The clinically integrated revenue cycle

Beasley: Angie, how did you become part of this revenue cycle transformation and specifically the part about clinically integrating the revenue cycle?

Wilson: I've worked in various clinical departments. Case management, which is now care management. Discharge planning. That type of clinical work. I have a wide base of knowledge to be able to understand the utilization review process. I took this position in the project 18 months ago.

Beasley: It has been a journey. It's hard to believe it's been 18 months already. In addition to utilization review integrating with the revenue cycle, what other components have you added to that clinical lane within revenue cycle?

Shirley: We're working with our service line clinical leaders to ensure that we're doing charge capture in those spaces. We've invested heavily in our CDI program, ensuring that we have good tools, tech people, and process education around the CDI team. We've brought physicians into our revenue cycle to lead our physician advisory solutions. Clinician-to-clinician conversations are more robust than in the past. We've got nurses on the back end working medical necessity denials. CDI nurses are working DRG (diagnosis-related group) downgrades.

Bringing that clinical knowledge into the revenue cycle has been important for us as we try to bridge the gap between revenue cycle and financial functions and clinicians. We maybe thought we were saving the clinical teams from worrying about the revenue cycle. You treat the patients, and we'll handle everything else. But by doing that, we lost key connection points that allowed us to understand the value their work brings to the financial side of the house. With the clinical revenue cycle teams that we've built thus far, we've been able to bridge that gap and start to knock down those silos that had existed previously.

Beasley: It sounds like knowledge sharing has been powerful across the organization and has fostered empathy and a better understanding of each group. Angie, do you feel the same way, coming from the clinical side?

Wilson: Absolutely. I think they laughed at some of my first questions. The clinical side was like, “We do our piece. Then we send it off to the CBO (central billing office). And it miraculously gets paid.” I probably had a fair understanding of some of the ins and outs. But we never knew what the outcome was because we weren't connected well enough with the CBO. We did this work. We did this peer to peer. But did we ultimately get paid? We never had any visibility to that.

Bringing in those physician advisers and building our own internal program gives us an advocate. Most of our work is affected by physicians. Schools don't teach physicians about the value of documentation and the impact it has on an organization. They went to school to learn how to take care of patients. Why do I have to deal with these administrative pieces? Really getting them to understand that that's how we get those extras. If you're talking to a surgeon, it's why we have this robotic tool for you. It's because of you documenting better that we can validate our cases with payors.

Beasley: Tell me about how the clinical revenue cycle team balances the two parts of its mission—the clinical and the revenue cycle, and how relationships have changed because of it.

Shirley: One fear some organizations have of integrating the two is that they'll lose that clinical touch. They'll be totally financially focused. Angie, our physician advisory team, and our clinical revenue cycle team have maintained those clinical relationships and expanded them. They maintain a strong clinical focus. It's a clinical-first thought process with revenue cycle expertise as a secondary function.

We don't want our clinical revenue cycle team to become too revenue cycle. We don't want it to be too clinical. We really think it's important that they can live in the space between. We've been able to build a structure in which we're not chasing the dollar to chase the dollar. We're doing the right thing clinically. But we are pushing documentation. As a result, we're downgrading as many cases as we're upgrading.

Wilson: Historically it's always been us going to service line leaders, physician leaders. Now, just over 18 months into this project, it's those leaders coming to us. Proactively. They're saying, “We want to make this change. This is how it's going to affect us clinically. How is it going to impact us financially?” They're looking at things holistically, not just focused on the patient care piece. That's a significant change. We want to do what's best for our patients. We want to have the best outcomes. But we also want to have the best organization.