Managing for Outcomes, Not Just Metrics, in Revenue Cycle

Modern revenue cycle operations have heartily adopted the old adage about ‘managing the things that get measured’. Dashboards are ubiquitous, and most managers can cite a handful of metrics from memory, undeniably leading to better performance and outcomes.

But revenue cycle leaders should be careful to follow both halves of the famous quote – they cannot settle for merely measuring; they must also manage. That means selecting meaningful and actionable metrics and acting on them accordingly, not simply in the hopes of improving the metric but also in improving the outcome.

Productivity is a common metric that can be closely measured but not adequately managed. Meeting expected productivity is an integral part of good performance, but the number of claims touched needs to be balanced with other factors, such as the quality of the touch and the selection of which claim to touch. When the focus on quantity supersedes the need for quality, staff can get caught in the “churn” of just touching a claim for the count rather than working to get it paid.

One client we worked with consistently exceeded productivity goals and was proud of their staff effort. But a closer look showed that roughly a third of those touches were on claims less than 30 days old. While it can make sense to touch some extremely high dollar claims quickly, it is more effective to time most follow-ups at 45 days or more. If you review follow-up dispositions and see a high proportion of activities such as “Claim Pending” or “Follow Up in 14 Days,” it is likely the staff are touching claims too soon. This could be a function of seeking productivity or a failure in work listing. In either case, the opportunity is hidden as those low-value touches come at the expense of higher-value touches.

That same client, where one-third of touches were less than 30 days, also had $100m in AR that had not been touched in 30 days and another $27m that had not been touched in 60 days! For them, productivity looked good, but they were working the wrong accounts and getting subpar outcomes.

If you are closely managing productivity but not paying as much attention to the types of claims being worked or the outcomes, you may have a false sense of security about your results. If you currently have a work listing tool, ensure the disposition codes are granular enough to determine the benefit of the touch and confirm staff is using the codes appropriately. Sampling accounts is a valuable way to test the validity of the information and may be the only choice if your work listing cannot deliver clarity about the actions taken by your staff. Knowing a given metric’s role in the broader array of outcomes is vital to successful management.

A different flavor of this concept is measuring an outcome that requires other upstream processes to be completed. While the metric might not directly measure those upstream processes, it can help manage positive results.

An example of this approach would be a metric around a collection of patient balances.

Successful collection requires two necessary inputs – the staff must know how much a patient owes and be willing to ask the patient to resolve their balance. Asking patients can be uncomfortable, and staff often focus on the patient service aspects of their positions, assuming that asking for payment is intrusive and off-putting. Staff who understand the benefits of educating a patient about amounts they will eventually owe and are willing to take the potentially uncomfortable step of asking for that cash are markers of motivated, educated staff who are likely to care about maintaining high-performance levels.

The simple act of estimating a patient’s balance is also an indicator of high performance. An accurate estimate requires the successful completion of several important patient access functions. First, the appropriate insurance must be identified and gathered from the patient. Through the verification process, insurance should be confirmed, and patient benefits, including coinsurance and deductibles, should be obtained. These processes are critical parts of patient access operations and vital to avoiding denials and write-offs.

Next, the calculated balance needs to be communicated. If the process operates before service, this means reaching out to the patient, often by phone or text, relying on demographic information gathered earlier in the process. If that information is faulty, the error should be identified before service, allowing corrections to be made. If the process leads to a collection attempt at the time of service, the expected balance must be communicated to registrars. Communication from pre-service to point of service may also include other registration deficiencies, which, if corrected, will avoid further collection delays or denials.