeted

torest, solorpos

Q: In what areas are you planning to increase investments (financial, labor) to enhance payer collaboration and support increasing levels of risk? (Select all that apply.)

magnis molorepta dem ut occumet aut peligendita vewligen tectem atentia. Health insurance



Technilogical capabilities

Physician engagement

and accessibility.


Parchiciminte nonsequas ex expero et pos solore quam,

Member engagement

torest, solorpos magnis molorepta dem ut occumet aut peligendita veligen tectem atentia.

cost-of-care reductions in areas such as postacute care and building tight provider network relationships.” Providers also anticipate some hurdles as they pursue new models. More than 40% of executives suggested operational processes, such as contract execution and care coordination and management, will be the top challenges with maintaining risk-based capabilities.

Navigant Consulting, Inc. (NYSE: NCI) is a specialized, global professional services firm that helps clients take control of their future. Navigant’s healthcare segment is comprised of consultants, former provider administrators, clinicians, and other experts with decades of strategy, operational/clinical consulting, managed care services, digital health, revenue cycle management, and outsourcing experience. Professionals collaborate with hospitals and health systems, physician enterprises, payers, government, and life sciences entities, providing performance improvement and business process management solutions that help them meet quality and financial goals. This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.


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Do presidential Dem. candidates see a role for private insurance? Healthcare, rising medical costs, and high prescription drug costs are defining campaign issues

GAIL R. WILENSKY gwilensky@projecthope.org @GailWilensky

SOME CONCERN ALREADY IS BEING RAISED THAT THE DEMOCRATIC CANDIDATES ARE FOCUSING TOO MUCH ON PLAN DETAILS, and on how they differ from each other on these details, rather than on the broader, more basic goals of their reforms. None of them has explained the thorny practical concern of just how they would move the U.S. healthcare system from where it is now to where they want it to be. Candidates’ positions on private insurance Among the progressive candidates who are advocating “Medicare for All” (or some other kind of single-payer plan), none have expressed concern that it will mean more than 150 million people currently covered by employer-sponsored insurance will have their current insurance disrupted and replaced by something unknown and that isn’t of their own choosing. Meanwhile, very few of the moderate candidates have a clear role for private insurance. These include former vice president Joe Biden and former governor John Hickenlooper, who recently announced he is dropping out of the race and is considering a run for the Senate in Colorado. The positions of some candidates remain



unclear. For example, during the debate, Sen. Kamala Harris (D-Calif.) didn’t identify herself as supporting the continued availability of private insurance. But after the debate, she claimed she misheard the question and does not support abolishing private insurance. Later, she said that she would allow supplemental private insurance to be available even though everyone would be covered by Medicare. She also calls for a ten-year transition to her single-payer system, which would presumably eliminate private insurance. The position of the Democratic candidates, other than Biden and perhaps Harris, ignores the substantial “pushback” that occurred in 2013, when many people with individual insurance were informed that their insurance plans would no longer be available to them. In some cases, the reason was that their plans didn’t conform to the new requirements under the Affordable Care Act (ACA), and in others, it was that insurance companies deemed the remaining potential market insufficient to warrant their continued participation. It was particularly embarrassing for President Obama, who was on the record as saying, “If you like your plan, you can keep your plan, and if you like your physician, you can keep your physician” — neither of which turned out to be true. Many plans did not conform with the ACA requirements and, therefore, could not be offered after an initial grace period, and many physicians chose not to participate in the plans included in their state’s insurance exchange. THE BIDEN PLAN

The Biden plan, which was released in July, builds on the ACA. It provides a government-run public option, which is a concept that the Democrats regarded as too radical to include in 2010. Biden claims this approach would allow employer-based insurance to continue, thereby making private insurance available to those who want it. His plan is estimated to cost $750 billion over 10 years and would be paid for by rescinding President Trump’s 2017 tax cut, returning the maximum tax bracket to 39% and eliminating the capital gains tax lower tax rate for families with





Candidates' plans Take a look at some of the key points the candidates are pitching on their campaign trails and what it means:

Bernie Sanders speaks to a crowd in xxxx about his healthcare plan. Foto: AFP

incomes greater than $1 million. There is an important difference between what Biden is proposing now and the public option considered in 2010. The 2010 public option would have been relevant for only the relatively small percentage of the people buying insurance in the exchanges, currently estimated to be about 8 million, and 90% of the insured population would not have been affected. The current Biden public option plan differs fundamentally from the 2010 plan in that everyone would have a choice to purchase a public insurance option like Medicare, and the subsidies would be more generous than under the ACA. The Biden plan proposes to reduce costs by “negotiating” lower prices from hospitals and other healthcare providers just as Medicare does. The term negotiating is in quotes here because Medicare does not negotiate prices. Rather, it sets them administratively, and hospitals and physicians can either accept the lower prices set by the government or not participate in the program. Most politicians prefer to say “government should negotiate lower prices” because it sounds better than “government should set the prices administratively,” even though the U.S. Department of Health & Human Services (HHS) actually has never negotiated prices and has no experience doing so. ❚

Joe Biden (D-Del)

Provides a government-run public option. Estimated to cost $750 billion over 10 years, it would be paid for by rescinding Trump’s 2017 tax cut, returning the maximum tax bracket to 39% and eliminating the capital gains tax lower tax rate for families with incomes greater than $1 million.

Bernie Sanders (I-Vt.)

Provides comprehensive healthcare to everyone without any out-of-pocket expense, and it includes physician and hospital care; longterm care; dental, hearing and vision care; and prescription drugs. Although estimated to cost as much as $32 trillion over 10 years, it does not have a specific financing proposal attached to it.

Elizabeth Warren (D-Mass)

Warren suggests private insurance should be banned and all Americans should get their health insurance from the government.

Kamala Harris (D-Calif)

Does not support abolishing private insurance. She would allow supplemental private insurance to be available even though everyone would be covered by Medicare. She also calls for a ten-year transition to her single-payer system, which would presumably eliminate private insurance.

About the author Gail R. Wilensky, PhD, is a senior fellow at Project HOPE; a former administrator of the Health Care Financing Administration, now CMS; and a former chair of the Medicare Payment Advisory Commission. (a) CMS.gov, “Primary Care First Model options,” page last updated June 4, 2019.



features COVER STORY




The Healthcare CFO of the Future As the healthcare industry acclimates to disruption, major health systems are turning to their CFOs for crucial guidance.

LAURA RAMOS HEGWER lramosh@hfma.org @lramosh NICK HUT nhut@hfma.org @hfmanickhut


work each day at the suburban Chicago office park where his organization moved its corporate headquarters in 2013. While the commute has been constant since then, plenty else about his workday has shifted. As is true of most health system finance leaders, Nakis is feeling the impact of the changes that are transforming healthcare. “It’s really expanded my view and approach to my job,” Nakis says. “There’s certainly more in terms of mergers and acquisitions and getting into new and different lines of business.”


A prime example: That suburban office is now one of two corporate headquarters for Advocate Aurora Health, the product of a 2018 mega-merger and the ninth largest not-for-profit health system in the country. Nakis, who started as CFO of Advocate Health Care in 2006, played a central role in planning and executing the transaction with Aurora Health Care. Of all the changes to the CFO role in recent years, the most significant is that it’s become much more strategic. “Especially in mid-sized and larger organizations, the CFO is definitely focused on the future,” says Rick Gundling, FHFMA, CMA, HFMA’s senior vice president of healthcare financial practices. Having eyes on the future requires CFOs to work in partnership with not only their finance teams but also other members of the C-suite. “When I talk to CEOs, many feel like they cannot move their organizations forward without their CFOs,” Gundling says. CFOs also are having more conversations about technologies like analytics, artificial intelligence and automation that can bring greater efficiency to the revenue cycle and other functions, Gundling says. As their organizations become more technology-driven, CFOs need to understand how to apply such tools to drive down costs and improve operational efficiencies. NEXT PAGE

Dominic Nakis ADVOCATE AURORA HEALTH Background After spending eight years in assurance practice with Ernst & Young, Nakis joined Advocate Health Care in 1986, when it was known as Evangelical Health Systems. Appointed to CFO in 2006, he has helped Advocate through a slew of changes, including the 2018 merger with Aurora Health Care. Combined, the two systems had 27 hospitals and more than $11B in annual revenue.










The industry looked vastly different when Nakis became CFO. “You go back to 2006 and prior, most health systems were primarily inpatient and outpatient hospital providers,” Nakis says. “You had hospitals and maybe you had some physicians.” These days, he notes, large systems are likely to own hospitals, large physician practices, ambulatory sites, post-acute care networks and potentially insurance operations and retail pharmacies. They also face different forms of competition (e.g., Amazon, Apple) than they probably envisioned as recently as a few years ago. “And as we grow larger in scope and geographical coverage, other opportunities and complexities arise,” Nakis says. “Your people, processes and systems may become more dispersed, which then requires standardization and change management. We are also experiencing other partnership opportunities with for-profit and not-for-profit entities. Additionally, investment programs become larger and more complex. How do you use those investment programs then to help drive the strategies and purpose of the organization?”

Advocate Aurora Health Fast facts

the operations team. “While the CFO role will undoubtedly always require an operational focus to achieve positive operating margins, my focus over time has become more strategic in nature,” he says. Such a focus “facilitates the opportunity to engage with all other C-suite executives on a frequent and intense basis to stay abreast of developments and contribute financial perspectives of business activities.”

28 hospitals, 500 outpatient


locations and

IT is one department with which Nakis has been collaborating especially closely. The finance team has provided valuable perspective as Advocate Aurora installs a new electronic health record (EHR) and enterprise resource planning system across the newly merged organization. “In terms of our role, it’s working with our business partners to help put together strategic and business plans with ultimate end goals in mind,” Nakis says. “What are we trying to accomplish as we’re going down those paths? What are the paybacks, what are the processes and procedures that we’re looking to replace and eliminate? We help keep a focus on those types of questions as the organization evolves.”

63 clinic locations in Walgreen’s stores 70,000 team members, including 22,000 nurses and 3,300 employed physicians (plus 4,800 aligned physician partners)


Early in Nakis’s tenure as CFO, he oversaw departments such as construction and facilities, biomedical and clinical engineering. The organization since has shifted those over to

“The experience and learnings that you get when it comes to how to operate as a leader, how to help manage change in the workplace — those are skills and abilities that you learn that are going to carry you throughout your career.”


Nakis expects to focus even more “on the external environment around the organization. As we seek to transform ourselves, it’s going to require a set of skills in terms of analyzing what are appropriate opportunities for the organization as we enter new lines of businesses. How do we help predict what that impact is going to be on the organization’s sustainability for success in the long run?” ON ADAPTING TO CHANGE

“You certainly have a base of accounting and financial knowledge that is always going to be of value,” he says. “The experience and learnings that you get when it comes to how to operate as a leader, how to help manage change in the workplace — those are skills and abilities that you learn that are going to carry you throughout your career.”





UC San Diego Health


Lori Donaldson

Donaldson has been with San Diego’s lone academic medical center (AMC) since 1990. She started in healtcare after a stint in the banking industry, and was the company’s controller until being appointed CFO in 2010. She’s guided the company through a decade of substantial growth, with revenues increasing from a little more than $1 billion to $2.6 billion.

UC San Diego Health Fast facts 3 major care facilities with a combined 808 beds 9,100 full-time and per-client

The growth of the UC San Diego Health system and the macro-level forces affecting healthcare have impacted Donaldson’s role. “I continue to maintain responsibility over accounting and budgeting, revenue cycles, supply chain,” she says. “But a lot more of my time is really spent in more cross- functional -activities with our contracting department, our quality department — really balancing the financial-stewardship aspects with playing more of a strategic role and being more of a partner to our CEO.” ON MOVING BEYOND A TECHNICAL FOCUS

Alignment with faculty and community providers is vital to driving the transformational activities that UC San Diego Health is seeking to implement. Donaldson supports alignment by making financial information easier and more transparent for those stakeholders, and easier for them to act on. “I’ve also found that by asking physicians to participate in processimprovement activities, participate in the budget process, you can get them more engaged, and they will help us do some of the difficult things that we have to do to be successful in this changing environment,” she says. Such outreach comes naturally to her, she says, simply because she likes working with people and helping them get over their fear of change or the unknown.


“All of these market forces and challenges in our industry are going to drive CFOs back a little bit toward more of an emphasis on cash and capital management,” she says. “Our balance sheets are going to become more strained. That balance of investing in operations and investing in strategy is going to require a lot of discipline around capital management and how we set our priorities, how we evaluate competing investments.” ON WHAT SHE WOULD TELL ASPIRING CFOS

“You can’t be somebody who is resistant to change. To be successful as we look forward, we’ve got to be thought leaders. We have to be innovators. We have to help our organizations find new ways of raising revenue. We have to be willing to look at other delivery models and consider partnering with entities we might not have considered partnering with before.”

“You can’t be somebody who is resistent to change.”

clinical staff and physicians








Cleveland Clinic

Steven Glass, CFO


Steven Glass

Since becoming CFO of Cleveland Clinic in 2005, Glass has helped guide the critically acclaimed health system, which now includes 18 hospitals and more than 210 outpatient locations in Ohio, Florida, Nevada, Canada and the United Erab Emirates. Cleveland Clinic, which had $9.8B in operating revenue in 2018, is a top-five hospital nationally, according to U.S. News & World Report’s rankings.

Cleveland Clinic Fast facts

Today, Glass collaborates with his system’s chief strategy officer more than with any other leader in the organization. “We are working side by side on many growth opportunities and the strategic direction of the organization itself,” he says. One such project is Cleveland Clinic’s new London location, which is scheduled to open in 2021. Glass can make time for his expanded responsibilities because he has a competent and dedicated finance team. “If you don’t have a strong team and controls, as well as a good infrastructure and the ability to grow talent, you’re going to struggle to shift your focus as a CFO to spending more time on strategy,” he says.

To be effective in his changing role, Glass has had to carefully consider how he communicates and collaborates with colleagues. “What has made me successful today is having the communication skills to work with teams far outside of finance and be able to communicate the importance of what we are trying to achieve as an organization,” he says. ON COLLABORATIONS WITH TECH

For the past 15 years, Glass has overseen Cleveland Clinic’s data analytics and business intelligence functions, which continue to expand as the organization leverages analytics tools to reduce variation, improve quality and



Glass predicts that teamwork among C-suite members will be critical to the ability of health systems to improve care quality, the patient experience and financial and operational performance. He also believes that the responsibilities of CFOs, chief operating officers and chief strategy officers will continue to overlap. “Ten years ago, there were very clear lines between those roles,” Glass says. “Ten years from now, we are going to see the further blurring of those lines.”


210 outpatient 6,000 beds



18 hospitals, locations and

reduce costs. Glass also works closely with the health system’s head of compliance and its chief information officer on cybersecurity issues, particularly as the organization explores mergers and acquisitions. “Review of cybersecurity has become a key component of due diligence,” he says.

“If you don’t have a strong team and controls ... you’re going to struggle.”





Baylor Scott & White Health

Penny Cermak, CFO

teams prioritize strategic investments. “We have to be very diligent about where we invest and where our next dollar is best spent to support the organization’s mission,” she says. ON WHERE SHE SEES THE CFO ROLE IN FIVE TO 10 YEARS


Penny Cermak

Prior to becoming the system CFO in April 2019, Cermak served as Baylor Scott & White’s senior vice president and CFO for hospitals and clinics for years. In that role, Cermak led the integration of the health system’s financial operations following the 2013 merger of Baylor Health Care System and Scott & White Healthcare.

Integration has broadened the role of the CFO beyond financial oversight, particularly in large organizations, Cermak says. “The role of the CFO is becoming more focused on leading other leaders,” she says. ON CREATING ALIGNMENT

An emerging responsibility of CFOs in large integrated health systems is promoting alignment. In her new role, Cermak oversees 16 CFOs representing the system’s hospitals, health plan and accountable care organization. “By having all of the CFOs on my team, we are able to standardize and align across the organization,” she says. This reporting structure also helps finance leaders share best practices and transfer effective processes across the system, she says. ON HAVING A LONG-RANGE VIEW

Baylor Scott & White Health Fast facts 50 hospitals, 1,000 patient care sites and one health plan with 240,000 members

Beyond helping leaders develop action plans to contain costs, today’s CFOs also are responsible for driving growth to ensure financial viability, Cermak says. For example, Cermak and her team have been collaborating with clinical and operational leaders to develop more healthcare services in the growing Austin, Texas market. As healthcare organizations put more focus on the future, Cermak says, CFOs can use their logic-based and financial skills to help their executive

Ongoing cost pressures and the shift toward value-based care mean that CFOs’ skills and expertise will be valued by other organizational leaders for years to come, Cermak says. Given the industry’s continued evolution, she believes all healthcare organizations can benefit from CFOs who are innovative and creative yet disciplined. “Our boards and our teams are counting on us to ensure that our organizations are thoughtfully driving positive change,” she says. ❚

“We have to be very diligent about where we invest and where our next dollar is next spent.” HFM MAGAZINE | SEPTEMBER 2019 |






The Role of Data Analytics in Healthcare: 5 Key Learnings from the HFMA 2019 Annual Conference Focus Group FOCUS GROUP SUMMARY


t the 2019 Healthcare Financial Management Association (HFMA) Annual Conference, a group of senior financial and data analytics leaders from hospitals and health systems around the country gathered to discuss the challenges and opportunities in leveraging data analytics to improve utilization, clinical outcomes and financial performance. Intuitive partnered with HFMA to serve as a host for the focus group, encouraging participants to share their insights around the topic. Below are five key takeaways from the event.


DATA GOVERNANCE AND TRANSPARENCY ARE IMPORTANT FOUNDATIONS To get the most out of data analytics initiatives, healthcare organiza-tions must keep information organized and have strong governance practices to preserve data integrity and make sure it is easily present-able and usable. Governance groups should be comprised of clinical and financial leaders who meet monthly or quarterly. Once established and launched, these groups may evolve into more of a governance ecosystem. “When physicians and other clinicians are involved in decisions around the data points for benchmarking care, it fosters more engagement and confidence in the measures,” says Katie Gilfillan, director, Healthcare Finance Policy, Physician and Clinical Practice for HFMA. Transparency at the physician and organizational level are essential to drive change. To enable greater visibility into the data, one focus group participant developed self-service dashboards for clinical, quality and finance data that are


controlled by the finance team but can be custom-ized by different users — including physicians — through selectors and filters. To access the dashboards, users must go through an orientation process, so they understand what they’re seeing. Some reports require additional training due to added complexity. Within these reports, the organization currently can get to the charge level or service-line level. It is working toward the National Provider Identifier (NPI) level as well. The health system can run reports on the top 25 physicians and can slice and dice in any way to gauge performance and costs as well as benchmark against peers. Similarly, some of the larger systems are using data to compare cost and utilization across hospitals. Transparency between organizations is being used to create inter-hospital peer pressure, which is aimed at elevating long-term performance.


DATA TIMELINESS AND INTEGRITY ARE CRITICAL CONCERNS Generally, providers are moving through a progressive and evolution-ary process regarding data analytics, starting with the acute setting and then expanding outward toward the ambulatory and post-acute settings. Organizations are also incorporating health plan data, but progress in this area has been slower. There are a variety of data sources, but a primary one is the electronic health record (EHR). Most organizations leverage this tool to access clinical, utilization and sometimes financial data. Health plans supply utilization data as well, however the timeliness of the information and the


willingness of some health plans to share it are the hurdles many organizations face. Data integrity is also a challenge as information comes from diverse sources and is not always standardized. To overcome these roadblocks, some organizations are starting to think outside the box. For example, one focus group participant created a statistic around robotic surgeries, identifying ways to quantify costs, analyze utilization and track time. The organization trends the data year over year, creating feedback loops to improve performance.


PHYSICIAN TRAINING AND ENGAGEMENT ARE ESSENTIAL Most focus group participants agree that engaging physicians around the importance of data — especially cost data — can be difficult. The group concurs that providing some degree of education — between one and three hours —outlining the benefits of the information and how to interpret it can be helpful. Organizations found that when physicians appreciated the advantages of certain data and were presented with the right opportunities to dig into it, they were more willing to get onboard with the data analytics concept.


DATA CAN REVEAL PRIORITIES The group’s participants are using data to refine where they should focus improvement efforts. Some have chosen to benchmark against nationally known health systems around best practices and then use data to determine where they can assume risk. More specifically, one hospital is looking at several metrics, including the top 20 DRGs, avoidable emergency department use and long length of stay, which is defined by determining the mid-point for a DRG and then adding eight days. The hospital is working to benchmark costs in these areas to change utilization.

Another hospital has started examining small pockets in the health system, evaluating its quality metrics and where it may have poor star ratings. Still another organization is focusing on clinical data, mainly to improve quality and utilization. They have not yet integrated the financial piece or costing. The eventual goal is to determine how to cost at a patient level from EHR data. To accomplish this, the organization will need to integrate financial data to determine where to assume risk. Analyzing length of stay and avoidable admissions data has proven helpful to one entity. It uses data to determine where there are opportunities for improvement and discern what the standard of care across the system should be. As a result of this work, the organization has decreased supplies by 7% in the first year.


. DATA SHOULD UNDERPIN STRATEGIC DECISIONS Making decisions without data to back them up is no longer consid-ered strategic. In an effort to be more tactical, one health system uses data to drive decision-making in its pursuit of multiple risk-based contracts. Its goal is to engage with employer groups, but it wants to see that the system can manage costs effectively before entering in to direct-contracting arrangements. The use of data analytics in healthcare is just starting to gain momen-tum. In future focus groups, participants will delve further into different opportunities to advance data use and explore ways to better operationalize information to enable forward progress. Interested in joining the conversation about data analytics in healthcare? Contact Chuck Alsdurf, HFMA director of finance policy and operational initiatives, at calsdurf@hfma. org to learn more about upcoming programs. ❚

Intuitive, maker of the da Vinci® surgical system and Ion® endoluminal system, was founded with a simple belief: Medical intervention should help people recover as quickly and completely as possible. In more than two decades working closely with care teams and hospital leaders, we’ve learned that human understanding, smart systems and instruments, and digital insights are needed to enable better outcomes. We call this Intelligent Surgery. And, with six million procedures performed by tens of thousands of surgeons worldwide, we’re more passionate than ever about innovating for minimally invasive care. This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.







How an Iowa hospital earned 2MAP Awards for excellence in revenue cycle performance How an Iowa hospital earned 2 MAP Awards for excellence in revenue cycle performance

AT A GLANCE Henry County Health Center in Mount Pleasant, Iowa, earned two HFMA MAP Awards by taking three key steps: Assessing performance Creating a long-term plan Communicating initiatives



ASSESS PERFORMANCE USING MAP METRICS. Identifying the areas where the hospital was performing poorly helped Hammel and her team create a plan for success. One early goal was improving point-of-service collection by collecting copays in the emergency department (ED)


starting in November 2017. “A lot of our revenue came from the ED. Most insurance companies have an ED copay listed, so I thought that would be a good start to increasing the point-of-service payments,” Hammel explains. The first week, HCHC collected more than $2,000 in copayments, a number that continues to increase and resulted in the hospital’s highestever point-of-service collections in both February and March of 2018.


FORMULATE A LONG-TERM PLAN. At Henry County, price transparency efforts worked hand in hand with centralized scheduling. The hospital began by targeting elective procedures such as radiology services or sleep studies. A financial counselor would contact patients who had made appointments for such services and provide information about their share of the cost. Some patients would cancel because the cost was prohibitive, and others would make arrangements to pay, but overall, people were happy to have the information that allowed them to make an informed decision about their care, Hammel says. Training new hires to have a complete understanding of the revenue cycle is essential, even when their jobs don’t touch the full process, she says. “Schedulers, communication staff and patient access staff start their training with our cenPHOTO – ANDREA BEHREND


hen Karoleen Hammel accepted the director of revenue cycle position at Henry County Health Center (HCHC), CFO David Muhs presented a challenge: Align the hospital’s revenue cycle with HFMA’s MAP Keys and Patient Financial Communications Program and win a MAP Award. Two years later, the critical access hospital in Mount Pleasant, Iowa, has earned two MAP Awards and more important, made noticeable strides toward financial transparency. “The HFMA MAP Award is more than just achieving the best metrics for an organization,” says Todd Nelson, HFMA’s director of partnerships and chief partnership executive. “It encompasses the need to balance patient financial communications, transparency and patient satisfaction with the strongest revenue cycle metrics.” To make those strides, HCHC took three key steps.



tral patient access members,” says Hammel. This gives them a great base to understand the financial software and how all visits start in the system. If the registration portion isn’t correct from the beginning, this can have an impact all along the revenue cycle as well as patient care.” Training can take anywhere from two to six weeks depending on the person’s role in the organization. In addition, patient-access staff in both main registration and ED registration are encouraged to complete HFMA’s Patient Financial Communications Training Program. At HCHC, the proof of success came when a secret shopper from the Iowa Hospital Association called to ask for a self-pay estimate for an MRI. The financial counselor asked whether the procedure would be performed with or without contrast and, when the caller said he wasn’t sure, provided estimates for both as well as an explanation that the radiologist would charge an additional, separate fee. She also offered the patient a 15% discount for prepayment, as is the practice at HCHC. At the end of the call, the patient identified himself as a secret shopper and said they were the first hospital that could answer his questions. “He said, ‘You are the only one who could give me an estimate,’” Hammel said. He said some hospitals could give a range, but not an exact amount, while others weren’t sure where to transfer his call or just didn’t call back at all. “It kind of blew us away. It was pretty cool.”


COMMUNICATE AND EDUCATE. Successful initiatives require buy-in from leadership and staff as well as an information campaign to educate patients when there is a change to a routine. For example, when Henry County began collecting copays in the ED, Hammel took several steps to ensure all stakeholders knew and understood the plan long before attempting to collect copays in the ED. The hospital’s board of trustees wrote ED copayments into its overall financial policy, and the ED director and key physicians were informed of the plan so the collection process could be carefully planned to comply with the Emergency



Medical Treatment & Labor Act, which requires hospital EDs to screen and stabilize all patients regardless of ability to pay. Finally, patients were informed via the hospital’s Facebook page, website and local media. But patient education goes beyond awareness, Hammel says. Providing cost estimates with full explanations of what a patient’s health plan will cover can help the patient make an informed decision. To ensure patients still receive the care they need, the financial counselor routinely communicates with physicians when patients say they can’t afford an elective procedure or service. If the physician insists the procedure or service is necessary, the financial counselor will work with the physician and patient to either amend the care plan or work out a payment plan. As Henry County looks toward the future, Hammel is hopeful that the hospital's performance will continue to improve. As the hospital works through its second year of centralized scheduling, Hammel’s goal is to have more services scheduled and provide a greater opportunity to communicate financial estimates to patients prior to their service. Nelson encourages other hospitals to follow in Henry County’s footsteps. “The HFMA Patient Financial Communications Best Practices provide the basis for performance and taking the next step toward becoming an HFMA Patient Financial Best Practices Adopter like Henry County Health Center shows an organization’s commitment to the patients it serves,” he says. ❚

Successful initiatives require buy-in from leadership and staff as well as an information campaign to educate patients when there is a change to a routine.



Live Education Save the Dates Learn about everything from the essentials of healthcare finance to the latest industry trends. Participate in a face-to-face or online event.


November 12, 2019 The Virtual Conference is a convenient way to obtain high-quality, relevant industry information. Hosted virtually, the conference enables you to view sessions, participate in chats and discussions, and ask questions in real time. Registration is included as a part of your HFMA membership.

December 5–6, 2019, Chicago, IL Enhance your skills, shape your career. HFMA Seminars provide in-depth education on the fundamentals of the business of healthcare and emerging topics.

March 30–April 1, 2020, New Orleans, LA Learn from best-in-class organizations and industry thought leaders about the latest revenue cycle best practices.



June 28–July 1, 2020, San Antonio, TX Be inspired to take action and get the tools you need to lead change. Join the 2,500 healthcare leaders who participate in this three-day event featuring five strategy-focused general sessions and keynote presentations and more than 50 best-practice breakout sessions. Together we can deliver on the promise of transformation.

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4 strategies for an AI-driven approach to improve revenue cycle performance Adopting machine learning and artificial intelligence (AI) to the revenue cycle can enable healthcare organizations to get ahead of the curve on transformational innovation.


oth artificial intelligence (AI) and automation hold strong potential to drive improved revenue cycle performance, and healthcare leaders seem to agree that AI should be a priority. A recent survey indicates:

75% of healthcare leaders are actively implementing or planning to execute an AI strategy. 43% say their first area of focus will be automating business processes, such as revenue cycle management functions, to reduce costs.1 For example, automating eligibility and benefits verification — typically the first administrative transaction in a patient encounter — could save providers $6.52 per transaction, or just over $4 billion per year.2 Meanwhile, machine learning tools can prioritize work based on the likelihood of payment or age of the account while reducing the risk for error. CONSIDER THESE 4 STRATEGIES

ERIK NILLSON enilsson@ssigroup.org

With use cases for healthcare AI still emerging, healthcare organizations should consider the following four strategies for applying AI and automation to revenue cycle management.


Replace highly manual tasks with automated processes and redirect staff efforts toward activities that





provide the greatest value. Replacing “timeintensive, error-prone, manual processes” for claims management and payment reconciliation is an implementation 92% of hospitals are planning.3 But there is still plenty of room for improvement: Providers could save $9.8 billion by automating key revenue cycle functions.4 Automating claims status inquiries alone could save $9.22 per transaction, or more than $2.6 billion. Front-end revenue cycle processes are ripe for automation. For example, real-time patient eligibility checks ensure providers have the most current information regarding patient coverage and the portion of the deductible met to date. Benefit information that is automatically pulled from the system to create patient charts helps to eliminate manual data entry — significantly reducing the risk for error. One study shows registration and eligibility errors account for 23.9% of denials.5 The time savings gained from automating these tasks accelerates the patient check-in process and allows staff to spend more time on value-added activities, such as patient financial counseling.



Use machine learning to stop denials before they start. Each year, 9% of claims are initially denied by payers.6 For the average hospital, this statistic means nearly $5 million in payments are at risk of being denied each year. And while 63% of denials can be recovered, it costs about $118 per claim in administrative costs to capture the monies owed. Machine learning positions providers to predict which claims will be denied before they are submitted. It does so by: Identifying the root causes of denials by payer and CPT code Applying this intelligence during automated reviews of claims Flagging areas where missing or incorrect information appears, such as missing charges or an incorrect patient identifier


This approach enables staff to correct claims prior to submission, increasing clean claim rates. It also helps revenue cycle teams more effectively manage work related to denials by focusing staff attention on high-value denials, as well as those that have a strong chance of being overturned.

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hfma.org/mapapp 44 | HFM MAGAZINE | SEPTEMBER 2019

The Heartbeat of Progress hfma.org




ANALYZE PATIENT DEMOGRAPHIC DATA TO PREDICT THE RIGHT BILLING APPROACH FOR EACH PATIENT. AI can help revenue cycle teams develop highly targeted collection strategies based on a patient’s previous payment behavior, demographic data, communication preferences and preferred payment methods. It can also point to the type of messaging most likely to engage individual patients and the optimal date and time to send communications. AI can even detect early warnings that a patient may default on a hospital payment plan — and alert patient financial services to signs of trouble. Given that half of patients lack confidence in their ability to pay their medical bills, AI-enabled approaches to patient financial communications and collections could be a critical support in the years ahead.7 One aspect of this approach, propensity-to-pay scoring, uses predictive analytics to determine the likelihood that patients will pay their out-of-pocket costs for care. But while propensity-to-pay solutions have been available for some time, according to one survey, just 14% of healthcare organizations use advanced modeling tools to segment accounts and predict propensity to pay.8 Fewer than one in four providers use a data source or external partner to support their efforts. To make a deeper impact in collection rates, more emphasis


on data-driven intelligence and processes is needed.


PREDICT WHEN PAYERS WILL REMIT PAYMENT. With predictive analytics, providers can review payer-specific payment behavior by CPT code to determine how long it will take for a specific claim to be paid and even the day and time the payment will arrive. It’s an approach that can predict the date of remittance for claims with a high degree of accuracy. The use of AI in healthcare is expected to grow 50.2% from 2018 to 2023, with hospitals and health systems expected to be the biggest adopters.i As the push to bend the healthcare cost curve intensifies, leaders should carefully examine the business case for AI-driven revenue cycle management and explore small-scale innovations with the potential for strong return. Dipping a toe into the waters now will better position healthcare organizations to keep pace with AI advancements while strengthening financial performance. ❚

About the author Eric Nilsson is Chief Technology officer, SSI Group, LLC, Mobile, Ala.




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5 lessons on launching a providersponsored health plan Market trends are shifting to enable increased adoption of provider-sponsored health plans (PSHPs), often through strategic partnerships.

KAI SAI ksai@navigant.com


s leading health systems begin to enjoy success in launching provider-sponsored health plans (PSHPs), the potential benefits of health plan ownership are coming into focus. Lessons learned from health systems that have succeeded in the area can serve as a guide to others that have struggled with finding the best way forward. Health systems that have navigated the PSHP terrain can show the way by illuminating the key challenges in operating a PSHP and pointing to the capabilities required for success. SHIFTING HEALTH SYSTEM INTEREST IN PSHPS

JAMES R. SMITH, FACHE jsmith@navigant.com

Interest in launching a PSHP has waxed and waned among U.S. health systems in recent years. By 2017, more than 100 health systems provided coverage to about 18 million members through PSHPs.1 It seemed that PSHPs might become the new normal, altering health systems strategies and enabling them to capture market share. Yet struggles to grow membership profitably caused excitement to dim for many health systems. NEXT PAGE




AT A GLANCE Health systems with plans to launch provider-sponsored health plans should take five lessons from organizations that have excelled in pursuing such a strategy: Use data analytics to identify where best to focus care management efforts. Prepare for sustained losses in the first years after implementation. Create programs tailored to meet the needs of specific populations. Seek ways to partner with the health system’s



Today, however, interest in PSHPs has been rekindled in part by health systems’ growing discontent with alternative “payer-provider partnerships.” Over the past three years, the paucity of payer-provider collaborations that have successfully built true joint-risk models has caused many health systems to reconsider their health plan strategies. It is expected that many of the plans entering the Medicare Advantage (MA) market in the next two years will be PSHPs.2 Among executives of leading health systems responding to a 2018 survey, 27% anticipate launching an MA plan and 29% are confident in their systems’ ability to do so. Meanwhile, a recent risk-readiness survey also finds emerging interest in PSHPs:3 Among provider leaders surveyed, 72% (i.e., 86% of health system respondents and 66% of hospital respondents) plan to assume additional risk, including sponsoring a health plan, in the next one to three years. One-in-five respondents say they plan to assume risk by launching a PSHP. One quarter of respondents are already part of a PSHP. (For additional discussion of the factors driving renewed interest in PSHPs, see the web-exclusive sidebar, “Providers explore new territory with health plan ownership,” included with the online version of this article at hfma.org/hfm.)

clinical team in developing high-val-


ue interventions.


Invest in high-

Health systems that have successfully

launched PSHPs invariably have already addressed capabilities and competencies needed to start a PSHP (see the sidebar on page 48.) Here, we offer lessons learned from four health systems that are beginning to realize real benefits from their PSHP strategies. LESSON NO. 1: USE DATA ANALYTICS TO INFORM YOUR APPROACH. Optima Health, the health plan division of Sentara Healthcare, a 12-hospital system based in Norfolk, Va., uses artificial intelligence to identify members who are at high risk of developing sepsis. The health plan’s approach has: Significantly improved accuracy of risk detection Reduced redundant nursing staff screenings by 70% Decreased manual screening hours by up to 72% while ensuring patients at risk receive the care they need more quickly Meanwhile, use of data analytics has enabled the health plan to identify unnecessary emergency department (ED) encounters, realize opportunities for millions of dollars in ED savings and develop protocols, including patient education, that help ensure the right care is delivered at the right time. “We’re just beginning to understand the potential to improve quality of care and member relationships through data analytics and artificial intelligence,” says Howard P. Kern, president and CEO, Sentara Healthcare. “Having a provider-sponsored health plan gives us a much richer

touch, high-tech solutions for member engagement.

Gauging Healthcare Organizations' PSHP Readiness Survey question: What are your organization's plans related to launching or partnering on a provider-sponsored health plan? (n=116) No plans for PSHP launch or partnership

56% 25%

Already a part of PSHP Plan to launch/partner in the next 1 to 3 years Plan to launch in 3+ years


15% 4%


Source: "Provider Risk Readiness Report: Navigant/ HFMA Survey," June 2019.



view of the data needed to drive improvement.” Among other leading PSHPs that also leverage data analytics to design care management services that focus on the areas of greatest impact is Danville, Pa.-based Geisinger Health Plan. Care managers at the PSHP work with 15% to 20% of the health plan’s Medicare population — a much higher percentage than under traditional payer models, where care management typically is limited to the top 5% of the highest-cost Medicare members. The results have been outstanding: Efforts to lower acute inpatient stays have reduced costs by 19% per member per month (PMPM). “If you want to reduce PMPM costs, you need to know where your costs are coming from, and that varies by line of business and whether the plan is commercial, Medicare or Medicaid,” says Janet Tomcavage, RN, MSN, chief population health officer for Geisinger Health Plan. “In a Medicare population, most of the costs are coming from hospital admissions, ED visits and post-acute care. If you can prevent the inpatient admission, you’ll also prevent a skilled nursing facility admission. The impact on cost is significant, since an avoided hospital admission for a Medicare patient saves on average around $12,000. If the patient has more complex medical conditions, that amount could increase to $18,000 to $20,000.”


WHAT TO KNOW Health system leaders interested in rolling out a PSHP should be aware of the following considerations: Start with a clear sense of the outlook for the PSHP. Know the steps to take to ensure the success of such an effort. Recognize that the capabilities and competencies needed to start a PSHP are significant, and that they often fall outside healthcare leaders’ traditional skill sets and the organization’s cultural predisposition.

LESSON NO. 2: BE PREPARED TO SUSTAIN LOSSES IN THE FIRST YEARS AFTER IMPLEMENTATION. Given the amount of investment in talent and infrastructure required to support a health plan, the enrollment thresholds required for success and the challenges associated with managing the health of complex populations, health systems should plan for the time it will take to get such a large undertaking up to scale and fully operational. “Until you’ve built sustainable scale, you have to accept that for a number of years, you’re going to have losses,” Kern says. “Many health system leaders think, ‘I’m going to get a health plan, and it’s going to be great. I’m going to make money, and I’m going to improve health outcomes.’ They

overpromise results to their board. As a consequence, when the health plan experiences losses, they are greatly disappointed, and they end up losing trust. They get a lot of pressure to dump everything and exit.” Kern notes that Optima Health lost money the first 12 years after the health plan was launched. “We learned a lot of hard lessons those early years,” he says. LESSON NO. 3: CREATE PROGRAMS TAILORED TO MEET THE NEEDS OF SPECIFIC POPULATIONS. Presbyterian Health Plan, part of Presbyterian Healthcare Services in New Mexico, offers home-based care for high-need Medicare Advantage (MA) members and Medicaid members with serious illnesses and functional decline who are at risk for long-term institutional care. The goal of this program, called Complete Care, is to focus on the 5% of members who account for 50% of total medical costs. Complete Care uses a multidisciplinary care team and wrap-around approach to care, including: In-home access to primary care Same-day urgent care Foot care (critical for members with diabetes facing high risk of amputation) Limited spectrum of acute care services, such as X-rays, lab collection and vaccine administration Social support and palliative care as needed

Understand substantial investments in capital and talent acquisition, data analytics capabilities and care management are required, as well as the structural changes to align interests equitably on the payer and provider side.

Complete Care began as a home-based program and expanded in 2018 to include an outpatient clinic. Its approach is designed to reduce costs of care while helping members achieve their quality-of-life goals. “Complete Care’s readmission and hospitalization rates are less than expected for this population,” says Sharon L. Fletcher, PhD, MBA, president of Fluent Health, a subsidiary of Presbyterian Healthcare Services that leverages Presbyterian’s 30 years of managed care experience to partner with providers seeking to start or strengthen their PSHPs. “Not only does this represent a significant decrease in costs, but also a seamless care experience,” Fletcher says.






At Optima Health, MA members are concentrated in specific medical practices that are uniquely positioned to meet the complex care needs of MA patients, including patients with multiple chronic conditions and behavioral health needs. “We’ve found that when the MA population is spread too broadly, we’re unable to achieve the same level of effectiveness as when these members are directed to practices that are finely attuned to working with MA members,” Kern says. Kern cites two other keys to success in managing MA members’ health: The use of extensivists who can extend care for MA members outside traditional care settings, such as the home or assisted living facilities. The addition of specialized coding staff within MA-focused practices.

LESSON NO. 5: INVEST IN HIGH-TOUCH, HIGHTECH SOLUTIONS FOR MEMBER ENGAGEMENT. At a time when tech-enabled MA startups are clamoring for enrollees, PSHPs are compelled to tightly hone their member-engagement strategies, including the use of digital tools that help members manage their health and the cost of their care. SelectHealth, the PSHP for Intermountain Healthcare in Salt Lake City, partnered with a vendor to develop a mobile pharmacy benefit app that helps members save money on their prescriptions. The mobile app provides information around: Drug prices and potential lower-cost alternatives Medications covered by the plan Tier statuses of prescription drugs The member’s prescription copays and benefits ❚

LESSON NO. 4: SEEK WAYS TO PARTNER WITH THE HEALTH SYSTEM’S CLINICAL TEAM IN DEVELOPING HIGH-VALUE INTERVENTIONS. At Presbyterian, the health plan pharmacist has collaborated with the care delivery team to promote the use of highly effective, cost-efficient prescription drugs, thereby lowering medication costs and driving positive member outcomes. Such innovative approaches are critical given that Americans spent $535 billion on prescription drugs in 2018, while rate hikes in 2019 average 6% for more than 1,000 medications.4 “Over 90% of our physicians now prescribe more cost-effective medications to our members,” Fletcher says. “We’ve focused on diabetes, hepatitis C and growth-hormone drugs to establish best practices in prescribing that improve care while reducing costs.” Through collaboration with clinical pharmacists, physicians and other Medicaid health plans, Optima Health has developed opioid prescribing interventions that have reduced opioid prescriptions by 43% since October 2017. Today, 30% fewer members receive prescriptions for opioids, which is a potentially life-saving improvement, given the addictive nature of these drugs and the nation’s opioid epidemic.

About the authors


Kai Tsai is Managing Director, Healthcare at Navigant. James R. Smith, FACHE is Managing Director, Healthcare at Navigant.

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How providers should adapt to demands of consumer-driven healthcare system The Patient Accessibility, Engagement and Experience cohort at HFMA's 2019 Annual Conference yielded 10 key takeaways AT A GLANCE The urgency to meet the challenge of improving the patient experience is growing throughout the healthcare industry. A worthwhile step for providers is to undertake a journey-mapping process to gauge where improvements are needed in the patient experience. An as-yet unrealized milestone in improving the patient experience is the ability to provide personalized out-of-pocket costs for services. Some providers are opening innovation centers to counter the momentum of industry disrupters such as Apple, Amazon and CVS, which specialize in catering to customers.


s patients and employers bear more responsibility for the costs of healthcare, they can be expected to act more like consumers do when interacting with other industries: actively searching out high-value services instead of simply seeking care where their physician or health plan directs them. For providers, adjusting to this emerging consumer mindset requires a new approach to their core operations. In all processes, from marketing to revenue cycle to clinical care, they must consider best practices for attracting patients and earning their loyalty. Strategies for acclimating to a consumer-centric system were discussed in depth during a cohort of three sessions at HFMA’s 2019 Annual Conference. Here are 10 key takeaways from the cohort, which was sponsored by Cedar.


PATIENTS ARE THE NEW PAYER, AND THAT HAS RAMIFICATIONS FOR THE INDUSTRY. With patients facing higher deductibles, providers should prioritize creating a positive and easy payment experience. They should be responsive to patient needs by offering options for making payments. To better meet patient expectations, patient navigators should be equipped with information on patients’ financial profiles and payment preferences.


PROVIDERS SHOULD DIGITALIZE AND PERSONALIZE THE PATIENT EXPERIENCE. Patients tend to willingly pay bills if the bills are comprehensible and making payments is easy and convenient. Providers can remove barriers to payment by creating a digital experience and offering real-time availability for patients to ask questions, such as via live chats and 24hour customer service. A range of options, from old-school mail to digital, should be available for making payments. “We embarked on a digital experience for patients to increase patient satisfaction with the billing experience,” said Vicki McKinney, COO and chief revenue officer, WESTMED


THE END-TO-END CONSUMER EXPERIENCE SHOULD BE PRIORITIZED. “See me, hear me, know me” is the demand from patients today. Providers should look to revamp revenue cycle processes to provide individualized, personalized healthcare financial experiences. Journey-mapping patients’ experiences can provide insights as to where improvements are needed. Challenging assumptions is crucial. For example, it turns out that many seniors prefer to make payments digitally.


Vicki McKinney (right), COO and chief revenue officer, WESTMED Practice Partners, speaks during a session on personalizing the patient experience. At left is Sue Gillies, vice president of revenue cycle management, Crystal Run Healthcare.





Practice Partners, Purchase, N.Y. “However, we found an added benefit was a significant decrease in time to collect and self-pay [accounts receivable]. Patients are consumers, and they’re used to the digital world. Healthcare has to catch up.”


MOVING TO A DIGITAL PAYMENT EXPERIENCE REQUIRES ACCOUNTING FOR VARIOUS FACTORS. Size and resources may dictate the degree to which a provider can offer a digital experience. Certain aspects can be outsourced — for example, a physician practice may prefer to handle its own patient calls while outsourcing a chat feature. Providers can consider moving to a digital experience in phases, starting with patient payments before incorporating registration, scheduling and more.


PROVIDERS SHOULD BE MINDFUL OF THE COSTS BORNE BY PATIENTS. “The healthcare industry needs to take the next step and show patients where they can get

care for less,” said David Kerwar, chief product officer and head of digital consumer innovations with Mount Sinai Health System, New York City. By using analytics to predict order sets and care paths, providers can work toward establishing a true out-of-pocket estimate for a patient’s care plan. When referring patients for services, providers can use data and artificial intelligence to show patients appropriate access points with price comparisons.


A MAJOR RESHAPING OF THE PATIENT EXPERIENCE IS AT HAND. New entrants into the healthcare space, such as Amazon and CVS, are drawing on their experience with consumer-centric business models. An example of a game-changer is Apple’s use of Fast Healthcare Interoperability Resources (FHIR) transactions to allow patients to integrate and track their health information across providers.



Michelle Stansbury, vice president of IT innovation, Houston Methodist, speaks during a session on the challenges and opportunities that await providers looking to enhance the patient experience. At right is David Kerwar, chief product officer and head of consumer digital innovations, Mount Sinai Health System.







The patient experience gets measured beyond clinical care. Here’s how to improve it. Florian Otto, MD, PhD, co-founder and

Once you have mapped all the pain points

CEO of Cedar, provided insight on the

along the journey, prioritize the most critical

patient experience as a lead-in to the

issues and develop improvement plans. There

Patient Accessibility, Engagement and

will likely be some eye-opening findings and

Experience cohort at HFMA’s 2019 Annual

trends that you may not have expected.


It’s a critical exercise that helps keep you

On the financial benefits of improving the patient billing experience: Margins of hospitals are very low, around 2% nationally. Bad debt rates are 4% to 7% of net patient service revenue. So if you increase the collection rate by just 10%, that adds another 40 to 60 basis points directly to the bottom line, given that it’s service already rendered. With a relatively small collection-rate improvement, the profit margin now averages 2.4% to 2.7% — a 30% lift.

On key strategies for becoming more consumer-friendly: We recommend three strategies to make this transformation for provider organizations. 1. Prioritize the end-to-end consumer experience. To do this, map out each touch point of the journey through the eyes of the patient. Get patient feedback and put yourself in their shoes. See what it’s like to book an

connected to your primary stakeholder — the patient. 2. Digitalize and personalize the journey when possible.

With digitalization, you get much more immediate feedback on what patients react to. Why, for example, is Starbucks so accurate in sending you offers? It’s because they know your preferences. We need to do the same in healthcare billing. We’ve seen that for patients who engage in digital technology, there’s a 40% increase in payment rates versus those who aren’t digitally enrolled. In the beginning, we were a little bit worried that only young people use technology, which has been proven false. Digitization allows for better personalization, which drastically improves engagement. 3. Offer convenient support for patients

If you have a question for Airbnb or Uber, there is a 24-7 automated chat that probably responds to 80% of customer questions. Healthcare needs the same standard. Studies confirm that patients want to pay their bills. We just need to answer their questions and

appointment or to check in. Can you put down

remove friction.

your insurance information quickly? Can you

That said, technology is not always enough.

get an accurate estimate?

Some patients want to talk to a human, some

Then, repeat the exercise through the

still want to send an email. We need to give

hospital inpatient or outpatient experience,

patients convenient options, and we need to

up through checkout. How is the billing

have one single point of contact.

experience? Do you need to call different call

By improving the end-to-end patient journey,

centers to have two different questions from

there’s a positive impact on collection rates,

two different bills answered, or is there one

time to collect, cost to collect and patient

single point of contact?





centers as testing grounds for new strategies and tactics. Houston Methodist’s Center for Innovation has representation across the organization to bring diverse perspectives on improving the patient experience, said Michelle Stansbury, vice president of IT innovation. Mount Sinai put together a team from outside of healthcare to look at using journey mapping and technology to pinpoint hot-button consumer issues, Kerwar added.


PATIENT LOYALTY IS KEY TO POPULATION HEALTH MANAGEMENT AND AN ORGANIZATION'S FINANCIAL SUSTAINABILITY. For patients, the patient experience begins as soon as they think they need healthcare. “The healthcare experience predicts brand loyalty,” said Chrissy Daniels, partner in the Strategic Consulting Division of Press Ganey. Three factors in the patient experience predict patient loyalty, Daniels said: The patient’s confidence in the provider The cohesiveness of the care team The responsiveness of the care team



SOCIAL MEDIA AND REPUTATION MANAGEMENT ARE VITAL TO PATIENT ENGAGEMENT. A provider’s ability to attract patients and secure their loyalty — and to grow its brand in the community — may hinge in large part on social-media platforms. Recent data shows patients predominantly choose physicians after evaluating online reviews and ratings. Such reviews have five times the impact of traditional marketing, Daniels said. Providers thus should have processes for responding to patients on social platforms while understanding that the greater visibility offered by such platforms is driving urgency around the consumer experience.


THE SHIFT TO A CONSUMER-ORIENTED EXPERIENCE REQUIRES EXPERTISE IN CHANGE MANAGEMENT. Healthcare leaders are shifting to a culture of innovation, welcoming new ideas. “We believe innovation is a responsibility of all our employees,” Stansbury said. “Our approach is to succeed fast or fail fast. Within a 60-day time period we evaluate if an initiative is a success, and if it isn’t, we move on.”

The Patient Accessibility, Engagement and Experience cohort included the following sessions and speakers: IT innovation, Houston Methodist

Partners, Purchase, N.Y.

Florian Otto, MD, PhD, co-founder and

Raj Mehra, head of strategy and

CEO, Cedar

operations, Cedar

Personalizing the Patient Financial Experience: Thinking Like a Consumer

Transparency Is a Team Sport

innovations, Mount Sinai Health

Sue Gillies, vice president, revenue

Strategic Consulting Division,

System, New York City

cycle management, Crystal Run

Press Ganey

Joel Perlman, senior adviser,

Healthcare, Middletown, N.Y.

Niren Gandra, head of

Montefiore Medicine, New York City

Vicki McKinney, COO and chief

partnerships, Cedar

Michelle Stansbury, vice president of

revenue officer, WESTMED Practice

The New Reality: Challenges and Opportunities for Patient Experience David Kerwar, chief product officer and head of consumer digital

Chrissy Daniels, partner,




t’s no secret that the rise in high deductible health plans and the increasing amount of self-pay have impacted healthcare organizations’ bottom lines. But, is it fair to say that enhancing patients’ financial experiences can drive payment and improve an organization’s financial health? In this roundtable, sponsored by Change Healthcare, several revenue cycle leaders discuss how their organizations are tackling the issue of escalating patient responsibility, exploring how they are putting individuals on pathways toward payment that boost satisfaction as well as revenue. What are some of your biggest challenges related to improving the patient payment experience?

Jim Porter: At Edward-Elmhurst Health, we are constantly striving to engage our patients more effectively, so when they receive a bill from us, they understand it and are amenable to paying it. One of the hurdles we face relates to a lack of patient understanding surrounding insurance coverage. While patients may know they have insurance, sometimes they don’t realize it comes with deductibles, copays and co-insurance. Moreover, they may not know whether they have an HMO or a PPO and what is required for each. Things can get even more confusing when they go to access the health system. Maybe they must go to hospital A for services but not hospital B. If for whatever reason they choose hospital B, they now have a


higher financial responsibility, which is frustrating to them. To the extent that we can demystify their benefits and give them what we believe is a realistic estimate of what they’re out of pocket costs are going to be, we can help them more effectively navigate the system — sometimes having to tell the patient that they may be better off going to our competitor because it will be less costly. Although that might seem self-defeating, if we are going to be collecting a lot of money from the patient, and it’s going to be a difficult experience for us and them, then it’s to everyone’s advantage to point them to the appropriate facility. In the end, education is a huge priority. Many employers are doing their employees a disservice by not helping them understand the different plans and how they’re covered. It’s becoming the health system’s role to unpack the details, especially if we want to provide a good experience and maintain a

strong relationship with the patient. Shaun Ronan: The changes in patient responsibility are leading to a large growth in self-pay after insurance, which is extremely hard to collect up front. At Health First, we’ve put several resources in place, including a price estimation tool, to give patients an idea of what they will owe, so we can start to collect upfront. Even so, reliably capturing this money can be difficult. Part of the problem is that people don’t truly understand what it means to have a high deductible. During enrollment, they opt for the cheapest plan to save money. While they may be covered in the event of a catastrophic health issue, they are going to have to pay for more routine care — and that’s a hard concept to grasp until you experience it. Unfortunately, healthcare organizations are sometimes left to explain how insurance coverages work in light of these high-deductible plans and the potential


ROUNDTABLE Curbing bad debt by improving the patient financial experience high costs that patients must bear in these plans, and deal with the choices patients make. Rhea Heath: Part of the struggle we’re having at Beacon Medical Group is getting consistent patient access and payment processes and messages across all our practices. We are just now building a centralized pre-registration department for the entire medical group, because we are comprised of many different independent practices that came together. Those inconsistencies have caused patient dissatisfaction. For example, we had one practice that required patients to leave a 20 per-cent deposit for a procedure while other practices didn’t. We are trying to build some standardization, so the patient experience is the same no matter what practice they visit. Another point of patient frustration is that we may send them a bill six months after their date of service because it can take that much time to work through the claim adjudication process. By that point, patients don’t remember the service and how much they paid already, and they think we’re incompetent or trying to pull a fast one. Porter: It is important to set expectations upfront as to when the bill will be coming. We aim to talk with patients on the front end and

collect a deposit at the time of service, telling them that they won’t receive a final bill for about 60 days due to insurance company adjudication. By taking this approach, we help patients better understand what’s coming and what their responsibilities will be. For us, this is a work in progress, but we are making some headway in accelerating cash. We are also hoping this becomes a patient pleaser because they have greater insight into the process. Chris Johnson: It’s interesting to hear the different perspectives. Currently, Atrium Health doesn’t bill our patients until they have a self-pay balance, and that is an intentional choice. We made a judgment call a number of years ago that started us on this path. When we send patients statements that say they owe us X, we want to be sure that’s truly what they owe us and all that they owe us. Because the big complaint we got from patients was, ‘you bill me and I pay that, and then you send me another bill, and it’s a different amount, and I pay that, and then you send me a refund — it’s irritating.’ Since we don’t tell them what the refund is for, they end up calling us to sort out what the amount owed truly is. It’s time consuming for us and them, and for patients, it’s annoying.

HFMA Roundtable Participants Rhea Heath is executive director of finance and revenue cycle for Beacon Medical Group in South Bend, Indiana Chris Johnson is vice president of revenue cycle management at Atrium Health in Charlotte, North Carolina Kelly Black is vice president of revenue cycle for the ambulatory division of Novant Health in Winston-Salem, North Carolina Jim Porter is vice president of revenue cycle at Edward-Elmhurst Health in Naperville, Illinois. Shaun Ronan is vice president of revenue operations for Health First in Rockledge, Florida. Michelle Fox is director of revenue operations and patient access at Health First. Kelley Blair is senior vice president for Change Healthcare in Chicago.



Heath: Another obstacle that can slow down patient payment is the lack of staff training to handle patient financial conversations. As an industry, we don’t train our customer service and patient access people to engage in complex patient interactions. Patient access and customer service are entry level positions who directly impact the patient experience, determine whether we have accurate information for billing and affect whether a claim is going to be clean. We have to shift the thought process nationally around these job types, so that they are not always entry level positions, but ones that require more advanced skills, require more training and are above entry level. Ronan: From what we see, the labor trends are not going to change, and we have to consider other options, such as automation, to streamline repetitive processes and make things more efficient and ultimately easier for our patients. Heath: Yes, that’s true, but you need to find the right balance with automation, because when you’re dealing with people who are scared and who have just received a catastrophic diagnosis, they don’t want to look at the computer to figure out how much they’re going to pay. They want to hear a compassionate human voice on the phone. We need to figure out how we can best utilize technology while still offering a compassionate and caring experience. One of the things we’re budgeting for is virtual financial counseling. We don’t have enough people to put financial counselors in all our practices, but we need to make them available. Using secure digital connectivity and other online communication tools may be a solution.

How do you segment patients for collections, payment plans, charity care and so on? Heath: Primarily, we look at dollar thresholds. If a patient’s account reaches a certain dollar amount — whether through outstanding bills or new charges — then a financial counselor will speak to the patient and advise the customer of all the ways the bill can be paid. Based on this initial conversation, we determine if the patient


is potentially eligible for financial assistance. We look at that from a Medicaid perspective and from a charity care perspective, and we route them to the correct path based on a phone conversation. Johnson: We also consider the patient’s payment history. One of the complaints that we received several years ago was that we treated everybody the same regardless of whether they were good about paying in the past. We heard comments from the patient community saying, ‘You treat me like I don’t pay my bill, or that I’m not going to pay my bill. However, if you look at my record, I do pay my bill.’ We started doing some analyses and realized that the patient feedback was valid. Now we consider a patient’s payment history with us before we ever do a formal segmentation.

What are some best practices you’re seeing to maximize selfpay collections? Johnson: It’s about starting a conversation with a patient in which we identify some of the obstacles to payment and try to remove them. I believe this boosts patient satisfaction and also helps payments go up. Ultimately, we’re trying to send a message that if you have a balance and you truly have an interest in paying it, then we have a method to assist you with that. And we start that at the front door with education. Michelle Fox: Health First has seen positive results from our automat-ed price estimation tool. After we implemented it, we saw a 27 percent increase in our cash collections and a decrease in our bad debt. This solution loads our contracts and chargemaster, figures out an estimate, and provides a written copy. This has helped us establish credibility with patients and build relationships. Not only do we have something to walk through with patients based on solid information, but the estimate also gives our staff more confidence in talking with individuals. We provide an estimate to every patient, even when they don’t ask for one or they don’t owe anything. We have found that this has

been a huge patient satisfier, especially in the emergency department. Johnson: Providing a consolidated hospital and professional statement is also a patient satisfier. We made that move about three plus years ago based on patient feedback. I don’t have a quantitative measure of satisfaction, but we receive a lot less complaints. Patients get one statement about their professional and hospitals charges, and they can call one customer service team with questions and concerns, which has been a big win for us. Heath: We also offer payment plans. We facilitate up to a six month payment plan in house, and then we work with an outside vendor that provides a 36-month, interest-free payment plan to patients who are deemed in need and have a high propensity to pay. Ronan: It’s also beneficial to provide opportunities for patients to set up plans for themselves. Some of the technology out there is consumer friendly, and if we can take the burden off our staff, whether it be the front-end or the backend, all the better. Let’s say the individual has three or four bills with us, he or she can use the technology to combine these into a two-year payment plan that allows a $150 per month bill. The hospital won’t need to follow up with the individual about paying; it’s between the patient and payment plan vendor. Kelly Black: A credit card on file is also an option. That way we don’t even have to ask for the payment. We set the card up in a secure app, and it gets charged once everything has been adjudicated. We never see it or touch it. Porter: Putting technology in the hands of the patient lets them manage things on their own with minimal staff input, which is not that different than booking airline tickets. Ronan: That said, people still sometimes want to talk to someone to make sure they’re doing it right or they haven’t missed something. Johnson: There is also a motivation difference between paying a healthcare bill and booking a trip. If I’m a patient and I’ve tried to pay a bill and something goes wrong with that process, I easily can get discouraged and give up. With


an airline ticket, the person is going to hang in there and figure out the problem because he or she wants to go somewhere. Patients may not want to pay the hospital or doctor bills. As such, it is critically important that payment technology reliably works and is not overly complicated because there can be a significant drop off in payment if paying the bill becomes onerous.

What are some key lessons learned you would share with others looking to improve the patient experience and reduce bad debt? Porter: We’ve covered a lot of different approaches, but one area we haven’t talked about relates to incentivizing staff to collect payments. While educating them about the importance of the work is crucial, it can also be helpful to tie specific financial encouragements to the effort. We are rolling out a four-pronged plan this summer for our patient access and patient accounting department with an overall goal of increasing cash collections. The program also includes other metrics around denial reduction and limiting accounts receivable aging. With this plan, we’re hoping to incentivize staff. It’s not much, but the goal is to elevate performance and increase their compensation. Johnson: Another lesson learned is making sure you’ve got a path for every patient to get to

payment. We clearly recognize from the outset that there are some patients that it doesn’t matter how much education we provide; they’re not going to pay. We aim to figure out who those people are quickly and move them out, so we can focus on the people who are going to pay. It won’t fix everything, but in our world, there’s a difference between a patient who can’t pay but wants to and a patient who can’t pay and won’t no matter what. Black: Staff education is also important, and you have to continually update an education program. This is not a one-and-done project. People leave and go elsewhere, and you constantly have new people coming on board that need the information to be successful. There’s no school for studying how to handle insurance and register patients, and so we’ve got to create a program in house. At Novant Health, we have a revenue cycle university within our organization, but it’s in the early stages and we’ve only had it for a few years. It’s challenging to get everybody moved through the education process and offer relevant and up-to-the-minute material. Once staff finish the course and get up to speed in applying their knowledge, they often need to come back because it’s changed. Even amidst the challenges though, it’s critical to provide the education, otherwise the service you deliver to patients may not be that good. Fox: One way Health First has approached staff education is by hiring an observer whose

sole job is to watch staff-patient interactions. She makes sure our employees know how to speak to a patient, be respectful, engage in a conversation, handle difficult topics and so on. She observes each associate at least once a month — all 180 on my team. We found the money for the position through staff attrition, and thought it was a necessary resource, especially as we strive for a level of customer service we haven’t had before. Health First created the observer position three years ago, and the staff have found it to be quite beneficial. In part, because the individual is a neutral party. Instead of being unsettled by the fact that their manager is watching them, staff can learn from the neutral observer whose primary directive is to improve customer interactions. Kelley Blair: Addressing patient collections is a complex process that requires multifaceted solutions. Collecting data to segment patients is critical so you can appropriately focus your efforts upfront. Education for staff is also essential. You need to prepare your employees to enable a positive patient experience and monitor those interactions to make sure relationships are being formed. There are numerous methods for increasing patient payment, and the most successful ones will put patient needs first. By leveraging technology, data and expertise, organizations can make progress in this area, increasing patient satisfaction and driving revenue at the same time. n

Change Healthcare is a leading provider of software and analytics, network solutions, and technology-enabled services that optimize communications, payments, and actionable insights designed to enable smarter health care. By leveraging its Intelligent Healthcare Network TM, which includes the single-largest financial and administrative network in the United States, healthcare system, payers, providers, and pharmacies are able to increase revenue, improve efficiency, reduce costs, increase cash flow, and more to effectively manage complex workflows. Learn more at www.changehealthcare.com. This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.









Why prioritizing workplace integrity matters Although employers may have thought they were being vigilant about workplace misconduct, there is still significant work to be done

JILL GEISLER is the author of the book, “Work Happy: What Great Bosses Know,” produces the podcast “Q&A: Leadership and Integrity in the Digital Age” and writes a management column for the Columbia Journalism Review. Previously, she headed the leadership and management programs of the Poynter Institute and was one of the country’s first female TV news directors.


rom the #MeToo scandals that erupted in late 2017, we learned that, while employers may have thought they were vigilant about workplace misconduct, there was significant work to be done. It wasn’t enough to weed out the most egregious offenders (such as the high-profile cases we saw in the media). Organizations of all kinds had to look at the systems and cultures that kept people from speaking up when they experienced or witnessed something wrong. Leaders began to look at how misconduct could be happening on their watch. That led to a greater focus on the bigger picture. I describe the goal as workplace integrity: Environments free of harassment, discrimination and incivility and filled with opportunity, especially for those who traditionally have been denied it. From research done by a special task force of the U.S. EEOC, we’ve learned that harassment, discrimination and incivility are interlinked.1 If people are allowed to verbally abuse others, it creates a more fertile ground for other misconduct. It can cause good employees to leave because it’s easier to take another job than to push back, especially if the colleague who bullies others is powerful by virtue of title or tenure.



Managers understand the importance of compliance. Workplaces have mandatory training to tell people what’s legal and illegal on the job. We focus on safety, patient privacy or sexual harassment to ensure we follow the law. But plenty of negative workplace behavior doesn’t rise to the level of illegal; it’s just wrong. Rudeness, insensitive jokes, angry outbursts, condescension, constant criticism, cliques and bullying all contribute to workplaces that range from uncomfortable to toxic. People sometimes try to excuse such behaviors by saying, “We work in a high-pressure environment here, so it comes with the territory and people should just get used to it.” But that rationale perpetuates misconduct and blames the victims. And it’s bad for business. Christine Porath, business professor at Georgetown University, has done research on the impact of such behaviors. In her book “Mastering Civility: A Manifesto for the Workplace,” she reports that among workers who were the targets of incivility, significant numbers reported: Their work performance declined. They lost work time to efforts to avoid the offender. They intentionally decreased the time they spent at work. They took out their frustrations on customers, in some cases.





It’s no secret that the tone starts at the top. The leader’s words and actions send a stronger message than any written rules and guidelines. Sometimes, leaders think their values run so deep and their intentions are so good that they don’t even need to discuss them. They assume their commitment should be obvious. But we know employees are always watching their leaders and take their cues from them. When leaders truly believe in workplace integrity, they embed it in their conversations and communications. They don’t miss a chance to talk about principles and purpose. They know that when they talk openly about their values, the staff pays close attention to see whether their decisions and behaviors match their words. Employees want to see congruence, not conflict. If leaders talk about valuing a positive culture, then turn a blind eye when a bad actor happens to be a “star player” or key manager, their words are worthless. Leaders should weave workplace integrity into the organization’s most important systems, programs and processes: job descriptions, hiring, onboarding, everyday feedback, performance management, evaluations, promotions, awards, exit interviews. It should become part of the master narrative that describes the organization’s culture as one of respect and trust. HOW TRAINING CAN GO BEYOND THE EMPLOYEE HANDBOOK

Let’s be honest. The employee handbook is a great thing to have, but it sits in most people’s files and isn’t exactly everyday reading. A handbook is often seen as a set of rules, not a recipe book for a culture. That’s because culture is about assumptions so deep that we don’t even talk about them anymore. We just act on them. To upgrade flawed workplace cultures or sustain positive cultures, organizations need to use a combination of approaches. Measure. How’s morale and engagement?



Have you done any kind of formal or informal survey? Do your managers ever get 360-degree feedback? How are you doing on diversity? On retention? What does the data tell you? Listen. It costs leaders nothing to go on a listening tour. Tell your team what you’re up to, that you’re eager to hear what’s working, what they’d like greater clarity on or what keeps them up at night. Ask them what I call the “Million Dollar Question”: Is there anything you need more of, or less of, from me? That’s a great way to get feedback you can act on. Train. As a person who trains leaders and teams, I can tell you that training works best when people ask for it and when it’s delivered in an engaging manner. Adult learners want information that helps them solve problems, build opportunities and work more successfully. They want it to be practical and interactive, designed for the reality of their workplace (not a canned presentation). Some training will always be mandatory, but find space for training that employees request. Maybe it’s on emotional intelligence or working across generations or how to be an ally to people who traditionally have been underrepresented in your field. Your listening tour can help you identify some of those interests. HOW LEADERS BENEFIT FROM ESTABLISHING AN ATMOSPHERE OF WORKPLACE INTEGRITY

This is one of those truly good-news stories. Doing the right thing is also good for business. Workplace integrity — meaning an environment free of harassment, discrimination and incivility and filled with opportunity — creates employee engagement. Your veteran employees feel valued. Your newer employees want to stay longer. People who traditionally have been under-represented in your office or your industry feel they have allies who are committed to their success. And, as years of Gallup research documents show, there’s a payoff in everything from productivity to profitability.b Workplace integrity is a win for everyone.








How primary care physicians can navigate business intelligence challenges under risk models Primary care physicians have been enlisted in the value-based healthcare effort, with revenues linked to meeting targeted cost measures to entice practice participation, but many of these physicians lack the business intelligence capabilities needed to be successful under these models.



he new Medicare value-based care primary care models implemented by the Centers for Medicare & Medicaid Services (CMS) require physicians not only to be accountable for their patients' long-term health, but also to control the costs of services that are beyond their scope of services, such as hospital inpatient and outpatient costs, specialty physician services and rehabilitation. The type of accountable expenses vary by model. Physicians can find it difficult to get a handle on these costs because they tend to lack the business intelligence capabilities required for success under these models, including systems for tracking patients by condition and risk and for measuring cost performance against targets. The primary care models described in the sidebar on page 63 require practices to actively manage their patients’ risks and care, whether or not they directly provide that care. Therefore, they must create a referral network that will help them control the costs. Doing so requires specialists and hospitals who will communicate with the practices and ensure that primary care physicians continue to be part of the medical decision-making process that drives costs. Practices will require knowledge and data —

through business intelligence technology and services — that they don’t have now. Tools must enable them to achieve savings and incentive revenues through better choosing referral physicians and effectively managing resources. 5 BUSINESS INTELLIGENCE STRATEGIES

The following five strategies and using the right business intelligence technology are the most critical to the success of primary care practices.


Collect risk data on patients, including social determinants of health and patient preferences. Using electronic health records (EHRs) that are interoperable and certified, primary care practices under financial risk are responsible for organizing patient information that can be used to develop care pathways. Data can then be used in coordination of care.


Organize patients in risk registries that reflect barriers and clinical status, and use that information to implement interventions. There are affordable outsourced vendors and systems such as clinical data registries or population health vendors that will aggregate data NEXT PAGE





New payment and service delivery models defined


hospitalization decisions of specialty physicians and

CMS has introduced the following new payment and service delivery models.

choose their referral partners in advance. Such partners

Primary Care First (PCF) model. The PCF model is aimed

choice is possible).

at small practices on the lower end of the resources and

The Direct Contracting (DC) model. The DC models (that

technology spectrum, some possibly still lacking electronic

is, DC Global, DC Professional and DC Geographic) target

health records (EHRs). Payment is basically fee-for-service,

larger practices with infrastructure to manage services and

plus a management fee and a performance incentive or

distribution of money to other physicians. These models

penalty. Cost performance is determined by the Healthcare

build on providers' past experiences with independent

Effectiveness Data and Information Set (HEDIS) Acute

practice associations or physician hospital organizations

Hospital Utilization measure that compares expected-to-

contracting and incorporating extra flexibility allowed

actual utilization of risk-adjusted patients. The incentive

to Medicare Advantage (MA) and accountable care

could be up to 50% of Medicare revenues, or, alternatively,

organizations (ACOs).

a penalty of up to 10%.

Direct contracting physician groups must control the

A variation on the PCF model, dubbed the PCF High Needs

full spectrum of patient care costs to achieve savings.

Population, is focused on populations with special or high-

Although similar to what's required of ACOs and MA

risk needs and includes additional participating providers

plans, this effort requires a considerable shift in the

such as palliative care providers.

core expertise of most group practices. Groups must

The dilemma for physicians is that the HEDIS indicator is

significantly address cost drivers, generate patient loyalty

a retrospective algorithm that permits comparison across

and cooperation and make it easy for patients to choose

all physicians but is not actionable. With a 10% penalty on

and follow therapies.

include specialty physicians and hospitalists who manage inpatient care, and they also can be hospitals (where a

the line, physicians must be able to successfully control

and perform population health management if a practice's EHR does not have this functionality.


Measure cost performance and select referral networks based on performance on cost and outcomes. Total cost per beneficiary and by category-of-care utilization measures and episodic costs should be used where feasible. Although some costs will require claims data, CMS is likely to provide quarterly data reflecting performance. If CMS does not include that data, practices should request it during the initial five-year testing period. The direct contracting groups accepting global capitation will have their own internal claims data to develop analytics.


Track and test interventions implemented to improve cost performance trends and patient outcomes. Cost control is an iterative process, and clinical registry and other analytics partners can help physicians adopt interventions

based on measured success.


Organize consumer-focused efforts to engage patients. Depending on the patient population, practices should implement convenience features and substantive patient medical decision-making initiatives to create trust and achieve better results. As primary care physicians enter the fray of provider risk, they require business intelligence to help them steer toward success. Coordination of care, by itself, cannot fuel the practice transitions necessary to achieve good care at lower cost. Value is attained by properly measuring and then navigating positive and negative effects of interventions on patients and costs.

About the author Theresa Hush is CEO and co-founder of Roji Health Intelligence, Chicago



Business Profile

Enabling Holistic Clinical Documentation Improvement How do you help healthcare organizations? Enjoin is a highly-experienced, physician-directed company that offers comprehensive solutions for improving clinical documentation. Our goal is to help organizations fully tell their patients’ stories through complete and accurate documentation and coding that reflects the risk, severity and complexity of the patient population, as well as the quality of care the organization provides. Our proven approach can be applied to any care setting, empowering organizations to transform their clinical documentation across the continuum. Through a robust clinical documentation improvement (CDI) program, our clients are laying the foundation for the Triple Aim — better care, healthier patients and smarter spending.

What are some of the biggest challenges you see affecting healthcare organizations? A significant challenge involves maintaining financial solvency amid the push toward value-based care. With reimbursements declining and denials increasing, it is difficult to move toward pay-for-performance while continuing to succeed in fee-for-service arrangements. There are so many diverse initiatives happening, and consequently, there are numerous ways an organization can be judged. Unfortunately, as entities work toward success in the various programs, they often don’t approach the work collaboratively, especially when it comes to the translation of clinical care or clinical documentation. The reality is whatever an organization’s goals are — whether it be assuming more risk, optimizing current performance, reducing denials or facilitating population health management — the focus needs to


be on improving documentation and coding because if those fully and accurately reflect the patient encounter, then everything else will fall into place. Conversely, if an organization trains providers to document based on a single desired outcome, they can lose credibility and physician buy-in for the work because the rules may change as different objectives take priority. The key is to train providers to document a concise, transparent view of the patient’s story that will meet organizational objectives across all areas of quality reporting, risk tolerance, financial performance and clinical excellence. Another issue with which organizations wrestle is big data. It seems like everyone is trying to determine the best ways to leverage the large quantities of information that are now available. Due to our deep experience, we’re

able to offer insights into how to turn data into actionable and operational information. Our practicing clinicians and clinical coding experts are positioned to support an organization’s providers, helping them create the exactness needed for documenta-tion without additional burden, which allows them to maintain the physician-patient relationship and avoid burnout.

How do your service offerings address these needs? Enjoin delivers a highly collaborative experience. As a first step, we assess where a client is on its CDI journey and work to understand its goals. Our team identifies vulnerabilities through data analysis, chart reviews and CDI process assessments. We’re able to offer predictive analytics to illustrate the areas that will have the greatest

Enjoin: Enabling Holistic Clinical Documentation Improvement ADVERTISEMENT

are also credentialed in coding and documentaimpact for the organization. Based on this tion, so they can link evidence-based medicine information and extensive conversations with organization leaders, we then craft a customized with coding and documentation profi ciency. Going a step further, Enjoin’s physicians are also strategy for realizing better documentation How do you help healthcare thought leaders in the industry and are deeply and coding at the local setting and across the organizations? involved in evolving clinical documentation as a continuum. As we start to develop a program, Enjoin is a highly-experienced, physician-directed company that profession, improving the consistency and integwe take into consideration the organization’s offers comprehensive solutions for improving clinical documentation. rity of the work. Due to this vast experience, we existing data and technology capabilities. Over Our goal is to help organizations fully tell their patients’ stories through bring adocumentation degree of documentation coding exthe years, we’ve come to appreciate that orga-and accurate complete and coding thatand reflects the risk, severitytoand complexity the patient population, as well as the quality pertiseofthat is unique to the marketplace, helping nizations are at different places with regard of care the organization provides. proven approach be to see our clients lookOur beyond their currentcan needs technology and data, so we build our offerings applied to any care setting, empowering organizations to transform what’s possible and transform their operations around an entity’s readiness for change and their clinical documentation across the continuum. Through a robust to achieve better quality and costour performance growth, using the organization’s current investclinical documentation improvement (CDI) program, clients are laying the foundation the Triple Aim — better care, healthier amidfornew and emerging payment models. ments to frame the program. patients and smarterAnother spending.consideration is whether a potential A fundamental component of our services partner can deliver a solid return on investment is peer-to-peer, specialty-specific provider What are some of the biggest challenges (ROI). Our clients see a demonstrable improveeducation grounded in clinical practice. Our you see affecting healthcare organizations? ment in coding accuracy, quality metrics, risk board-certified physicians off er clinical insight A significant involvesand maintaining financial solvency adjustment physician alignment —amid withthe an and coding know-how. Since our physicians are challenge toward reimbursements averagecare. ROI With of more than 700%.declining We alsoand focus actively practicing medicine, they canpush provide a value-based denials increasing, it is difficult to move toward pay-for-performance on knowledge transfer to help organizations real-world view of how to improve documentawhile continuing to succeed in fee-for-service arrangements. There are sustain the clinicaland documentation workare over tion based on evidence and what theyso are seeing many diverse initiatives happening, consequently, there numerous ways an organization can a betrain-the-trainers judged. Unfortunately, as time, embracing approach. in their own practices. This level of expertise entities work toward In success the age various programs, often don’t a dayinand where there’sthey constant and practical advice goes a long way toward approach the work collaboratively, especially when it comes to the change and evolution, it’s important that a CDI fostering provider engagement and buy-in. translation of clinical care or clinical documentation. The reality is partner embraces multifaceted approach to Our documentation and coding specialists whatever an organization’s goals are —awhether it be assuming more risk, optimizing current performance, reducing denials or facilitating documentation and coding that looks at revenue include internists, hospital-ists and specialists population health management — the focus needs to be on improving recovery, clinical validation and denial defense to across several disciplines, including cardiology, documentation and coding because if those fully and accurately reflect mitigate risks that stillinto critical pulmonology, urology and more. Our physicians the patient encounter, then the everything elseare will fall place.in today’s world but also considers how to appropriately don’t just feed information to an organization’s Conversely, if an organization trains providers to document based on a single desired outcome, they canadjustment lose credibility and physician buy-in to code for risk and quality measures doctors behind the scenes, they are intimately for the work because the rules may change as different objectives take enable success in emerging arrangements. involved in creating the infrastructure, strategy, priority. The key is to train providers to document a concise, transparent design and delivery of our services. view of the patient’s story that will meet organizational objectives across

Organizations need to establish a documentation culture where the work becomes part of the day-to-day fabric of care. To achieve this level commitment requiresrisk a multi-disciplinary allofareas of quality reporting, tolerance, financial performance and excellence. effclinical ort between coding, CDI, quality, physicians and theissue population health team —wrestle and this Another with which organizations is big data. It seems like everyone is trying to determine the best to leverage the collaboration must stretch across theways continlarge quantities of information that are now available. uum. This may mean regular meetings and Due to our deep experience, we’re able to offer insights into how to turn data into avenuesand of communication to support dynamicclinicians and actionable operational information. Our practicing informa-tion exchange. clinical coding experts are positioned to support an organization’s providers, helping them create Organizations also needthetoexactness be willingneeded to takefor documentation without additional burden, which allows them to maintain the a step forward and move out of traditional feephysician-patient relationship and avoid burnout. for-service CDI and embrace an approach that facilitates value-based How dopay-for-performance, your service offerings address care and population health as well. They need to these needs? understand that although the fi nancial compoEnjoin a highlyso collaborative experience. As athe first step, we asses nent delivers is important, is the quality piece and where a client is on its CDI journey and work to understand its goals. impact of holistic documentation on patient care. Our team identifies vulnerabilities through data analysis, chart reviews Probably most important thing to predictive analytics to and CDI processthe assessments. We’re able to offer illustrate the areas that will have theculture greatestis impact for the organization fostering a documentation physician Based on this information and extensive conversations with organization support. To fully engage providers, organizaleaders, we then craft a customized strategy for realizing better tions may want to create physician adviser documentation and coding at thea local setting and across the continuum program that encourages networking across As we start to develop a program, we take into consideration the the entire organization. The entity can then organization’s existing data and technology capabilities. Over the leverage individuals to continuously years, we’vethese come to appreciate that organizations are at different places with regard technology and data, so we build our offerings evolve the CDI to program. around an entity’s readiness for change and growth, using the organization’s current investments to frame the program.

In this Business Profile, James Fee, MD, CEO of Enjoin, discusses the importance of holistic clinical documentation to realize success with existing fee-for-service payment models, as well as valuebased care and population health initiatives.

In this Business Profile, James Fee, MD, CEO of Enjoin, discusses the importance As healthcare organizations of holistic clinical documentation to What are some key considerimplement your service into their realize success with existing fee-for1 September 2019 © 2019 Healthcare Financial Management Association ations for healthcare leaders when day-to-day operations, what service payment models, as well as choosing this type of service? advice would you offer so they value-based care and population health initiatives. The biggest consideration is whether your CDI can best set themselves up for

partner has clinically practicing physicians who


Value-based care and risk adjustment methodologies for payment and performance require increased transparency into providers’ performance and data integrity. With thirty years of direct physician leadership, Enjoin delivers complete solutions for clinical documentation integrity across the continuum and ensures evidence-based care is accurately refl ected through precise documentation and coding. Enjoin clients achieve a demonstrable improvement in CMI, coding accuracy, quality metrics, risk adjustment, and physician alignment. For more information, visit enjoincdi.com. This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.





STEPHEN MORGAN, MD Senior Vice President and Chief Medical Information Officer at Carilion Clinic in Roanoke, Va.





How one organization uses analytics to optimize its EHR


ncorporating analytics to optimize the electronic health record (EHR) adoption process and maximize EHR functions was one topic presented as part of the business intelligence, data management and analytics track during HFMA’s Annual Conference in Orlando in June. After the session concluded, Nick Hut, HFMA content manager, spoke with one of the presenters, Stephen Morgan, MD, senior vice president and chief medical information officer at Carilion Clinic in Roanoke, Va., about how his organization incorporated analytics into its EHR function. Here’s an excerpt of their conversation.

NICK HUT, HFMA Content Manager

Listen Insights and in-depth stories The Healthcare Financial Management Association provides industry insights and in-depth stories about hot topics in healthcare finance. podcast@hfma.org

Nick Hut: What difference would you say analytics has made, overall, in the use of the EHR at Carilion Clinic? Stephen Morgan: We’ve used [analytics] in a number of different ways. Certainly from a provider perspective, to improve the provider experience with more efficiency and workflows, being able to understand where we have deficits in those workflows. We also have been able to use analytics from a revenue cycle perspective to start to drive looking at denials. For instance, we have a denial dashboard that we’re able to get back to our department chairs and section chiefs so that they can educate and help to make changes within our providers. We use a number of different visualization tools to be able to deliver analytics in near-real time that will enable us to provide everything from clinical care all the way to improved financial well-being for the organization. Hut: In a negative context regarding EHR, do you hear clinicians feel that it impacts the quality of

HFMA’S Podcast Series is available here:


patient care? Certainly, it’s a drag on their time and adds to the stress and strain of their job. How do you use analytics to mitigate or solve those problems? Morgan: Well, we haven’t solved all the problems, but we certainly have used analytics to give insight on where clinicians are spending more time in their workflows. Sometimes they’re spending more time doing non-clinical work that we can see in some of the dashboards we’ve created to monitor the efficiency of how the providers are working. We’re able to present that back to the providers and, in a lot of cases, change the way that they’re interacting with the system to be able to make improvements. Just having those kinds of tools has allowed us to pinpoint where physicians are having the most difficulty [so we know where] we need to change some things in the system, make a workflow different [or implement a] process improvement to improve their efficiency and ultimately improve the quality of the work they’re doing.


Engaging Patients in Their Financial Journeys By Professional Credit

How do you help healthcare organizations navigate the biggest challenges in healthcare? Professional Credit helps healthcare clients effectively and positively engage patients throughout the financial portions of their healthcare journeys. We provide full transparency into all patient interactions through a secure portal, and by giving clients access to recordings of any patient contact. In addition, we keep our clients apprised of industry changes, best practices and share insights from our in-house behavioral scientist. We also offer patients multiple ways to access account information, set up payment plans or get details about their providers’ charges through our mobile app, patient portal, interactive voice response (IVR) system and help desk. Patients can also communicate with us based on their preferences, including email, text or live chat sessions. Whether interactions occur through the mobile app or directly with our knowledgeable staff, our use of data and behavioral science enables effective and positive collaboration to help patients solve their financial challenges.

What advice would you offer to healthcare leaders when choosing among vendors? Look for the following characteristics: • True visibility into all patient communications. Health system leaders need to know how their patients are being treated and their brand is being represented. This means real-time access to data on patient interactions, and the ability to access transcripts or call recordings. • Strict security standard compliance. The Professional Practice Management System® (PPMS) certification from ACA International is the industry’s gold standard for quality and compliance; however, very few collection agencies have achieved this. Also, any qualified agency must have regular SSAE 18 SOC I Type II audits, maintain PCI compliance, and meet ISO/IEC 27002 and NIST standards to ensure that health system and patient data is protected.

QUICK FACTS Number of years on the Short List: Four years 100% of Professional Credits’ clients and prospects agree or strongly agree that its services are easy to use and have value.

• Referrals from satisfied clients. Specific references from organizations of similar size, structure and philosophy are a must. Do these references illustrate that the potential collections partner can serve a multi-facility, multi-state health system or an independent clinic? • Can act as a guide for the future. Healthcare organizations need a strategic ally that can advise them as inevitable industry and regulatory changes occur. This partner should be able to adapt to changing patient communication preferences; be focused on process improvement, employing an active Lean program; and incorporate the latest technology and behavioral science methodologies when engaging patients.

What is some advice you can give providers for a successful implementation of a new product or service? Move forward with the knowledge that changes will occur and adjustments will be necessary. Plan-Do-Study-Act (PDSA) is a model geared towards implementing process improvements quickly but with safeguards to prevent major setbacks. Plan the way implementation should work and set up metrics. Do or execute the process as a prototype or pilot in a limited area. Study or evaluate the results and adjust the approach. Act or execute on an increasingly wider scale. ■

Professional Credit makes the lives of providers and patients easier by incorporating innovative tools, behavioral science and analytics to improve financial engagement and resolve financial obligations. With more than 85 years of experience, Professional Credit is an industry leader in accounts receivable management, offering collection services that yield higher than expected results while treating patients with the utmost respect. As part of the Hawes Group of companies, and its affiliation with KG Hawes, a consumer engagement technology partner, Professional Credit is able to offer a wide range of patient financial services and technology. TO LEARN MORE ABOUT HFMA’S PEER REVIEW PROGR AM , VISIT HFMA .ORG/PEERREVIEW


HFM MAGAZINE | SEPTEMBER 2019 | 67 hfma.org





A Q&A with Tasha Bell, who holds 5 HFMA certifications


consulting for 20+ years, I have had amazing opportunities to work across the continuum of healthcare and operations, gaining knowledge, practice, understanding and skill. In consulting, I not only work as a project manager, but also serve as a healthcare operations subject matter expert. These skills can be called upon for any assignment. WHAT DO YOU HOPE TO ACCOMPLISH WITH THE KNOWLEDGE YOU’VE GAINED FROM OUR CERTI-






I am currently a project manager in the healthcare practice of RSM US LLP, the nation’s leading provider of audit, tax and consulting services focused on the middle market.

I currently use these skills on a day-to-day basis in my field. Hopefully, these certifications will provide clients with additional confidence in my skills and abilities, and the security of knowing that they are working with a knowledgeable and industry-validated professional.


I have been a member for less than one year. Which HFMA certifications did you earn? I have earned five certifications: CRCR, CHFP, CSPPM, CSMC and CSBI. WHAT MADE YOU WANT TO DO SO MANY?

I felt like the certification options provided a great opportunity to validate my existing knowledge base. Having been in healthcare and

New Plante Moran principal announced Sue W. Marr has been named principal,


Leisure traveling and shoe shopping! What’s the last TV show you binged? I don’t have a TV; I love books! If you could take a year off to travel the world, where would you go, and what would you do? I’d travel the continents of Africa, Europe and Australia!

Full-time manager graduates with MBA

healthcare practice at Plante Moran in Chicago.

Billy Trujillo, MBA, earned his Master of

She previously worked as principal at Salute

Business Administration degree from

Healthcare Solutions, also in Chicago.

the Georgia Institute of Technology in

Founder of a Texas-based law firm accepts new role in Nevada

Atlanta. While attending evening classes, he also worked full time as manager at Triage Consulting Group, Atlanta, where he continues to work today.

Mark D. Herbert, Esq., has transitioned into a new role as general counsel at Red Dot Management in Reno, Nev. His

To have your professional announcement

previous role was founder of the Law Office of

published in People, contact Jennifer

Mark Douglas Herbert in Cypress, Texas.

Novoseletsky at jnovoseletsky@hfma.org.



Technology-Driven Underpayment Review Services By BLS | Revecore

How do you help healthcare organizations navigate the biggest challenges in healthcare? More than anything else, healthcare providers need to increase revenue, which is BLS|Revecore’s singular focus. Our mission statement highlights our commitment, stating: “We are dedicated to assuring that our hospital clients are fully, fairly and accurately paid for enhancing and saving the lives of their patients.” Our underpayment review uses unique, customized technology to collect dollars that would otherwise go unrecovered. We combine robust, proprietary software — driven by more than 500 algorithms and underpayment queries — with more than 20 years of experience to ensure that our clients receive maximum reimbursement. Further, we leverage information and ideas from our nationwide experience to help hospitals improve their internal revenue cycle processes and strengthen their payer contracts. The synergy of our collective knowledge, comprehensive technology and vast library of payer data allows us to recover full reimbursement and reinforce our unwavering commitment to revenue cycle improvement.

What advice would you offer healthcare leaders when choosing among vendors? Selecting a qualified vendor with exceptional service and recovery results is key when seeking an underpayment review services provider. It is important to choose a partner that offers a highly automated solution but does not underestimate the value of human touch points. Although our robust technology reduces the need for human intervention, a critical component of our offering is the experienced-based, specialized knowledge our analysts bring to each claim. We also recommend providers seek out vendors that will establish a true ongoing partnership and provide regular feedback on trends and reimbursement opportunities. With all our clients, we take a consultative role, advising where improvements can be made to help prevent future underpayments. We also employ extensive analytics and sophisticated data mining to identify payment errors and additional reimbursement opportunities to ensure maximum reimbursement. The bottom line: Healthcare leaders should

QUICK FACTS Number of years on the Short List: Four consecutive years. In HFMA’s 2018 Peer Review process • 100% of Peer Reviewers agree/strongly agree that BLS|Revecore’s underpayment review services exceed expectations. • 95% agree/strongly agree that the services provided are a good value. • 100% agree/strongly agree that they would recommend BLS|Revecore’s underpayment review services to a colleague.

partner with an organization that offers the combined benefits of technology, expertise and unsurpassed experience to provide invaluable process improvement and industry-leading collections.

What is some advice you can give providers for a successful implementation of a new product or service? It is valuable to partner with an expert that has a clear process for implementation but can also provide flexibility based on a hospital’s unique needs. During implementation, the vendor must ensure that it has all processes in place for data privacy and HIPAA compliance. It is increasingly important to contract with a company that is SOC 2 Type II certified, which confirms the effectiveness of the vendor’s systems. In addition, vendors that offer an onsite analyst not only greatly accelerate the implementation process but strengthen the partnership and maximize recoveries by providing ongoing feedback and recommendations for overall process and contract improvements. ■

BLS|Revecore provides revenue recovery solutions focused on underpayments and denials prevention services. BLS utilizes proprietary technology and a highly skilled team of billing, coding and clinical experts to identify and recover additional revenue for hospitals and health systems throughout the U.S. In addition, BLS|Revecore provides clients with continuous feedback in order to improve revenue cycle processes and payer contracts, and increase future reimbursement. BLS|Revecore was founded in 1996 and is based in Crescent Springs, Kentucky. For more information, visit www.bls.revecore.com. TO LEARN MORE ABOUT HFMA’S PEER REVIEW PROGR AM , VISIT HFMA .ORG/PEERREVIEW


HFM MAGAZINE | SEPTEMBER 2019hfma.org | 69


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Healthcare Bad Debt Recovery by Professional Finance Company, Inc. Self Pay Services by First Party Receivables Solutions pfccollects.com

Transfer DRG Revenue Recovery Service www.drgtransfer.com Full Revenue Cycle Services including Facility Patient Access Services, Pre-Arrival Services, Health Information Management, Revenue Integrity Services and Central Business Office Services www.ensemblehp.com Financing Solutions offered by First American Healthcare Finance www.fahf.com Investment Advisory Services www.feg.com MedData Eligibility Services www.meddata.com Merchant Services Analysis, Negotiation and Account Monitoring www.merchantadvocate.com

Investment Consulting www.nepc.com/focus-areas/healthcare HIM Technology & Services Suite (including Transcription, Clinical Documentation, Improvement Services, Coding & Audit Compliance, nThrive Education, HIM Strategic Sourcing, HIM Consulting, Oncology Data Management & Cancer Registry) and Revenue Integrity Services www.nthrive.com Revenue Cycle Outsourced Services parallon.com


Technology-enabled Revenue Cycle Management Services r1rcm.com


Resource Corporation of America Third-Party Self-Pay Eligibility Services resource-corp.com Underpayment Review for Commercial and Governmental Payers www.bls.revecore.com MRA’s AcciClaim™ - Accident Claims Management Solution www.mra.revecore.com Revenue Recovery Service revintsolutions.com SEI’s OCIO Solution for Healthcare SEIC.com/healthcare Debt Collection Services for Healthcare simonsagency.com Healthcare Collection Services statecollectionservice.com Healthcare Technology Financing winthropresources.com

PRODUCTS Auth-DPTM by Recondo ClaimStatusPlusTM by Recondo EligibilityPlusTM by Recondo SurePayHealthTM by Recondo recondotech.com

Centricity Business virencehealth.com CareCredit Credit Card by Synchrony Financial carecredit.com/hfma

Simplee Platform for Patient Financial Care simplee.com

ChargeAssist® by Holliday & Associates—including: CDM Auditor™ , Price Analyzer™, Change Monitor™ and Ultimate Research Center™ chargeassist.com


SSI Billing by The SSI Group, Inc. thessigroup.com

Chargemaster Toolkit® craneware.com

StrataJazz® Financial Analytics and Performance Platform stratadecision.com/our-solutions

EPSi ™ Budget Manager EPSi ™ Cost Manager EPSi™ Product Line Analyst epsi.io

TransUnion Healthcare ClearIQ® Patient Payment Estimation TransUnion Healthcare Insurance Discovery for Acute Care Hospitals (eScan) STINGRAY™ Medicare Bad Debt STINGRAY™ Medicare Disproportionate Share Module STINGRAY™ Transfer DRG STINGRAY™ Shadow Billing Compliance transunionhealthcare.com

Axiom Healthcare Suite kaufmanhall.com/software/healthcare Optum® LYNX ED Charging Application Optum360.com

TruBridge’s Rycan Software Solution trubridge.com

CDMauditor.com Hospital Zero-Base Pricing (including ComparativeHospitalData.com and Unit Cost Estimator) panaceainc.com ®

A Career Step Company


VitalKnowledge™ vitalware.com

AuditLogix – iPas offered by Pelitas pelitas.com

Blueprint Enterprise including Secure Release Here, Beacon Fleet Manager, Toner Savings and Mobile Print pharos.com

Waystar Charge Integrity Waystar Claims Management public.zirmed.com/solutions-overview/ charge-integrity-solution/


PMMC Estimator PRO PMMC Contract PRO pmmconline.com

ClearBalance® ROI Value Model (for ClearBalance Zero Flex and Non-Purchase Programs) clearbalance.org

ERP premierinc.com/solutions/finance-operations


Learn More! hfma.org/peerreview

*HFMA staff and volunteers determined that these healthcare business solutions have met specific criteria developed under the HFMA Peer Review process. HFMA does not endorse or guarantee the use of these healthcare business solutions or that any results will be obtained.

The Heartbeat of Progress hfma.org

from the president THE VOICES OF OUR COMMUNITY

Finding our way to meaningful price transparency JOSEPH J. FIFER, FHFMA, CPA President and CEO, HFMA @HFMAFifer

About 15 years ago, while on a business trip, I went for a run in San Antonio, Texas. My goal that day was four to five miles. Long story short, I got lost. I could see the hotel in the distance, but I couldn’t figure out how to get there. Each road I took twisted or turned in an unexpected direction. My quick run wound up becoming a 13-mile half marathon. And I was pretty wiped out for the rest of the day. This August, while in Peoria, Ill., for an HFMA board retreat, I set out on another quick run, this one across and along the Illinois River. While returning to the hotel, I soon realized that the road I had chosen wasn’t right, even though I could see the hotel in the distance, just as in San Antonio years before. Rather than repeat my San Antonio experience, I pulled out my phone, opened the mapping app and figured out the most direct route. The result: A 4.5-mile run, just as I had planned. The difference: In Peoria, I had two things going for me. One, I used technology, which didn’t exist at the time of my San Antonio run, to chart a direct course to my destination. Two, I had the experience to know I should use the tools available to me rather than relying solely on instinct. What does this have to do with healthcare finance? Well, it’s not unlike the state of our industry regarding price transparency and financial interactions with patients. Meaningful price transparency appears elusive. Although we can visualize it, we


can’t seem to get there from here. We know posting charges on a website won’t get us where we want to go. Our destination is a patient financial experience that includes out-of-pocket estimates prior to service; clear, understandable patient statements and no surprises in the billing process. Consumers want to be treated in a reasonable way — the way we like to be treated everywhere we shop. Although we can picture the destination, many of us struggle with how to get there. We may improvise and lack confidence in our process. We may end up turning a four-mile run into a 13-mile run. Or worse, we may give up on the run altogether. The thing is, we have the technology we need to reach our patient financial experience goals. And we have the experience to know how to use it. In Peoria, I had to be smart enough — and humble enough — to admit to myself that I was lost and use the available tools to reach my destination without wasting time and energy on the wrong roads. Likewise, in healthcare, we should use the IT that’s widely accessible now and rely on the collective experience embodied in HFMA’s Patient Financial Communications Best Practices to deploy it the right way. An old proverb tells us, “No matter how far you have gone on the wrong road, turn back.” If we leverage technology and draw on our collective experience to guide us, we can get on the right course much sooner. ❚

View HFMA’s Patient Financial Communications Best Practices hfma.org/communications and Price Transparency Guidelines hfma.org/ transparency

Over the last ten years, we’ve: Helped overturn $640 million of denied claims; prevented $1.2B more denials; eliminated $240M of unnecessary touches; developed great relationships with our clients and partners; and soaked a few friends with our cannonballs

Sorry about the cannonballs. We got a little carried away celebrating our tenth anniversary. But who can blame us? With clients who trusted us to help them fulfill their mission, and all the things we’ve done together, we’re proud to celebrate our tenth anniversary. And we’re even more excited about the next ten years. A big thanks to everyone who's been a

part of this journey with us, we couldn't do it without you.



Navigating a Legacy A/R Wind Down Getting over the mountain: choosing your path through a revenue cycle conversion.

You would not climb a mountain without advice from mountaineers who did it before. When it comes to planning for a revenue cycle system conversion— either standalone or as part of an electronic health record system conversion—there is a lot to learn from experts who have traveled down the same path before you.

Download the full e-book: parallon.com/LegacyAR