FQHC Revenue Cycle Management Best Practices | PMG

By: PMG

Categories: FQHC, PMG Insights Blog

December 19, 2019

By: Ken Christensen, CEO
PMG, Inc.

I’d like to take this opportunity to offer my perspective on a topic of intense interest to many of our clients: Overlooked Revenue Cycle Optimization Opportunities

There are unique challenges facing operators in the community-based setting which can impede optimal revenue cycle performance and impact cash flow.  Through organizational evolution and service line growth, many FQHCs have unknowingly created a siloed approach when it comes to revenue cycle management. Some leaders were led to believe that RCM doesn’t extend beyond their billing department, however, the most successful community health organizations understand it takes a coordinated effort to support an efficient and effective RCM operation.   One that involves everyone in your organization that has a hand in RCM outcomes.

So how do you foster the collaborative spirit needed for success? It starts by identifying the key performance indicators (KPIs) for each portion of the billing process in order to define the outcomes that you want to achieve. Identify and engage key stakeholders in each functional team to gain buy-in and consensus on the performance measure.  From there you will need to capture and analyze the data from your practice management systems to establish baseline performance measures as well as the individual goals.

Starting With the Front Desk

Your front-desk patient associate plays a critical role in the revenue cycle. What types of skills do you look for when filling this role and do they match up to the expectations that you laid out in your RCM road map?

Obviously, customer-service skills are critical. You need an individual who is empathetic and welcoming when greeting and receiving patients. It is equally important to require technical acumen as he or she must be accurate in entering visit data, skilled in recognizing insurance plans and updating patient demographic and financial information.

Once you hire someone, what are you doing to ensure he or she succeeds? A one-day onboarding and shadowing process won’t cut it. You need to offer ongoing training on the soft skills around dealing with patients as well as the technical aspects of the job, including consistent, data-driven guidance on areas for improvement. Feedback on registration accuracy through a quality review as well as by examining actual registration denials are a critical aspect of the training process.

Of course, one common challenge with front-desk operations is high turnover. Providing robust training and meaningful performance feedback can help with employee retention. But if you’re still seeing high turnover in this role, you need to ask whether your organization is placing enough value on this portion of the revenue cycle.

Provider Engagement

Many FQHCs don’t cover coding or documentation processes during provider training. Skipping this step at the outset can lead to bad habits that are hard, if not impossible to fix.

It’s crucial to convey to your providers the value your organization places on proper coding and documentation. Within a month of them coming on board, you should offer data-based feedback on their performance in these areas. During a chart review, for example, you can discuss the accuracy of the information recorded and whether the codes match the work actually performed.

Conversations around coding-related denials are particularly important. By reviewing a fatal sampling of denials directly related to provider coding behaviors, you can size an opportunity to help prevent the provider from making the same mistake again or implement particular system edits that need to be updated in your practice management system.

Denial Management

Your health center incurs costs in investigating and resolving every claim denial. According to MGMA, each denied claim costs $25 to rework.  As a result, you should have dedicated resources who focus on:

  • Resolving existing denials
  • Identifying the root cause of denials and preventing them from happening again
  • Measuring first pass rate to gauge success

Analyzing denial trends and sharing this detail with all of the functional leaders is critical.  Your teams should have access to actionable data organized by denial reason (e.g. registration, coding, credentialing, payer). Each team should have a stakeholder who takes ownership of any issues uncovered and is responsible for correcting them going forward.

As part of this process, you’ll need to set specific goals (e.g. “reduce denials by 3%”) and then consistently measure progress toward that goal.

Data Analytics

As a foundation for all these activities, you must have a well-organized data repository with optimal drill-down capabilities. That is, the voluminous claims you generate every day must be organized in a way that makes it easy to identify trends and make informed decisions.

Be sure to spend the time to create a denial-categorization directory that supports resolution. That means every specific anti-code or denial code should be categorized according to your organization’s definitions. Ask yourself, “What does each code mean to us, as an organization? And what specific action, if any, is subsequently required?”

From there, it’s a matter of developing reports that can quickly identify trending behavior. After all, every delay in resolving a denial means lost revenue. By getting actionable information out of your practice management software, you can find and put out fires faster — and stem your losses.

The bottom line: Optimizing the revenue cycle in the FQHC environment requires everyone in your organization to be working together toward a common goal.

If you are like many other FQHCs, you may be concerned about cash flow problems at your health center.  PMG has over 20 years’ experience working exclusively with FQHCs across the country and we have a deep understanding of your world.  We’re proud to say that we have a successful track record of improving the financial and operational position of every one of our clients.  Contact us today to see how we can help your center.