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welcome everyone thank you all for joining us for today's webinar on lien tragedies in healthcare revenue management did you know revenue cycle inefficiencies accounted for 15% of 2.7 trillion spent on healthcare which is about 400 billion my name is Zack know and I will be a host for today's session a brief introduction about us in rent system is leading healthcare service provider and medical billing medical coding and Bernie cycle management in Renta's expertise in healthcare domain has helped its clientele and the u.s. deployed high quality medical care by efficiently managing patient engagement and communication in Vince's has achieved compliance with u.s. Health Insurance Portability and Accountability Act and have been operating since 2000 with an office in Wilmington Delaware USA and every centers in Bangalore in Rajamundry India in Manchester 2000 plus member organization that has delivered unparalleled services across IT Finance and Accounting health care back-office BPO ecommerce photo editing and call center for businesses to streamline their processes and generate greater ROI a leading market research company has rated Invensys as one of the most prominent global medical billing outsourcing renders in the report inventors also host webinars on some very interesting topics across various workflows so follow us on LinkedIn and other social media platforms to stay regularly connected and updated on upcoming webinars today's webinar will be presented by dr. Steven M Wagner he is an executive director and faculty instructor of the Paul L fossa School of Medicine at Texas Tech University Health Sciences Center at El Paso a for the instructor I'm sorry a faculty instructor at Independence University in Department of Health Sciences for Healthcare Administration health information management and public health a research fellow at University of Phoenix and he has over 40 years of experience in revenue cycle management for hospitals academic medical centers and physician practices he has also authored a book on Health Sciences I'm sorry had insurance and had how does health insurance change patient health behavior and many other journal and peer-reviewed publications so just a little housekeeping before we get started if you have any questions during the presentation please type them in the Q&A panel which is on the right side of screen and I will bring them up at the end of the presentation also there would be poll questions during the session so kindly participate to make the session much more interactive now at the further adue I've landed go to dr. Wagner to take this webinar session forward right now okay well hello everyone and good morning good evening and good afternoon since we have participants from all over the place glad to have you aboard today for this webinar which is somewhat of a redo from one that was held on September 28th so those of you who are there then can can also hear the recording of this and since it's a redo it really has a lot to do with Lean Six Sigma and redoing it because we had technical issues finding the root source of the problems fixing those problems and redoing it again so that we can conduct this webinar so you'll see by the end of this session that you should be able to identify the Lean Six Sigma criteria that was used to reproduce the webinar if nothing else it comes full circle but to go ahead and begin in order to understand lean strategies we have to have a brief history of Six Sigma and many of you may have already heard of Six Sigma Sigma being the Greek symbol for deviation from the mean and when you include deviation from the mean it means that when you produce something the deviation needs to be very small in order to be relevant and viable in in any kind of Ries and so Six Sigma is how close the deviation is to the mean so that you have a near perfect end product when you are working with quality production and so just as a brief history we see that quality management dates back to the 18th century involving accuracy of parts to produce quality products by hand and in the late 19th and early 20th century Henry Ford included a lot of what is included in Six Sigma because he was one of the first to employ the assembly line procedure and in the assembly line workflow parts are available in each section of the assembly line and those parts have to fit exactly right or near exactly right so that the quality product at the end will produce a a car that can be driven and that will be held together and will work just fine and the same processes in place today of course there's a lot of robotics in car manufacturing today but the Six Sigma process is still in place in most if not all of car manufacturing and so quality control and management back in the 19th and early 20th century took a higher priority in production especially due to the assembly line process and continuing with the brief history the Japanese took on Six Sigma and and not just Six Sigma but the quality control processes so that all the parts fit just right so that you have a longer lasting and enduring product for whatever it is that you're producing and consumer goods and the more efficient one became in Japan at the time the lower the cost of the production of these Goods because in the production of the parts - to make them near-perfect meant that you didn't need as much labor you can develop and innovate more machinery to make the machinery and you could produce more Goods and sell them at the same price so you you had higher productivity and higher profitability and so by the mid-1960s productivity and quality improvement methods led to what was known as TQM and and some of you may be as old as I am and remember TQM is toll quality management and which moved from quality improvement from production line of consumer goods to service lines in in service and service and and one of the biggest services is hospitality but also in healthcare and anything involving the process of service lines in healthcare so TQM emerged as an integration of working and reflecting that focused on meeting customer expectations and and when we talk about revenue cycle management what are those consumer expectations most people expect that if they're going to provide us with their insurance that that insurance is billed that they're charged for the correct copay coinsurance but meeting those expectations is very important at TQM inclusive of all members in the institution which means that TQM was something that hospitals took a hold of and presented to their entire staff and every department in the hospital would have assigned to them a total quality improvement process which included continued quality improvement which meant that improvement never dies that nothing is ever I shouldn't say good enough things can be good enough but it can always be improved upon to make it better and increase the patient centricity and set satisfaction of that service and understanding and quantifying the costs for quality and the cost for failure failures of quality and so the in in determining all this since the mid-1960s we found in the healthcare industry that the cost of failure can be quite costly and cost more than the cost for making it a quality product or quality service in the first place and then TQM also was focusing on composing the process rather than the production inspection so if you relate it to producing cars you don't want an inspection of the car after it's been through the line and then find out that it's faulty and have to put it back in the line if you relate this to revenue cycle management it's like viewing the claim after it's been rejected by the insurance company you've just produced a car or a claim that does not work and so if you're going to do that you need to go back to the process and the workflow process and putting these things together to make sure all the parts that go into this quality product are there before the product is released whether that's a car or whether that's a claim and then integrating policy and procedure in your organization to support improvement methods and rewards for the development and flexibility for change and and we all know that as human beings we have a very hard time accepting change change can be difficult change can be create anxiety and but it also creates a lot of excitement and a lot of energy to see that what has been identified as a problem researched fixed in the assembly process and and watching it work is a very telling moment for staff and and for physicians and for revenue cycle management in general and instilling innovation and continuously envisioning processes for improvement and and many of you may remember that not too long ago paper claims were the standard for the day sending paper claims by mail a lot of times we would attach a card to register that mail so somebody would have to sign forward so we know they got it and then we'd follow up by telephone one claim at a time and it would take a very long time and it wasn't a very good process and so including technology and innovation into our processes now most of if not almost all of our claims our original claims are sent electronically they're processed electronically at the insurance companies and we're notified about the status of those claims electronically and when we call many times we don't call by telephone many times we call by portal and we can batch check the status of claims in revenue cycle management so innovation and instilling innovation is part of the Lean Six Sigma process so what is Lean Six Sigma mean the TQM process Wayne in the mid late to late 1990s and it that took quite a while it lasted for about twenty years it wasn't so integrated into the process that it was a formalized process where you would train people on on noticing quality problems and finding solutions for them and formalizing that process and so it began to be ignored or passed over and there were so many regulations and so many things that needed to be done that TQM waned but at the same time the government put together through the Department of Commerce the Malcolm Baldrige Quality Assurance award introduced in 1987 and this was part of the Quality Improvement Act by Congress and it was personally awarded by the US president and Motorola was the first to win this award based on a TQM type project that expanded production quality by fully integrating the process into its manufacturing of electronic processes but also not just integrating the process but making it a formal process that management would recognize that they would have quality improvement Tiger teams as they called them to to come in and find the problems even to the extent that they would ask the staff or the line personnel where are you finding the obstacles and producing quality products and let's research them and let's research the research that we're doing and so this became very interesting and Motorola created the DMAIC process called where you would define the problem measure the extent of the problem analyze it to find out what was the root cause of these problems that would lead towards improving the process and then after the process wasn't proved and reanalyzed it was then controlled to ensure that this problem wouldn't happen again and then begin again to start on the next problem because problems tend to be problems and issues and quality control tend to network themselves so you have one problem once you fix that you've opened the Pandora's box of the problems that have occurred because of that or as a result of that down the road and sometimes your fix causes additional problems down the road that also need to be fixed but the idea is to create quality efficiency and effectiveness in this error control quality improvement type of process which became known as Six Sigma because of the like I mentioned earlier when you measure how close this quality control has been improved you measure how far from the mean or the the the desired metric that you say quality is how far from that is this production and this quality improvement so Motorola institutionalized this process and and created Six Sigma employees whose only job was to not only learn about the DMAIC process but to teach it to others and to use it to train users on on controlling their own process or owning that process for quality and reporting additional problems that may occur so that the green belts and the black belts they had these levels of expertise in Six Sigma only on DMAIC and handed off the project to process owners for implementation and so Six Sigma began with Motorola and the Malcolm Baldrige Quality Improvement Award and it's spread and this was was widely written about and even today when you go to a website if you've looked up Six Sigma before you'll find advertisements for Six Sigma training online or in schools nearby or in companies that will provide their own training for Six Sigma so what is Lean Six Sigma but first let me tell you that Six Sigma here's your Six Sigma standard deviation right here if the results did not meet the expected outcomes then the black belt and green belt teams were sent in again to rework the process and do it again now yes this took time yes this took fortitude and it took patience on the part of management but in the end Motorola claims that having done this and taken this time in making this investment that they claim in their financial statements over 16 billion dollars 16 billion in savings from Six Sigma projects since 1987 now that was 30 years ago which makes it about a half a billion dollars a year if you were to average it out I would think that if we saw a graph we would see most of the savings at the beginning while these these savings kind of waned towards the end but as a result 16 billion dollars over that period of time means much more in inflated dollars less so since 2008 so right now we have a Six Sigma poll question oh how many participants include a formal Six Sigma training and process in their institution or their their practice or in their quality improvement do you have a quality improvement department and so a is yes B is no n C is unsure all right so we have like 43% on yes 29% don't know and 29% are unsure all right so I'm hoping that the 29% that is no or untanned also unsure which is about 58% of you will consider Six Sigma and a quality improvement department or at least the lean portion of Six Sigma so we'll get to lean which is right here so lean is not the entire Six Sigma program and that's why it's a Lean Six Sigma it's a skinny Six Sigma if you will and in the lean management process it is instead of define measure analyze improve and control we have plan do check and act or PD CA and that is basically a skinny Six Sigma or as we like to call it lean a lean strategy of the same process of Six Sigma and so this is an offshoot and lean management does not call for statistical measures of near-perfect performance like Six Sigma or do-over because finding the Six Sigma or finding the standard deviation from the mean and service lines is very difficult and somewhat amorphous so lean management calls for quality and cost containment to agreed-upon metrics and expectation so that's the measuring so if we put this in plain language and plain English cost containment quality and accessibility are the three precepts of the Affordable Care Act of 2010 and it applies to revenue cycle management in ways that it applies more so in revenue cycle management than anything because who is what is the main component of the Patient Protection and Affordable Care Act is claims and insurance and so in in terms of regulation and data gathering and workflow and process improvement and holding down administrative costs that in health care take up thirty to sixty percent of the costs of health care and so lean management is is is strategy and revenue cycle management that is a must in order to obtain quality cost containment and certainly accessibility for patients so lean management does not require the specific education on productivity and quality management to ensure that you have a specific standard deviation which I mentioned before and leads management does provide for accountability for ownership and planning testing performance and measurement to two objective metrics and actions to readjust to retry another method which means that you put your minds together that work in your institution that have input into each process that you define as an issue that is obstructing your quality production and in revenue cycle management that would be quality production and payment of claims through adjudication so lean management includes all ideas for solutions to reach agreed metrics which is like workflow smoothing workflow smoothing as taking I saw in one institution in which I was consulting with a when you mapped out the workflow in the revenue cycle from registration all the way through adjudication of claims in the business office I saw that there were many many workarounds and hand backs and you have to fix this because you're the one that put it in the first place and and how you gonna learn if we don't send it back to you they would do it by fax sometimes the faxes were picked up sometimes they were filed in the medical record I mean it was a mess and so there were there were offshoots and workarounds everywhere in the workflow process the workflow smoothing is using your practice management system to work out these processes and assigned trained personnel not necessarily increasing your labor force or decreasing your labor force but using your labor force in a more productive way where you smooth out that workflow so that when a problem pops up or an exception pops up that it can be taken care of before the claim leaves the door or before the car leaves the factory so paperless workflow with prescribed instruction and desktop schedules and daily management dashboard reporting is how management will keep its eye on its production line in revenue cycle management so training teams are super users whether they're dedicated teams that are separated from the rest of the group which is a sigma Six Sigma like approach where you have a dedicated team of training and watching for the workarounds is essential in lean management to capture those that found a workaround and are not using the smoothest workflow process that the institution agrees upon and you can find these because most of the time workarounds will keep some metrics from being met and when a metric is not met and it's continuously not met is a signal out door saying coding billing follow-up and collection to contain cost and link to outcomes is another Lean Six Sigma strategy that if you find that well I'm going to have to hire 25 people to be able to implement the Lean Six Sigma approach maybe it's time to examine the outsourced companies that already have the Lean Six Sigma approach in their processes to notify you as the owner of these claims to see where the problems may lie and eventually be able to take it back once the outsourcing company has resolved these problems and then you you copy this process into your own organization now what got to me and in these next three slides I have three different revenue cycle graphs or graphics that baffled me and I'll cover them real quick and why did they baffle me is because when you this is revenue cycle demonstrative and I've taken them from HFM A&M GMA and and in journals and took pictures of these revenue cycle phases and processes where you start with registration or you start with scheduling and then registration you have charge capture coding and documentation review etc down to claims processing you also have managed care contracting in there let's not forget about that because that's our case study today and then as part of the process they put in denial management now denial management means that you're managing errors so you put you expect when you draw a graphic like this you're expecting errors if you're expecting errors lean strategies will take you out of the expectation of errors and more in the expectation of payment posting and adjudication of all claims so if we look at the next one here's another one where they've added in not only denial management but the appeal procedure these both are error processing functions that they're accepting as part of the process not as an exception to the process and if you look at the next one even though it is a bit smaller you see that denial management is right here in processing these claims through these concentric circles that that work around the patient centric revenue cycle this is a great graph except for the addition of this denials management right here accepting it as an integral part of the process it should not be it is an exception so what does revenue cycle even produce well it produces a financial record the start of a medical record because 80% of the physicians in this country and about 65% of the hospitals in this country use an electronic health record or four hospitals sometimes they don't use the entire electronic health record but they use a lot of that health record it produces revenue cycle produces data for claims processing data for statements to patients have not collected upfront payment receipts the OB records payment posting this revenue cycle process is a is a big process a big part of what equals to dollars collected which equals claims sent and paid quickly so claims sent and paid quickly is the key to revenue cycle management because we predict we don't produce cars we produce claims but if we produce a claim with ADD or missing or with an address missing or with a birthday method missing we send it out anyway yes we meet the metric of sending out our claims within a certain period of time but it's only going to be sent back and we know it's going to be sent back because the insurance company's not going to correct it they're going to send it back for you to correct to make sure that you're sending in the right patient for the claim that represents the treatment so a lien strata in revenue cycle removes denial management from the process so if you use lean strategies the plan do check and act outside of the routine production of claims and find ways to prevent the denials and rejections in the first place then you can take denial management out of the cycle as part of it and use it not as a rule but as an exception to the rule and and so here is a case study that right after we do the revenue cycle poll question on on how this was actually done in an academic Medical Center how many participants include a working section of staff dedicated to claims denial rejection and appeals management in the business office so if you could please answer that poll either a yes B no or C unsure all right we have some already starting to answer feel free to keep answering so far everybody has said yes okay so if we look at the previous examples of the graphics we can see that most of us that those graphics were correct and that we use specific employees and and staff just to correct claims that are sent back for denial and rejection I don't know what percentage it if it's all of them I wouldn't be surprised because everywhere I've been that's the way it was but including a lean strategy again will allow you to use those same employees who have much talent in correcting claims to make the claim correct in the first place prior to its being sent out to the insurance company now in revenue cycle management we saw managed-care contracting and here is a case study and this is a true case study where I consulted with lean strategy utilized by a multi-specialty academic group practice with over 200 physicians and and multi specialties everything from pathology the only thing they didn't have was zoology I think but we this this company or this practice was contracting with different managed care organizations and and we noticed that the contracts they were signing had in their commercial contracts fee schedules that were approved for about a hundred and twenty five percent of Medicare and in an academic Medical Center that accepts a lot of indigent care because their teaching facility was the county hospital that that had a lot of Medicaid not so much in Medicare but a lot of Medicaid and a lot of indigent care a hundred and twenty five percent of Medicare reimbursement on a commercial claim wasn't so bad I know many of you out there probably have higher reimbursement rates some of you may have lower reimbursement rates but one hundred and twenty five percent was something that the practice plan wanted to take a look at and say is this the right percentage we just accept it but is it the right percentage so the obstacles to income identified upon examination of every fee on the fee schedule showed an analysis of providers indicated all CPT and the Medicare Medicaid rates per provider per specialty in primary care so you had three columns you have the contracted rate and what Medicare pays and what Medicaid pays and from there you can measure above and below what is paid above and what is paid below because the hundred and twenty five percent was a blended rate of all the CPT codes that the insurance company would pay for when then the practice plan compared average reimbursement per total rvu over the last three years by all non-government or commercial payers they calculated the total practice costs from the general ledger for departments net of education because they were an academic medical center they had a medical school and funding and grants per total rvu so they were just looking at their practice plan reimbursements for treating patients and the costs associated with that just in general by the GL took all their CPT codes all their total RV use which included practice costs malpractice costs and the work RVU and came up with an average cost per rvu and what they found was that the estimated average margin between their cost and their reimbursement per rvu was about 200 percent of cost so they were making twice as much as it costs them to do services on a blended rate and 175 percent for primary care now that means that the academic Medical Center if you just take a quick and dirty analysis of that that the academic Medical Center was keeping its costs under control because they couldn't have this kind of margin over costs at these rates if that's what was happening in managed care contracts so what happens next in the plan so from the analysis providers set budgeted margin metrics at these levels over costs of a hundred ninety percent over costs and reimbursement at a hundred and forty percent of Medicare reimbursement government payers not included so because you know government payers are only going to pay either Medicare or Medicaid so the commercial insurances they were looking at their costs over the reimbursement and then they were flexible with the payer mix since the AMC teaching hospital was County like I mentioned before and the provider market when he took a market study indicated that the majority or some exclusivity of specialists at the academic medical center but not for PCP so pc tease were plenty in the community whereas the specialists they had either a lock or the majority of the specialists in the city so the lien plan complete on contract negotiation with room for exception on volumes and exclusivity providing overall market share of services at 20 percent to 25 percent for the academic medical center and sometimes 90 percent of some specialties in the market so now it's time to do something about it so after planning this they compared and contrasted most common or all specialty code reimbursement metric against the proposed contract fee schedule to see whether it met that metric of a hundred and ninety percent for specialty code and for primary care one hundred seventy five percent they compared and contrasted the least common or non-use procedure against the proposed contract fee schedule what they found was that the insurance company to get the blended rate of one hundred and twenty five percent was paying very little on the most commonly used CPT codes less than a hundred percent of Medicare on the most commonly used procedures in the academic medical center and they were paying this enormous Lea high rate on procedures that was not used by the academic medical center and so where did they get these statistics to to manipulate the fee schedule this way and and they got this from previous claims that were sent into this insurance company by this AMC or perhaps upon their population of networks this was very interesting and enlightening using the lean strategy and so the academic Medical Center created counter fee schedule to the managed care organization which came up with the same blended rate of a hundred and twenty five percent but flipping it to where the most common you see pts were brought in over the 125 percent and the ones that were not used or the least commonly used were brought in under the Medicare rates but still came back at a blended rate of a hundred and twenty five percent and so the anticipated rejection of some reimbursement requested for use procedures encounter with a bonus plan so if if they felt that they were you know using their metrics they came up with this particular price anticipating that this may be rejected they were planning on using a bonus plan for quality measures and collaborative reconciliation between the two parties so that is taking your plan and actually doing a counter proposal that incorporates our or anticipates anticipated rejection of particular codes and without telling them or proposing that perhaps we can do this as well to help keep your cost down because in a good negotiation you want to make the managed care organization happy and you need to make the practice plan happy in order for both of them to have a good solid reimbursement contract in revenue cycle so to do this the continuation of this was they check the contract for any other requirements such as waiting times for specialist appointments when you're one of the few specialists in town or you have 90 percent of the specialists there's a great demand for these specialists so scheduling is very very important and so this would take more lean management on the departmental level regarding specialist appointments and how long does it really take and is there any waste in those appointments patient satisfaction ensuring that the patient was satisfied with the the treatment and and use like a patient portal to provide reading for the patient to remove this informational asymmetry or the lack of understanding of the patient and the the best understanding of the physician and bring it more in symmetry together that is also a lean strategy to create patient satisfaction that not only did they help me treat my disease but they taught me about my disease and what my risks are and give the patient some say-so in this which is what the ACA and the government is looking towards to help the patient think about types of treatment that they want and that are the most cost effective and enrollment requirements enrolling physicians into managed care organizations is something that is in those contracts and if they're not they should be to cut down the amount of time if the hospital is not already delegated to do that for the practice so if the practice holds exclusive specialist presence in the community consider lower rates in exchange for exclusivity and quality bonuses so if if you have exclusive specialists you can talk to the MCO about sending all your patients to the practice for these specialties if you know that you're the only horse in town and but give them a reasonable rate so you're not running off with the armored service that takes the money to the bank and then the counteroffer with proposed new rates reasonable expectations for appointments and accessibility and then urea proach them and so you check so in lean strategy you check by finding out what the response is from the MCO and you give them a week or two not six months to get back with you just like you will take a short period of time to get back with them so it turns out the managed care organization accepted the counteroffer proposed fee schedule from the practice they did decline a quality bonus program and that was likely because they saw how much they would be paying for some of those specialist treatments even though overall it came out to a blended rate of one hundred and twenty five percent and the actual rate from those procedures being used kind of averaged out to about a hundred and forty percent of Medicare one hundred and forty four percent of Medicare not a hundred and twenty five percent and the MCO did not grant exclusivity for specialists or PCPs but the practice found many referrals from outside PCPs for specialists in the network at the academic Medical Center because they were the majority the vast majority or exclusive specialists in town so they got the referrals anyway and then it was time to act and in acting is like controlling in the Six Sigma process where after implementation one year later they performed an analysis and they found that comparing and contrasting they met there and actually exceeded their budgeted metrics for costs over reimburse I mean costs under reimbursements and so was more than 190 percent over costs and it was more than one hundred and seventy five percent for pcps and in the end they made four hundred thousand dollars in one year in reimbursement for services performed over what they would have received had they accepted the first offer and so this translates from this lean strategy and to dollars and cents without our even talking about claims management yet in revenue cycle but that was still part of the managed care process so Kaelin we have another poll question here we do and I've gone ahead and opened the poll so feel free to respond when you're ready this one asks how many participants including a working section of staff dedicated to managed care contracting analysis of proposed contracts and counteroffer with lean strategy your options are a yes B no or C unsure there are responses already coming in so we it's going a little back and forth right now we're at 60% no and 40% unsure let's just see if a few more answers come in it looks like there's some still responding nobody with yes yet though okay so it's getting higher in the no category and so if you had a dedicated staff working on managed care contracting doing the type of analysis of using this lean strategy of analysis of your managed care contracts this particular AMC is now doing this on every one of their contracts and looking to see which ones and when they can start their renegotiation process with their MCO now there's always contingent factors like your geographic location your population of patients that are covered under that MCO and so forth but this is one of the more successful lean strategies that work with the managed care contracting portion of revenue cycle and now we can go over real quickly here about claims edits rejections denials and why so we can move that out of the revenue cycle and put it in to claims processing so if you evaluate all claims edits rejections and denials on three separate lists why are what are the claims of its what are the claim rejections and those claim rejections are when you send them in to the insurance company they're rejected because something is missing and then denials because the service was not covered the the patient was not covered even though it was verified at the time of service those are used in lean strategy to to fix this so what claim edits are pronounced prior to billing the go uncorrected and pass through to accounts receivable because our billers whether they're physicians or hospitals are given metrics that they have to get all the bills out within a certain number of days and they'll skip some of the information that's needed just to get the claim out the door because they're not responsible after that so that would be a problem addresses that are missing or bad missing certificate or insurance numbers or you know they're they're put in wrong birth dates that do not match to the insurance response and you know if in your practice management system you have an insurance response system where you can send out for a response on verification directly from their system in I would advise taking advantage of that and and using that integrating at your practice management system to keep your people focused on the patient rather than on simply verifying their insurance and if you get an electronic response you can pretty much count on that if you certainly if you get it sent and responded to from the right insurance carrier and the possible duplicate accounts in billing and and we find that happens a lot of time in the follow-up process because I have found in my consulting endeavors that and follow-up instead of making a call or a batch claim status check over a portal I find that some follow-up personnel will send in another claim and if they get a response that says we don't have the claim yet they just automatically send in another claim instead of checking to see whether that claim was not edited up here or somehow we have to check and see in the account and take the time and effort so we don't have a rejection sent to us on a duplicate account so in the planning process the notice of rejections receive prior to denial and appeals made or not on rejections time spent investigating that is the cost of failure is the time spent investigating the labor resources used in investigating rejections that could have been prevented upfront Corrections made online with the portal these again are corrections that could have been if you examine all those that have been done and the documentation required demanding paper transmission of data with return receipt requested is another cost of failure and so the do in the plan do is root cause evaluation so all of that above documentation and edits rejections and denials need to be looked at from defective front end verification and pre admission information gathering and a lot of times I say a lot of times a lot is not a number many times and and I can't say it's the majority of times and I can't say it's it's a few times but we find that we're under-resourced in labor at the front desk which is the most important part where you have face-to-face centricity with the patient a face to face relationship with the patient and where everything can be taken care of any doubts can be taken care of at that time and so this is during the scheduling and registration process at the front desk whether it's a hospital or whether it is in a practice plan staff evaluation and user inclusion in the process at the front desk coding billing follow-up and collection in other words bring them all in and say this is what we found this is the data we found these are the things that we can correct before that claim goes out and look at your practice management system to see whether you have a claims editing process that alerts the coder the biller the the collection person or the front desk prior to the time that claim is released to the insurance company to notify them that this is unacceptable to the MCO or this diagnosis does not match the cpt all those things are available in practice management systems today and compare the root cause evaluation of users to outsource evaluation and again you have to look at if you're under resourcing at the front desk if you're under resourcing on the back end for follow up and and for things like that many times and and this has always been it was a dirty word for me many years ago because of the requirements that we have our own business office and that you know we knew we could do it best but today we have outsourcing that is very very efficient and and very very cost effective that can take over some of these processes without losing control of your practice or out without losing control of your hospital business and even large hospital chains centralize their business offices so that they're doing work for several hospitals in many different geographic areas is a type of outsourcing anyway although they're they may be owned by their own company they're still outsourcing and why because of the cost effectiveness of outsourcing which is an option and the lean strategy so solutions to review in doing in the lean strategy for claims is central registration or central pre-admission with standards and other words we we need to review and not just cursive ly cursory do a cursory review of 10 charts out of a hundred that we've done but do something more on the Six Sigma side which is review every one or find a way to to make sure that it passes inspection before it's entered verification of information prior to arrival and this is where your electronic response from your insurance company comes into play and notification to patient of any discrepancies and patients are are more reachable today than they ever have been with cell phones now of course using text messages is something that you need to get their permission to do because many times it costs money for every text message they receive a lot of their calls cost money but you know if they have an email address if you can get that get their permission to send them emails this is a good way to fix your discrepancies before the patient even comes in patient portals are extremely valuable in in this process and not only that but in a way of getting paid through a patient portal rather than sending a payment through the mail and I can tell you personally anecdotally I sent payments through the mail a check or and I hate putting credit card numbers on statements if I'm paying a medical bill because you have to put everything down there from your security code and everything else but having a patient portal or an online way to connect and pay through PayPal or one of the other more secure forms of payment is an excellent way to increase your self pay reimbursement calculation of copay and coinsurance and a notification to the patient prior to arrival and collection of that and reasons why it may not is something that we would need to listen to our front desk personnel not just say why didn't you do it it's what what is happening that makes it difficult to collect the copay from the patient what are you hearing from the patient how can we make the patients happier to pay that copay and a lot of that is how the patient is approached and and how the patient is treated when they're receiving their service - and again patient portal is an excellent lean strategy - to using your labor more effectively confirmation of authorization and referral from insurance companies prior to arrival that all has to be done so again the authorization referral systems are many times incorporated into the practice management systems and so if you don't know about that already check your practice management system and if your practice management system does not have it again think of outsourcing so you can rid yourself of the practice management system costs bring it over to outsourcing but but always have a backup for yourself - so that outsourcing may be something temporary for you or it could be something permanent depending on how it works out for you but you have to set the metrics to be able to do that and then in finding the root cause evaluations I always say set the standard so the standards are available in many cases from the Medical Group Management Association and the healthcare financial management Association from the faculty practice solution centers for the academic medical centers where you can look at what the mean is what is the expectation of all the other practices and go a step beyond that and make your standard more because the mean or the median or at least the mean is not always the best approach maybe you should think about along with your users can we beat the standard and if we beat the standard what's in it for everyone what's in it for the patient what's in it for the provider what's in it for the staff and insurer transaction notifications to coders and billers that arrival has a missing charge resolution of standards and reporting prior to claims outbound filing deadlines notifications to staff and management reports daily on copay collections and again review with your staff what may be the reasons why co-pays are having a difficult time being collected and then Institute procedures that using the lien strategies that would be most acceptable to the patient and most encouraging to pay their copay and keep you from having to bill for that copay and send a statement and wait for that payment to come back etc etc missing fields a notification prior to claims release this would be in your practice management system on a claims editing prior or transaction editing process determination of process ownership and accountability who's going to be held accountable to not enforce the standards but try to meet those standards make it a contest make it make it something that is encouraging and blame free as we move towards this lean strategy as a blame free environment because what we're interested in is we are interested in whether our staff is performing their job correctly but a lot of times what I found is their lack of training a lack of policy and procedure which goes back to our training staffs and and our super users that are there to help those who are falling behind and consistent low standard performance of individuals have mandatory retraining and second attempts prior to exit counseling nice way of putting that but sometimes this kind of work is not meant for some people and you know convincing them that maybe another career is in the offing is unfortunate but it does occur but lean strategy can help you avoid those with the with the retraining and then of course resolution measurement measure each issue at start from deviation new standard set not from the mean four but from the new standard set graph and measure each process from beginning for set period which I would use no less than six months I would use more like a period of a year and and each root cause resolution so if your standard is not being met look at it again for the root cause resolution and then consider other lean strategies in case this seems unresolvable and it's the cost of failure its exceeds the cost for improvement and then set your standard at the back end for edits rejections and denials based on front end root cause resolution and see and account for those hundreds of thousands of dollars that you're letting slip through the cracks or slip through the table by not using these Ling's strategies and so you can determine whether the standards were met exceeded or do not meet the standard and so you can act once you've integrated this process over and over and over again it's cyclical just like revenue cycle analysis results in met exceed or did not meet standard and so if they were met ensure the integration through ownership response ability team practice and new improvements rewards and accountability so there's there's a carrot and there's the stick but the accountability doesn't have to be a stick the accountability can be retraining the accountability can be second chances the accountability can be certain warnings that are very polite and diplomatic and say we understand that you're running into this problem or this group is running into the problem it's a group is running into the problem then we need to go back and either reset the standard or do the process smoothing and then exceeding the standards reset to reasonable expectation ensure the integration through ownership responsibility team practice and new improvements rewards and accountability but reset the reasonable expectation so if you exceeded the standards you've just raised the bar now that doesn't mean that you raise the bar to what you met which exceeded the standard but you raise the bar just so much that in case of anticipated events such as we didn't have any flus this season because everybody got a flu shot you may not get the visits you wanted and then that's not the fault of anybody except good public health so we want to be able to exceed the standards but we want to be able to exceed them reasonably and then finally if you did not meet the standard then you need to do the lean strategy examine documented issue obstacles labor training absenteeism time management skill sets and reset standards if unreasonable and begin process analysis from the start and so that is like Six Sigma starting again but it's well worth it considering the hundreds of thousands of dollars just from that one contract at the or that one case study of the contract at the academic Medical Center so here's the the one thing that you should be walking away with from this webinar and that is that the lien strategy insists that errors are managed only by exception not the rule take it out of your revenue cycle parts it shouldn't be there the people that are dedicated to denial management and rejection management should be in the process of correcting those problems before the claim even goes out and lien strategy means error free processing and let me add blame free processing so that we take the blame out we remove the fear and we motivate people to to really accept the lien process and that things do have continuous quality improvement there is no saturation point for this because technology and innovation is always out there especially these days and here's other areas right for lean strategies lag days from data services to claim billing date lag days from date of payment to date of posting lag days from date of billing to date of payment under coating overcoating follow-up from expected reimbursement date these should also be available in your practice management system lag days from expected reimbursement date claim rejections prior to transmission aging of a are beyond metrics of like institutions and this is one thing aging of a are and like institutions are a pretty good standard from what I saw and that most institutions get this even the best performers to the worst performers you could really see the difference and correlation of metrics to gross charge collection percentage to gross AR days so if you have a gross collection percentage of 20% and your AR days are sitting at 25 there's there's something wrong so either you're way overpriced where your contractual adjustments are are just absolutely huge but the idea is to take a look at that that ratio and if you see something funny in there there probably is something funny in there and it's and it's not funny it's costing you money and so that's lean strategies and revenue cycle management so do we have any questions not that I see it both so far thank you dr. Wagner excellent well thank you again for that and I look forward to hosting you all again soon thank you for tuning in today and have a wonderful day ahead you