Rayanna Moore is system director of revenue cycle at Appalachian Regional Healthcare System, a three-hospital health system based in Boone, N.C. Moore spoke recently with editor Richard Pizzi about the challenges she faces managing revenue cycle at her health system.
How is revenue cycle organized at your health system?
We have a centralized business office for all three facilities. We achieve efficiencies that way. Reporting to me directly are patient access, HIM, patient accounting, and chargemaster. I have two directors who run the patient financial services piece, one handling HIM, one over admissions and one who handles the reimbursement piece. Our HIM departments and patient access departments are in all three hospitals, but we do try to operate them as one. Two hospitals are on the same HIS system, and the third will go on it in October. That will complete our CBO connections.
How has the recession impacted revenue cycle at Appalachian?
We are seeing many more patients with the inability to pay. We’re a resort area, so we’re very much a community of the haves and have-nots. Our Medicaid volumes are up, and our self-pay is up. But our bad debt is not up as much as I thought it would be.
Has the increase in self-pay prompted you to put more emphasis on collecting payments at the point-of-service?
Yes, we’re definitely working on that. We’re having more discussions with patients prior to procedures and asking for co-pays and deductibles on the date of service. We’re also seeing co-pays and deductibles rise through the roof! I saw a deductible of $5,000 the other day. People aren’t realizing how much money will have to come out of their pocket. It may not be explained well enough to them. For that reason, we have an increasing number of discussions with patients on that issue.
Do you find that you’re putting more emphasis on customer service issues to improve revenue cycle?
Yes, that’s something that we might not have done so well in the past. It is done partly out of necessity, in order to help patients better understand their bills. Most patients want to pay their bills, but they might need help understanding the details. We’ve really been working on that the past few years, so patients know what to expect. This is something that healthcare in general hasn’t been very good at doing.
You have had some success dealing with denials. Could you talk a bit about that?
Some time ago, if you had asked our staff if we had a lot of denials, the answer would have been ‘no.’ That’s because most of our denials were being written off in the contractual adjustment, so people didn’t equate that non-payment with a denial. Because of that, we didn’t have a good understanding of what our denials were. We had to go back to the basics and determine how we were going to count denials. For two weeks, we wrote down every denial. It was pretty painful. Once we defined what we considered a denial, it was much easier to address the problem. Now we’re getting down to the granular stuff – CPT code checking, watching the CCI edits, medically unlikely edits, and other things that we never addressed before.
Are denials a real problem for health systems of your size?
Absolutely. It’s a problem for everyone, but more for systems of our size than the larger systems. When you’re our size, the 200-500 bed systems, you’re trying to do more with less. You have a lot of Medicare patients and quite a few Medicaid patients. The denials hide in “contractual adjustments,” and health systems don’t realize that something can be done.
What other aspects of revenue cycle are most critical to maintaining a healthy bottom line?
At least in North Carolina, the thing that we’re watching is the number of outpatient procedures that insurance carriers are requiring to be pre-certified. They usually require the physician to do the pre-cert, but we have to check to make certain it has been done. If we run the CT and find that there was no pre-certification, then we don’t get the money. North Carolina Medicaid now requires more pre-certs. It’s getting ever more challenging to get procedures approved. I understand the insurance companies’ perspective, but in my opinion it’s just another way to not pay claims. I see this problem growing, just as I see audits increasing. Everyone’s looking for a way to get his or her money back or to not pay a claim.