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but revenue leakage, I think, is a serious threat to our financial stability, because then it becomes common.

0:42
Well, the chart, a business of medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today before we get started. Just a quick note, medical economics and physicians practice. They're hosting a free webinar. Is AI, making medicine better, what physicians really think on Wednesday, April 29 at 12:30pm Eastern, sponsored by Heidi health. Speakers include Dr Nancy sabati, Chief Medical Information Officer at Heidi health and medical economic zone, Chris mazzolini, they'll break down survey data from more than 100 physicians on AI, adoption, ambient scribes, documentation, burden and the real world. ROI of these tools, you can register for free today by clicking the link in the show notes. But with that said in today's episode, the physicians practice Managing Editor Keith Reynolds sat down with Kem Tolliver, CEO of medical revenue cycle specialists. They're talking about what a strategic revenue cycle work plan actually looks like in practice, and why most practices are managing theirs reactively instead of proactively. Kem walks through the first three moves to make when payer friction is out of control, how to identify where your cash is getting stuck and why you're approaching payers with frustration instead of data is one of the most common mistakes practices make. Kemp Tolliver, thank you for joining us, and now let's get into the episode.

1:59
Hey there, folks. Today we're talking to Kim Toliver, CEO of medical revenue cycle specialist. How you doing today? Kim,

2:04
I am wonderful. How are you

2:08
well, it's just another day in paradise. All right, so let's get right in just, just get into it. So when you say strategic revenue cycle, work plan, what does that look like in real life?

2:20
So the way that I kind of envision a strategic revenue cycle work plan is the alignment of all of your revenue cycle priorities with your overall business plan. And it's so fascinating when Taya and I conduct this workshop, usually we're conducting it for folks who do not oversee a revenue cycle, but they are the COO or the CEO of healthcare organization, and it gives them insights into the activities that we want to align within their revenue cycle departments for the entire organization. So what that looks like is internal auditing. What? What are you auditing? You're auditing your denials. You're auditing your your cash flow. You're auditing inefficiencies. You're auditing auditing your documentation. You're auditing the processes that your team's using to oversee and to manage the relationships with payers. So you know, that's kind of what a strategic revenue cycle work plan looks like. But what I also like to do is I like to break that down by quarter. So when you're thinking about, how do you manage this type of a work plan, you can't. What is it? What's the saying you can't eat an elephant in one bite. You have to, you know, eat it piece by piece, one bite at a time. So what I like to do is break down that that work plan by the quarters of the year. So the first quarter, you want to think about, okay, what's really important in this first quarter, first quarter, we have new codes, right? We want to look at our fee schedules, we want to look at our contracts. We want to look at auditing our credentialing. So we really want to break that down into the four quarters of the year, and again, aligning that to the overall business plan, and doing that, it gives you the opportunity to go back and look at your business plan. Many healthcare organizations and medical practices in particular, their their business plan was developed, you know, eons ago, and healthcare has evolved so much, so we want to align that revenue cycle work plan with the overall strategic plan.

4:42
All right, so if a practice has 30 days to get control of, you know the friction they have with payers. What's the first three moves that you would make?

4:52
The first move that I'd make is understand what is driving your denials and the way that you. Want to look at those denial drivers. Are two ways, volume and dollars. Now looking at the volume and the dollars, that's going to be super helpful. But you also want to look at the complexity. When I was a biller and when I was a, you know, I was responsible for working accounts receivable, I created, and many of my co workers, we created these micro workflows, right? So I would, I would say, You know what? We want to deal with the easiest, the easiest accounts, right? Let's get those out of the way. But what we want to do is we want to, we want to encourage our teams to look at denial drivers and look at those root causes and dig into the complex be complex accounts as well, so volume dollars, and don't forget about complexity. The other area that I would want to look at, when it comes to friction within a 30 day timeframe is where is your cash getting stuck? So is it getting stuck in the zero to 30 day bucket? Is it getting stuck in the 90 day bucket? Is it getting stuck in the over 120 day bucket? This gives you a lot of insight. Usually, if it's getting stuck in the zero to 30 day bucket. There's something going on with your EDI, with your electronic data interchange. So you want to take care of that. You want to work with your clearing house, right? So they so I would want to look at the the areas that your cash is getting stuck. The other thing that you want to do again, you know, if you have 30 days the three moves that you want to make, understand your payer escalation processes. So we want to make sure that we have really sound relationships with our payers. And that's one of the things that we're going to talk about at the financial conference, is building and securing those relationships with your payers. So when you're when you're trying to get get your AR under control within 30 days, you want to build those relationships with their payers so that you know what it takes to escalate an account and you have someone who's available and willing to help you, you know, waiting in a queue with an insurance company. That's not really a strategy, that's just a reaction. So we want to build those relationships and understand what it takes to escalate when it's necessary.

7:32
Alrighty, so you know, what's the biggest mistake that practices are making when they try to engage with payers?

7:40
You know, I think part of our relationship with payers is they have something that we want, we want to get paid. So when we approach them, we're usually approaching them with a complaint or a grade. I mean, that's, that's the reality, right with with something that's wrong, one of the, one of the areas that I find as the biggest mistake, is not having data. When you approach a payer, that is what really matters to them, right? If we provide them with data and give them examples. Show them why something should have been paid, show them give them justification. That's really what's going to break through in that in making a correction to a claim. So my my suggestion is, yes, we know that we're frustrated. That is, again, that's not a strategy for solution. Strategies for a solution are going to be preventing providing them with data, making sure that you have examples of your claims before you make those calls or before you engage with their payers. Show them trends. That's what really is going to matter to them, and let them know that you need assistance with what corrective actions they need from you right. Make sure you document when you're when you're engaging with patients, with with payers. Get your reference numbers, get the first name, and, you know, last initial, get, get your dates in order, but the complaints and the frustration, you know, they're frustrated too. They get loads of calls all day. So, so, yeah, that that would be my approach.

9:36
Okay, so when denials are spiking, what's the you know, where do you start first to find the real root cause of it? And you know, what data should you be pulling? You know, right off the bat,

9:48
right? So I break up the revenue cycle in four kind of quadrants, or four categories, right? So you have the front end, you have the mid. The front end is obviously patient intake free visit. You know, before the patient has their has their encounter with the provider mid cycle, that's the documentation of the visit. That's coding that, you know, we're preparing to submit our claim. That third quadrant is the communications that we're having with our payers. So we need to make sure in that fourth quadrant is the data that's in our system. So the you know, the first thing that we want to do when denials are spiking is identify which of those four quadrants is the are the denials originating? Are they originating are they originating from the front end? Are they originating from documentation and coding? So we need to understand where within our revenue cycle is the spike coming from. Then what we want to do is we want to understand our denial reason code so x twelve.org is the location that you can go to access all of your carts and all of your works with the with an interpretation. So we want to understand those reason codes. We also want to identify are these. Are these spikes a result of authorizations not being not being captured. Coding edits, Clearinghouse rejections. So you know one thing that I would suggest that you do when you're thinking about spikes, identify where in the Revenue Cycle those spikes are coming from group those denial codes so that you can know where the root cause of those denials are coming from, make those corrections and then go back and do that training and education in any workflow realignment that's necessary, and I would also include making sure that your practice management software has customizations, your customizations to put in some edits to prevent those types of denials to continue to spike.

12:08
Alright, so what is one denial type you see again and again, the practices could prevent with a simple workflow change?

12:16
Oh, just one.

12:19
I mean, we got time for a couple

12:24
Okay, so I'll, I'll say CPT because so I'm a certified coder, and CPT just always, you know, is top of mind for me. We want to make sure that we understand that there's, you know, there's, there's two ways to look at CPT when I was getting my coding certification. You know, over 15 years ago, I came to the the coding course with a reimbursement mindset, and that really, it really threw me off, because I was now being trained on how to code regardless of payments. And that's not the real world. The real world requires us to modify our coding based on the payers reimbursement guidelines, not to say that we should not follow correct coding initiatives, but we do need to follow the payers guidelines. So if a certain payer requires a modifier, or a certain payer does not pay for a certain CPT code with a certain diagnosis code, we need to understand those payer reimbursement guidelines. So that's a workflow change that I would recommend, is understanding the payer reimbursement guidelines, and this would apply to everything from coding to the number of units that are required to authorization to referrals. So it's really about understanding the payer reimbursement guidelines, creating the workflows internally so that you can follow those guidelines.

14:02
Okay, so what does a strong payer specific action plan include, and who should own it, you know, on the day to day?

14:10
Well, let me say that yes. Well, the quick answer to who should own it would be billing team, right? That's what we would normally expect. However, I do believe that it's the responsibility of everyone in the organization to own some component of that action plan. So you know what that action plan is going to look like, is making sure that we understand internally, what are our top denials? And with those top denials, which payers are we get? Are we getting those denials more most frequently from right?

14:53
We

14:53
use that to create an action plan so that we can mitigate those denials from happening.

14:59
Mm.

15:00
We also need to understand timely filing risks making sure that our providers close their notes in a timely manner. When we make sure that our providers close their notes in a timely manner that is now including them in that payer you know that payer specific action plan, right? We want to make sure that we're able to submit our claims in a timely manner. The other thing that we want to do with the strong payer specific action plan is again, thinking about those root causes, fixing them internally, understanding who is responsible. So let's say, for example, we have a we we're continuing to get denials for patients who have eligibility issues. Certain certain specialties have different types of benefits, and when you're using your EMR practice management software to check eligibility, let's say for behavioral health services. Guess what? You're not going to always get to the nitty gritty of the the benefits, right? So what does what does that look like within a payer specific action plan? Well, what we need to do is we need to say, okay for behavioral health payers, we need to reach out to the payer, rather than using our EHR EMR practice management software to do that eligibility or benefits verification. So what I would say is, look at your aging AR, because that is going to give you insights into the troubles that you're having. Use that to identify your top denials, the reasons why you're getting denied, which categories within your revenue cycle they're they're coming from, and start developing payer specific strategies based on the reimbursement guidelines that you have pulled together so that you can work with each individual that is in your practice To make those corrections so that would look like documentation that that falls on the provider, right? So understanding, making sure that your providers understand the documentation requirements for for all of the payers your medical assistance, making sure that they understand the authorization requirements for each payer, your your patient access, make sure that they understand the coordination of benefits and eligibility requirements for each payer, and then with your billing and your collections team, making sure that they understand those claim edits that are necessary before they submit the claims to reduce the demands you

18:00
Keith,

18:07
hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow. Hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds, at mjh, lifesciences.com with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute, when it comes to you know, the metrics that you're looking at with your revenue cycle. You know which actually predict cash flow, and you know which of them are sort of given, you know, practice leaders, a false sense of security.

19:10
Okay, so let's, let, let's unpack that question. Because when we think about revenue cycle metrics, we're looking at days in AR we're looking at, you know, the amount of time it takes for you to collect right? Those are, you know, those are some of the typical revenue cycle metrics. But when you think about finding that, to predicting what your cash flow is going to look like, that's a whole other level of ensuring the financial sustainability of your revenue cycle. So aging AR is going to help you predict cash flow, right? So the more money that's that's aging, the less money is in your bank account, right? The. Say the time it takes to collect, or, I shouldn't say the time it takes to collect, the time of service collections at the front desk. This is a really important cash flow indicator, if you have patients who have balances of, let's just say out of pocket balances of $5,000 for the day, right? That's how much should be collected at the front desk. And you get 50% or less of that. I mean, you know 70% 60% or less of that, you think about this, right? The this is this. These are monies that could be collected without any expense to the practice. This is just the patient showing up if we can't collect with a person, a human in front of us with No Barriers other than asking for the money. We don't have any expenses, right? We're not sending a statement. We're not doing any of that stuff. We're not paying a collections agency. That is a very good indicator to predict what your cash flow is going to look like, right? So if your team is non compliant and is unable to collect at the front at you know, at the time of service, that's going to be that's going to be a huge predictor. Others are going to be the clean claims rate, right? So what percentage of your claims are paid the first the first go around, right? So the lower that percentage is, the you know, the the harder it's going to be for you to collect denials rates by the dollar amount. So you know, if you have denials that are, you know, ballooning in in volume, that's going to be another predictor for your cash flow. Now, you also asked another really good question about what gives us a false sense of security? The gross collection rate gives us a false sense of security. Okay? We have to be very mindful because, just because we've, we've collected, you know, a, you know, a certain amount, we have to compare that to what was actually owed, right? And we have to, we have to compare that to our adjustments. What if we wrote off stuff that was collectible. But guess what? Our AR is clean. That's, you know, that's a false sense of security, right? Total charges. That's another false sense of security, because just because we charge a certain amount doesn't mean that we can collect that amount. The allowable amount is not always our charge amount, right? So that's another false sense of security. I could go on with that, but those are some of the indicators that I would I would look out for. What I would say is just be mindful of the the predictors or the metrics that you're using, because they could really mask, you know, some, some significant, some, some significant problems in your accounts receivable.

23:14
Alright, what's you know? Do you have a rule of thumb for deciding, you know, when to outsource, when to automate, and you know, just when to hire. You know, get more bodies in the the practice.

23:27
So I have a rule of thumb for automation. Anything that's repetitive, we constantly have to do the same thing over and over. If I have to tell people call patients to remind them of their appointments, and it's the same script for every appointment that needs to be automated. Eligibility, we're asking the same questions for the same purpose that needs to be automated, right? I mean, when we think about it, when we used to submit claims, I used to submit claims on hic for 1500 that needed to be automated, right? So, rule of thumb, anything that's repetitive, anything that has a rule that needs to be followed, anything that's high volume, get people out of the way, automated people should be used for more complex tasks. So that those are, you know, those are my thoughts there when to outsource. What I would say is, I outsource when I need someone who has the expertise that I don't have. I mean seriously, if something's if something is super complex. So I'll give you an example. What you'll find is, if you're about to switch EMR practice management software, you're transitioning from one to another when you think about assigning your current staff to work down old AR in an old system, as you're preparing to implement a new system and. Have to do all the transitioning and all the training and all the build out and set up and all that stuff. Outsource the old AR, get somebody else to do it there, if they're saying, get somebody else to do it. Get somebody else to do that complex stuff, while you focus on what really matters, while you focus on staying up to date on your current on your on your current collections. When to add staff? Well, if there is time or when there are times where you need highly skilled individuals for specific projects, that's when I would suggest adding more staff. But before I add staff, I like to do a staffing ratio analysis. I like to use HFMA and MGMA, and there's one other source that I like to use, but essentially doing a staffing ratio analysis to understand how many accounts can my current staff work, or how many patients can my current staff see, or how many providers are my medical assistants being assigned to assist, right? So you want to do that, that ratio analysis. You want to understand what the needs are of the practice, what are the capabilities of the individuals? And that's not to not the people, but we want to understand what their capabilities are, and if they need more support, I want to justify that so. So that's that those are the the the the directions that I would go, the pathway I would take before adding more staff.

26:46
All righty, all right. So what's one tip you would give a practice leader that they can implement, let's say next week. You know, what's one tip you'd give

26:56
look for areas of revenue leakage and I know that, you know when, when we think about tips, revenue leakage is, it's something that is often hidden, right? It's, it's, it's, it's masked under other stuff that's and it doesn't feel as important, right? But revenue leakage, I think, is a serious threat to our financial stability, because then it becomes common, right? So one area of revenue leakage that I that I see as a threat is under coding. So the tip that I would give is, although we know that these leakages exist in our organizations, we kind of push them to the side, because it's not a fire. If it ain't broke, we're not going to really fix it. I suggest fixing the areas of leakage so under coding a writing off balances that could be collectible, but maybe we just don't want to invest the time. We can outsource that, right? We can get some, get somebody else to do it, not charging interest for late payments with payers, right? Accepting virtual credit card payments, not not negotiating fee schedules, rates you know, for higher reimbursement. So one tip that I would suggest to look into is areas of revenue leakage.

28:42
All right, that's all I got for you today. Is there anything I'm overlooking or anything you want to

28:48
add? Well, I just want to thank you so much for this time. It's always so great to connect with you. Thank you so much for everything that you do for the industry, all of the information that you share. I love listening to the folks that you that you get to interview. So again, thank you so much. And thank you for your team for having me,

29:09
oh, and

29:09
for doing this great work. You're

29:11
going to you're going to make me cry, and you're going to give the team a big head. So but thank

29:16
you so much.

29:17
Alrighty, thank you, and have a great

29:21
flight. Thanks. I appreciate it

29:22
once again. That

29:31
was Kemp Tolliver, CEO of medical revenue cycle specialists, speaking with physicians practice Managing Editor Keith Reynolds, on behalf of the whole medical economics and physicians practice teams. I'd like to thank you for listening to the show and ask me please subscribe so you don't miss the next episode, and don't forget our free webinar is AI making medicine better. What physicians really think? It's coming up on Wednesday, April 29 at 12:30pm Eastern, sponsored by Heidi health. Register today by clicking the link in the show notes, as always, be sure to check back on Monday and Thursday mornings for the latest. Conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts, and if you like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicianspractice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell. Medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you.

30:40
You.