Turn Revenue Cycle KPIs Into Real Performance Gains

I want to thank everybody for joining us today. I really appreciate you taking time out of your schedules. I know we're all really busy and coming back from the holiday that's getting towards the end of the month. I know you have a lot on your plate, so I appreciate you joining us.

Just to go over very quickly what the agenda will be, I wanted to kick us off and start by talking about the current economics of health care. There is a lot happening, and I think in order for us to take a deeper dive into KPIs and benchmarking, we need to really understand what the current state is.

Then we can jump into those specific KPIs. We're not gonna go over all revenue cycle KPIs, but we're gonna go over quite a few of them.

And then we'll lead into benchmarking and how that benchmarking can work and things that you need to be aware of as you're looking at those thresholds for benchmarking data. And then what I'm going to do is kinda combine the KPIs and benchmarks and give you some real world examples that we have either worked with specific clients or clients that have had thoughtful discussions with us here at AAPC. Then I'll jump into a thirty, sixty, ninety day action plan of how you can start monitoring and really tracking and taking action on these KPIs that you set for your organization. And then we'll wrap up finally with a future state conversation.

So I really feel like we can't talk about revenue cycle without understanding the current economics of health care. So I I'm apologizing in advance. I will be reading some of the content on my slides and some of the stats. I just want to make sure I'm getting, the information one hundred percent correct to you. And, incidentally, that slide deck that Cordell said in a few days would be available, the reference links of where I pulled this data are available there.

Okay. So let's jump into it. Let's talk about physician productivity versus reimbursement. There was a study that MGMA did in twenty twenty five, so fairly recent, where they called out that physicians' productivity was really starting to stabilize according to the survey.

They said that seven out of ten of the groups that participated in their survey reported that they're seeing higher patient volumes, and part of that that uptick is based on hiring more advanced practice providers. So those mid level providers, they're bringing them more into their their practices. And so obviously, that's gonna increase pay patient volumes as well as increase the reimbursement a little bit. What's interesting with this article is a lot of the customers that or clients rather that participated in the survey, they talked about how they were utilizing telemedicine and utilizing those advanced practice providers for those follow-up visits, and it was allowing them to be more efficient with their overall practice expenses and being more efficient seeing those patients.

So I thought that that those key indicators kind of went hand in hand.

There was another study by PMC that showed organizations that are using ambient scribe AI technology or voice recognition technologies were able to significantly cut down on charting time, which makes sense. Right? If the physician is seeing the patient and you've got the ambient scribe in the background running and doing the lion's share of the documentation, makes sense of why we're seeing these big improvements. This PMC study actually stated that the providers that participated in their study, they're saving on average one hour of documentation per time or per day.

So if we add that up five days a week for primary care, if you're in the office, who wants to save five hours a week? Right? Everybody does. Your providers do.

So that's pretty significant. That's some good success stories there.

We also know that the CMS twenty six fee schedule changes are really starting to have an impact. So I shared a webinar last summer, and we did another one in December when the final rule came out. And we talked a lot about how we thought there might be an impact with primary care, the surgical specialties, and the non surgical specialties. Well, data that I recently pulled really came to fruition where they said for most primary care providers, their reimbursement has been pretty flat for this first quarter.

Surgical specialties, some of them are seeing a little bit of an uptick with increased revenue due to those fee schedule changes.

But just as we predicted, nonsurgical specialties like oncology are seeing huge pay cuts.

Some of them as high as thirty seven percent decrease in their reimbursement. That's huge. Right? We're seeing OBGYN practices, infectious disease practices having a little bit of a decrease around five percent, so not quite as significant.

So practices can't sustain these huge reimbursement cuts. Right? Something needs to change.

So let me flip over really quick. Sorry. I thought I skipped slides. There's a little bit of delay when I'm making the quick changes.

Anyway, let's talk about the operational costs. So back to that MGMA study that I just talked about on the previous slide, even though some of the primary care providers were seeing an increase as they're bringing in these advanced practice providers into their organization, they're using more telehealth services for those follow-up visits, the article did state that reimbursement still is inadequate because there's this rising operational cost that's overshadowing any type of reimbursement adjustments that organizations are getting. So just as, you know, the operational cost is increasing with health care, we feel that same burden every time we do our shopping.

Right? Every time I go to the grocery store or I'm shopping online, I have to stop and think, do I really wanna buy all of these items? Do I maybe wanna wait for a while? I might have to make different choices just for me personally because of the economics of of the world that we live in.

Well, this is no different than healthcare, right?

So this MGMA article that I referenced, they stated approximately ninety percent of medical organizations that reported this are reporting a higher operational cost in twenty twenty five compared to twenty twenty four. Ninety percent. That's huge. Right?

That's a an eleven point one percent increase of of operational costs. So I thought, okay. Well, where are those operational costs? This MGM article allude to salaries.

Well, where are those salary increased costs coming from? So I went and pulled more data, and I found that the medical staff are costing an increase of four point three percent just in one year, where the technical staff, on average is a five point five percent increase in salary, management, a nearly seven percent increase.

It's harder to find good qualified, experienced, skilled folks. Right? And oftentimes, we've gotta pay that that higher salary to bring in these good these good qualified folks.

The other operational cost trend that I wanted to point out is malpractice insurance. So we've talked about this over the years, but in some states, it is skyrocketing to just a ten percent increase just last year alone.

That's huge. Right? Practices and some of these specialties can't sustain at those huge hikes of malpractice insurance premiums. You know, you work really hard, and and it's just like, it's gone. It's swept away.

Medical supplies are increasing.

When we have gas prices that increase, our supply chains that get limited, of course, we're gonna see that economics of these costs of increased supplies.

Rent is increasing. We saw rent increase during and after the COVID pandemic. Right? I was hoping maybe that would even out a little bit, but what's even more alarming is the cost of construction.

That's been increasing the last six years nearly double. It's at forty percent. So what happens with these, practices that want to increase their patient volumes, increase revenue, and try and get ahead of these operational costs, and they're bringing in these advanced practice providers, but their building's too small. Now what do you do? You can look for maybe higher rent or a forty plus percent increase in building brand new.

Something's gotta change. Right? We can't sustain these these operational costs as they are.

Another reality that I wanted to talk about as we talk about economics and health care is burnout. Right? We may not really think as burnout as an economic impact, but it really is. The AMA said burnout is a health care crisis for doctors and patients.

Some different research that I went and looked into, I found some articles and surveys claiming that forty three percent of our providers are burnt out. Others were claiming as many as fifty five percent physicians are feeling burnout. I think we're all feeling burnout. I think physicians in general are feeling burnt out.

Right? There's a lot happening. Replacement costs when physicians are burnout and they they just wanna retire early or they wanna, you know, change change organizations and and have a little bit of a different type of a practice, it will cost organizations anywhere between five hundred to two million dollars. So if you think about it's not just when a physician leaves or retires to replace that physician, to rebuild your patient population, rebuild that trust, and and that impact is felt over time.

It's just not, you know, one month one and done. Right?

Other data that I pulled that physicians are spending for every one hour seeing a patient, they're spending perhaps one, one and a half to two hours documenting. Some of these patients are very sick. There is an extreme amount of complexity to these patients. There's a lot going on, and it takes a while for for physicians to make sure their documentation is correct.

This data that I'm sharing in health care economics is kind of alarming, and I don't mean to bring doom and gloom, but I think it's really valuable for us to understand the reality of health care, understand the situation that we're in. Because when we have that knowledge, we can start to think a little bit differently and start to make changes.

Okay. So let's talk about physician burnout just a little bit more. In twenty twenty six, so this year, Medical Economics released a report.

It was at in the first quarter of this year, and they cited that documentation and coding related tasks were the number one reason physicians were getting burned out.

And I thought this was so insightful. Physicians are getting stressed out at having to select the proper enum level. Right? They're worried about it.

They they know that they need to get it right. They're stressed out and making sure they're meeting all the different payer medical necessity requirements. Blue Cross wants this before they can can perform a particular procedure or or advanced treatment instead of conservative. This other payer wants this other thing documented.

Modifier use. There's still a lot of confusion which when is it appropriate to bill modifier twenty five, and and what about fifty nine? The split shared conundrum. Right?

What is substantial portion? So all of these things around their documentation coding is stressing them out. They're getting burned out. And if you talk to your doctors and ask them, they'll probably tell you similar things.

Another leading cause of burnout, this this came in number two with the medical economics report that physicians feel like their environment is being defined. They're they're such a high level scrutiny by the DOJ and CMS that there's they feel like there's just a sliver margin of error, and that's increasing sliver increasing that stress level where, you know, they they really wanna do what's right. They wanna see their patients and do what's good for the patients. They wanna get their documentation correct. They wanna get their coding correct. Otherwise, there there's the this scrutiny, right, by the government agency that they've got to worry about.

The third leading cause of burnout is all of the electronic medical record and administrative tasks.

They lumped the medical economics report lumped prior authorizations into this category because that's really what it is. Right? If the physician's seeing the patient, they're doing all of the things that need to be done, providing good care. And now all of a sudden, treatments have failed or the conditions expanded.

There's a need for a particular treatment or procedure that needs prior auth. Now there's this whole laundry list of things, of hoops that they have to go through to make that happen. That's not necessarily what physicians went to med school for. Right?

They know what the patient needs, but they've gotta jump through these barriers.

There's lots of inefficient workflows within the EHR system. Right?

There are alert fatigues. There's all the quality reporting that they're required to do now as they're they're trying to provide quality care and meet MIPS and MACRA and their risk adjustment requirements. So many things they're just getting bombarded with.

There was another survey that talked about physician burnout and was published by PNC. They had very similar top three issues, almost paralleling the medical economics, but they added a fourth component, which is loss of autonomy. And I think part of that feeling burnt out and this increased level of scrutiny and this increased level of administrative burdens that that have to take place, of course, you're gonna feel like somebody is taking control out of your practice. They're feeling like there's they don't have control over their schedules anymore.

Right? They can't leave the office until everything's documented. They feel like that their administrators are worried more about RVUs and targets rather than trying to care for the patient. So whether that is true or not, that's what burnout does.

Right?

Something needs to change. So I thought this was interesting, in one of the articles that had this little snippet. So sorry. It's a little, blurry and fuzzy on your end, but it it lists signs and symptoms of burnout. So we know that not just physicians are feeling mental fatigue and physical fatigue and emotional fatigue, but it everybody is. Right?

The physicians aren't the only one that are unique to this burnout. It kinda trickles down throughout the revenue cycle, throughout all of our staff. We just need to be mindful of these symptoms. Right?

So we can perhaps do something about that, and we'll talk about what we can do in just a moment. The denial crisis. Right? We can't forget to talk about the increase in denials.

This is what every revenue cycle is experiencing firsthand. I don't care what type of practice you have, revenue cycle and denials, or even if they just come from your your patients not being able to pay their their patient portion.

This it's real. Right?

Claim denials are increasing. So webinar that I did last year, I kinda talked a little bit about these increase in denials. And last year when I did all that research, we were seeing that professional services were increasing as much as a hundred and twenty six percent. That could be even more this year. We know facility denials are on the huge rise at two hundred percent compared to previous years.

But the good news is is there's been a lot of studies and data around these increasing denials in this economic shift over the last couple of years where they've done a lot of research research with different organizations and finding about eighty six percent of these denials can be preventable. Right? And that one less than one percent of denials are getting even appealed and getting worked. Well, to me, instead of my cuff being my cup being half empty, I think my cup is half full because this tells me, you know what? Good. There is opportunity for me to come in as a revenue cycle leader and make some changes within my organization that can have a meaningful impact.

So this is just a list of some of the top denials. We're not gonna go into a lot of detail here. Prior OS, not only is is that a top denial regions, but it's it's so complex now. All those hoops we have to jump through, it's creating some billing complexities, missing or incomplete data, you know, coding and documentation, eligibility. All these things are combining into those the denial crisis that I just mentioned. Something needs to change.

And let's talk about what we can change. So let's talk about the KPIs that really matter. Right? There's a lot of different key indicators that you wanna look for within your organization. I'm sure your CFO is constantly talking to you about these different KPIs. But what we need to do as revenue cycle leaders is we need to be smarter and more strategic about these KPIs and what the triggers are and when to take action.

So KPIs are not the goal. It's the action that's the goal. So most organizations track KPIs just as I was mentioning. We do within our practice even though we're we're not necessarily running accounts receivable on patient visits because we don't see patient visits. We work with lots of organizations, and we do have internal indicators that we monitor. Right?

And we know that those indicators is just that an indicator. Right? The back end goal is really what matters. Why is this indicator there?

What is the goal? What's the value of that indicator that's going to tell you something? What is that value? And then what is the trigger that prompts you that you're like, you know, I really need to make a change here?

Well, let's talk about some of those.

The revenue cycle starts with the provider, not the claim. I think that's often a misconception that we've had in the past.

Most KPIs issues happen upstream either when the patient's getting scheduled or at the documentation and coding level. A lot of revenue cycle issues are behavioral issue too, really not a billing issue. So we need to think about that shift and think a little bit differently.

So what I did with these KPIs, I broke them out with between professional and facility because I knew that we'd have a combination of folks on the call today.

For professional services, I'm going to call out eight specific KPIs. And, again, I know that there's many more that you're probably monitoring, but these are kind of the key ones that I wanted to focus on.

And they tie into the some of the benchmarks that I'm gonna share in just a moment. So I categorized these eight professional service KPIs, and they're similar to the facility, right, in two different buckets. So this first bucket is cash versus accounts receivable. There's two different main KPIs that you should should be monitoring.

And keep in mind, although I'm listing kind of what best practice goals are for these indicators, know that your organization is different. Not everybody has a one size fits all. Your organization could be in a different circumstance. Maybe you're implementing a new EHR system.

Right? And so your net collections rate maybe for this month, this quarter, maybe you wanna lower that best practice from ninety six percent or greater. Right? And you wanna lower your trigger a little bit.

That's okay to make changes to these KPIs. Right? The thing is is you need to be aware of them, be aware of what's happening in your organization, and make the appropriate adjustments and make sure you're including the appropriate people. Like, make sure your c f CFO knows if you're making any changes.

So the ideal net collection rate of ninety six percent is great. Anything below ninety five should trigger something. This is an in indication that you're missing revenue.

Right? There's something happening. So you would need to take action fairly quickly. Don't let it slide. Don't think, hey. You know, I'm gonna just monitor it for the rest of the month or the rest of the quarter.

You need to take immediate action because there's revenue at stake here.

Days in AR is another very important indicator. We always wanna be between thirty, maybe forty days, but anything greater than forty five, that is where your trigger should hit. As soon as you see that greater than forty five days, you need to start segmenting out your data so you can identify what the root cause is. Right?

You may think you know what that direct cause is, but it could be compounded. It could be more than one thing. So you need to start separating out your accounts receivable data and look look at, different questions. Is this a payer driven issue?

Is it a denial driven? Is it productivity driven? What else could have happened within our organization that perhaps could lead to the increase in our days of AR? The important thing is just to get your data segregated so you can start to look at it more holistically.

Alright. So KPIs associated directly with denials and quality. This is another category that I bucketed these three different KPIs in. So remember study where it stated eighty percent eighty six percent rather of our denials are preventable?

Well, any den denial rate above the five percent, you should be looking at. That should be your trigger. Right? Maybe once you you go through this process and you're getting really good and you're fine tuning your denials and fixing some problems, maybe you wanna shorten that from five percent to maybe three percent. Right?

Just, you know, you gotta play with the numbers and figure out what's gonna going to be work best for you and your organization. Typically, these denial rates are gonna come from coding, authorization, eligibility, all of those things we listed on the other side.

Coding denials greater than two percent are highly actionable because coding, we can fix. Right? So you might want to segregate your denials. We talked about doing that on the previous slide with some of your different KPIs.

No different with denials. Right? Segregating them and having different folks review and have different triggers would be a very smart thing to do. If it's a coding issue, we can usually track that back to the source, the beginning.

And where is that beginning? It starts with the provider and their documentation.

K? It could start with the the coder as well. So not always a billing issue. Go back to the beginning.

When you start to see clean claim rates drop at ninety three percent, that's when you want to start looking immediately at upstream problem. It could be tied with scheduling patients and eligibility for their insurance plan. It could be a typo information.

We're human. Things happen. So when you start to see that clean claim rate, then you that's where you would want to start looking.

Okay. Now we have behavioral KPIs, within your organization as well.

This is something that you wanna look at at your charge lag. Right? How many days of when the patient was seen compared to you get that claim out the door? This is definitely a KPI that you want to adjust depending on where you're at.

Back to that example of migrating to either a major EHR upgrade or a new system. You wanna change your charge lag KPI a little bit. Right? Because you don't wanna stress anybody else out during an already very stressful time.

Your e and m or even CPT distribution of codes, that's something that you should be monitoring.

Maybe check with your CFO. That's something a lot of organizations will have them look at that, and then make sure you're meeting with them to go over those results if you're not looking at them yourself. And then, of course, work RVU and clash collections. If your work RVU is got jumped up, it's higher or it's remaining high, but your collections dropped, that's an indicator that there's something wrong with documentation, perhaps coding. And a easy solution could be simply just educating.

Alright. Let's quickly go through some of the facility KPIs. They're very similar. I just wanted to kinda point out some of the differences. If you notice, the triggers are a little bit different here, and that's intentional because facility services are very different than professional services. There's different workflows that are involved.

There's different length of stays. Like, it's just a different animal. Right? So even though we might be looking at similar KPIs, those triggers are going to be very different.

So an accounts receivable of greater than sixty days is not good. Right? Something that should be escalated not just within your billing department, but you need to bring to the attention of maybe your HIM, your your your payer contracting department, you know, even your billers. Right?

Find out what's happening. It's usually an indicator of something happened with a payer contract or something changed there.

And then you have your discharge not final billed. That's very similar to the charge lag time. Right? It if you're starting to see this trigger where it's greater than seven days, it almost a hundred percent of the time is going to be associated with a process of documentation, a coding delay, or even something that's hung up with the CDI team.

Then we have our denial rate. A final denial rate, I wanted to touch on that. You wanna have both of these different denial rates. If you're seeing a final denial rate of greater than three percent, you've lost revenue. That's a permanent loss. Right? So it's definitely an indicator that rev cycle leaders in the facilities need to monitor very, very closely and take immediate action so that you can prevent that revenue loss into the future.

Alright. So let's kind of bring it together. The biggest risk is reacting with these KPIs and the triggers in a broad sense. Right?

I talked a lot about segregating the data, breaking things down, going back to the beginning, really do a good faith effort of root cause analysis, And and don't wait. Right? Immediate review, immediate conversations is super helpful to get on top of these things. You you because oftentimes, you may think you know what the problem is, and you may fix it.

But next month, next quarter, you may be seeing the same thing or that trigger could be worse. Right? So my experience working in revenue cycle, it's usually always more than one issue. It's multifactor that's causing that KPI to trigger.

Okay. Let's move into benchmarking done right.

Benchmarking without context could be misleading. It only tells you where to look. It doesn't tell you what to do.

Right? So there's two different organizations that we were working with, and they had a very similar denial rate. Their percentages and their triggers were very similar.

These were very different specialty groups. It was a professional group.

And so that required a completely different call to action. So what we did is we came in, and we did a documentation and coding review with each of these groups. And during that review, one group, their documentation coding was practically perfect. Right? They they scored really well, above ninety five percent overall.

And, the other group, they didn't do so well. Right? We could tell immediately where they're potentially were, the cause of these denials.

This other group, it took another conversation, and ultimately, what happened is we found that a manager was headed for retirement, had quickly renewed some payer contract. The new manager came in and didn't realize there was this contract language change that removed reimbursement from some of their top codes for the services that they perform. Right?

No will ill. It it just is what it was. Right? Contract renewal. Hey. We've been doing this forever.

Oversight. Things happen. We're all human.

So simply aiming for the average on benchmark data is less than ideal. Right? It can actually come back and backfire on you and put you at audit risk and exposure with DOJ, with CMS, and even with your under with your other payers, it could lead to over underpayment. Right? And when we know that happens, payers are starting to do claw clawbacks.

You know? And in addition, we can't ignore medical necessity. If we just wanna look at a threshold, a benchmark, and and make sure we're within that given threshold, we're not looking at the whole picture. We're not looking at medical necessity for these particular patients. Right?

And there could be mismatches with incentives of meeting these thresholds. So here's some really good examples, the EM bell curve. Right? We know that this is just an average.

Depending on where you get your bell curve data, it could come directly from CMS. That's where that's an industry standard, but we know it's flawed. Right? It's two years behind.

We saw some huge discrepancies when we all moved with the twenty one e and m guidelines and the twenty three guidelines. Right now, we're kind of past that point.

Pediatrics, they'll have pediatric benchmark day data, but most patients that are pediatric age don't have Medicare. Right? So the data is a little bit flawed. Right? So we have to make sure that we look at this data, but we need to understand that we can't set specific thresholds solely on the data alone.

Work RVUs is another area that oftentimes health care organizations are using as a financial success. Right? They're paying their providers on work RVUs or their the CFOs are are looking at that to identify their finances.

Well, just looking at work RVU RVUs alone is a problem because that was never the intention of the work RVU. The work RVU was designed to identify the physician work effort, so basically kinda track their production.

Over time, as an industry, we've just kind of moved it over to finances. Right? I'm not saying you can't do that. I'm just saying that you need to look up more than just work RVU. Right?

Organizations that rely too heavily on this benchmark, they're not taking into account the uniquenesses about individual practices, payer guidelines and rules, bundling and unbundling, all of those things that come into play.

Alright. We reviewed KPIs and benchmarking. Now let's talk about how sometimes these KPI triggers and benchmarking thresholds can collide.

KPIs don't operate in isolation. Right? You're starting to get this theme that I'm sharing with you is that their KPIs aren't just, owned by one department or one individual. For example, billing doesn't own accounts receivable, right, alone. Accounts receivable is going to have impacts from the beginning of the revenue cycle. Coding doesn't just own accuracy.

Documentation is part of that.

Tools that we use is part of that. The front end doesn't just own the clean claim KPI. Right? Revenue cycle just doesn't work that way.

It's an ecosystem in and of itself, and there's it's constantly moving and churning its cycles, and there are so diff different interdependencies across your organization. Right? So, again, we need to look at KPIs and these benchmarks or triggers and understand where those interdependencies are so you can make smart changes. So let's talk about this example.

This is a real scenario that we worked with a different physician group where, independently, they decided they wanted to increase their work RVU by twelve percent. That was a group decision that they decided to do, and they met that.

However, they started to see that their net collections went down. So this is kind of that that trigger that we needed to watch for. When we went in and did some root analysis, we found that the physicians were rushing their documentation. They they felt like they needed to see more patients to increase their productivity, to increase that work RVU. They were rushing through their documentation, and there were key things that were being missed.

They weren't documenting data and interpretations that they were doing.

They weren't documenting comorbid conditions and how it related to the condition the patients were treating. We also found a misalignment with the coding staff.

They were utilizing established patient, total visit times for new patients. Right? So little bit of an oopsie there.

Clean claim illusion. This is another real life example where we had an organization that wanted to improve their clean claim rate, and they they were currently at, ninety one percent, which isn't bad, but certainly there's opportunity for improvement. And they set a goal, a trigger of ninety seven percent. So after, you know, a quarter or so, they achieved that. They celebrated. They you know, lots of things were happening, but then very quickly, they started to see their denials increase.

They asked us to come in and help do a revenue cycle analysis, and we discovered that they were allowing they had removed some edits in or and or altered some claim edits that allowed claims to go through without having some of the claims stopped by a coder and have a coder review. So a lot of these were being impacted associated with ENIMS and modifier twenty five. So you can see how there's that interrelationship that starts at the beginning, not just at the the end, the billing.

In this example, we had a group that came to us, and in the past, they largely compared all of their providers, even their pediatric providers, to the CMS in a benchmarking table. And we all know what happened with that. Right? That it's not it's it's a threshold.

It's an average. It is not an absolute. Well, long story short, they they were inadvertently overcoding some of their levels because certain groups and providers, there was a mismatch between aligning with that bell curve exactly that, there's some misinformation that happened. Right?

And, this occurred just about a year before it got caught. And then we had to reeducate and, start utilizing some of the MGM a MGM data, to get realigned with what that threshold might look like for some of these other specialties.

The AR versus write off trade off.

So this is a good example of where an organization wanted to improve their days in AR, and leadership came in and said, okay. We feel like our billers are wasting a lot of time on these small balances.

Let's go ahead and have them write them off. We feel like we're not we're not gonna win these leftover balances, and so they rewrote their policy, rewrote their approval levels, and what happened after that? Right?

Their collections, their cash flow started to decrease.

They went back and did a root cause analysis. This was something that a client reported to us, and they identified that they were inadvertently including in that dollar amount threshold some collectible items. Right?

Data that actually were really collectible. There was some patient balances in there. There were some other collectible items with a little minor effort, make a change, resubmit the claim, and they could have could have gotten paid. So they had to readjust that policy.

Right? Because they initially, they just didn't think of everything that potentially could have been impacted.

So don't just monitor your KPIs. Understand them. Understand how this health care rev cycle equal ecosystem works together.

Alright. Let's move into this ninety day action plan. I I carved this out into a thirty, sixty, and ninety day plan for you.

Most organizations, they move too quickly into, here's our KPIs, here's our triggers, let's take action. Right? We just saw some from some of these real life scenarios that it's worth your time and effort to do some data collection. Make sure you're segregating your data.

You understand your data. You understand your organization so you can really set and define the KPIs that you want to to monitor. You you don't always want to, or have time to look at everything all at once. Right?

But identify those KPIs that really matter to your organization where you think you can really make an impact and identify what that best trigger might be. Right? So this thirty day is all about clarity and identifying where your triggers are. So you're you're thinking and working smarter.

During that next sixty days, what you wanted to do do is monitor. You set your KPIs you wanna really monitor closely. You set what your triggers are, and now you wanna look at it. Right?

You wanna look at it often, not just at the end of the month. If you have the capability, run your reports, ask your your billing department to run some early reports, and really keep a pulse on. And if you're seeing triggers start to hit a little bit, ask questions like, is this a front end issue? Is it a coding documentation issue?

Is it a billing issue? Is it a quality issue? Is it a behavioral issue? Start thinking and asking and looking into it, instead of just waiting.

And, again, you can't do everything. Right? We how busy you you all are.

So maybe you could ask yourself as you're monitoring these KPIs and triggers, what makes my cash move? Right? That could be an action item of one of your triggers. If it's impacting your direct cash, then, of course, that kinda trumps and and prioritizes above some of the others.

So make sure that you're just not the only owner of these KPIs and triggers. Bring in the team. Right? It's multifactored. It starts at the beginning. So make sure everybody within your organization understands what you're doing, what you're looking at, and why.

Okay. Your ninety day plan, this is where you start to make smart, impactful changes. K? You've set your your KPIs, your triggers that you're monitoring.

You've monitored them. Now you need to, take on what you've learned in that sixty day period and maybe expand your root cause analysis in this ninety day and make decisions, decide what needs to change. Have a focused approach. Too many organizations, if they identify, oh, it's it's a documentation coding issue.

Let's just educate all the providers. Well, I don't know about you, but if I'm thrown in a group, I might not always recognize where I'm making the mistake. Right? Unless I'm actually called on it specifically, sometimes I I look over it.

We're we're all humans. Providers do that. So make those educational sessions targeted. Right?

Don't feel like you have to fix every single denial. Categorize your denials and work on the ones that are going to move your cash. Right? Let the lower ones kinda sit and rest for a minute. Alright.

Let's move over to the future state.

Proactive prevention is the key to success when you're talking about your KPIs and your benchmark threshold triggers.

Going through that ninety day action plan can really help you and help you as an organization as you bring on your your, different departments and divisions and team into the loop and can really help you once you go through a couple cycles of this, start to think into the future. Right? Sometimes we have to just focus on the bleeding, what's happening today.

But once we get past that, as we're putting these actions into motion and over time, you you need to start thinking about the future. And the future state needs to needs to start with lightening the physician's documentation burden.

K? We know that that is one of the number one causes to stresses, denials, and issues within this health care ecosystem, right, that potentially we have something to that we can do about it now. We have seen a lot of really good success with the ambient scribe tools, with CDI tools that have AI embedded in them and into the workflow now within EHR systems. We know a lot of EHR vendors understand how workflow is so critical now, and we need to, you know, be more efficient with those different workflows. They're starting to come on board and starting to partner with these AI tech companies to help make these necessary improvements that start at the beginning of the rev cycle with documentation. Right?

Using AI technology, any technology for that matter, can introduce risk.

Using AI technology like AmbientScribe, computer assisted coding, or even autonomous coding tools are starting to come out, you are at risk for overcoding. You are at risk for potential hallucinations and potential clinical documentation errors, which is why you need to make sure there's always a human in the loop from start to finish.

Right? AI tools need to be governed, and being governed means keeping the human in the loop. The human in the loop isn't just the responsibility of the tech company. It's your responsibility, right, as an organization. Right? Make sure your coders, your auditors, your billers, your clinical staff, your CVI staff, make sure everyone is involved in vetting the AI technology and understand the different workflows so your selection is going to work within your organization.

There was a recent article by Garner Health that stated part of the reason why there's an increase in denials by payers is due to higher utilization of AI tools. Right? Payers are starting to use AI tools.

They're not immune to these risks that I just mentioned. As we're using and implementing these AI tools, we're not immune either. Right? So we need this layer of governance that's ongoing. Ask these technology vendors, how are you governing your technology? Are you running your technology outputs, whether it's documentation for ambient scribing, coding outputs? Are you on a quarterly compliance program where you're constantly governing those outputs as you're making these ongoing enhancements to ensure the highest quality of accuracy?

AAPC, we're working with a lot of these tech vendors, but there's so much more that we can all do together. You can do internally as an organization, and we can help the overall industry with this governance.

Workflow changes are equally important. Right? My dad, he grew up on a farm. He, was a professor at the university and had a lawn care business for us kids.

And the worst thing I hated when he came and said, hey. That wasn't good enough. You gotta go back and redo it. I hated that. Right? And that really instilled in me do it right the first time. Well, how do we do things the right the first time?

We we need to start changing these workflows, try and lessen the overall burden for the providers as well as the rest of us that are supporting the providers with different workflows that are either in the EHR or workflows that are outside of that. I believe if we can come at this where we're letting the physicians be physicians, having them focus on the patient and focus on their documentation, we can eliminate the majority of those number one reasons for physician burnout. Let coders do what coders are trained to do.

Let auditors and other folks within the organization be that governance and help and support the physicians in that way.

We also need to change workflows where we're bridging the gap between billers and coders. Right?

Revenue cycle leaders, it's not a matter of we just need to collaborate together.

We need to change that and look at it as a team holistically of how can this team be more efficient and change the workflows that matter, eliminate unnecessary steps, upskill each other. All of those things can have a very meaningful impact.

Another change that needs to take place is moving edits to the front end. Right? Billing doesn't own AR alone. Right?

Billing doesn't own reimbursement alone. We need to move all of that to the beginning and work together to solve some of these problems. A a really good thing that you could do is get your CEO and your CFO's buy in on the different KPIs and triggers that would be appropriate and this movement shift to the beginning. And I guarantee you, when they hear what you have to say, they're going to believe you.

They're it's gonna make sense, and they're gonna support you in those those endeavors.

Alright, Cordell.

It's time for q and a. I think we just have a few minutes left.

That is correct. I think we've got time for one or two questions if you're willing and able.

Alright. Let me pull some of these questions over.

Coding denials, are you referring to documentation requests as well? Because payers want documentation for everything nowadays. Oh my gosh. I feel your pain. They absolutely do are requesting documentation more than they ever have.

Yeah. I think coding denials or a delay in getting the payment in the door, I think we need to lump those together. I think whoever asked this question is spot on in that.

So maybe that's another KPI we need to look at is the payer delay and all of these requests for additional documentation. I actually met with a technology vendor last month, and they're developing AI technology where they can review the payer contracts and review documentation requirements. So they'll review the payer contracts, review the on the EOB or letter, what documentation is required, and then review your EHR system or, you know, your release of information stack that you have to make sure everything that's needed is there before you send that information in. Because sometimes you not all the information gets sent in. Right? And it's denied.

Or they make a decision, and sometimes it's really hard to come back from those decisions. So excellent question and point there.

So another question is, are you saying let coders do what they are trained to do? Do you believe in coding and documentation by coders, or do you think providers should be responsible for submitting their own CPT codes?

This is such a great question.

I think providers that have been submitting their own CPT codes, this is going to be a huge shift for them to just say, hey. You're not gonna do it anymore anymore. Let a coder do it. I think there needs to be an evolution in having a thoughtful conversation.

Are your providers that are doing the coding, that are submitting their CPT codes, are they burnt out? Is it stressing them out? Right? Is it an opportunity to say, hey.

It's okay to let that go. Let's have you just focus on seeing the patient and providing documentation. Other providers, they've embraced coding. They know the coding very well.

They're very successful. They may not be stressed about it. Right? So I don't think that there's a one size fits all in immediately changing and making that shift within your organization.

But I bet you if if you worked with your doctors and asked them what's really burning you out, how can we help you? What what could we do to take some of this time and effort away from you? I bet you a lot of them are gonna talk about the coding.

If your coders are only reviewing a sampling, a lot of times you have EHR systems or the autonomous coding that's suggesting the code, and the doctor's like, yep. That looks pretty good, and they are agreeing and pushing it through. All the more reason why you need to have that coder human in the loop for those reviews. So, again, not a one size fits all answer. I think we just need to slowly make that shift and make the shift when it's appropriate.

One final question.

Oh, nope. Sorry.

Let me see if I can get it really quick, Cordell. Lag days, KPI. Are you using calendar days or business days? I've seen organizations do both.

They'll have a separate KPI for business days versus the calendar days. So you might wanna in your sixty day thirty and sixty day plan, look at both and kinda see where you end up after your your ninety day review there. Alright, Cordell. I'm gonna turn it over to you.

Okay. Well, thank you very much, Stephanie, for the presentation, and thanks everyone for joining it.

We are going to be setting out, and just as a reminder, the slides and a recording of this presentation in just a couple of days, so keep an eye out for that. And finally, if you're interested in Stephanie and her team helping solve some of the challenges or building KPIs or identifying the root cause analysis for some of the issues, in your revenue cycle that you're experiencing, you're gonna be able to let us know on a survey that's going to pop up in your browser just as soon as we shut this webinar down. So thanks again, everybody, and we hope to see you next time.