Donna Graham uses her strategic planning background to guide revenue cycle initiatives at the MetroHealth System in Cleveland.
She is the system's executive director of revenue cycle and has worked for academic medical centers, multispecialty healthcare delivery systems and medical practices. She also led a strategy firm that serves U.S. hospitals and providers.
Becker's Hospital Review recently spoke to Ms. Graham about how MetroHealth is handling revenue cycle challenges and advice she would give to other hospital revenue cycle leaders.
Editor's note: Responses were lightly edited for length and clarity.
Question: What is one thing that piqued your interest in becoming a revenue cycle leader?
Donna Graham: Being a revenue cycle leader is to be able to thrive as a change champion. All patient revenue-producing initiatives, whether via claims adjudication or moving into value-based pricing, impact my team and me. As a revenue cycle leader, it has been said that we can manage the front end, middle and back end or any variation of the same. That is old nomenclature. We are caregivers. We navigate the complexities of healthcare and promote preventive care and the continuity of care. Whether managing or mentoring, I think of revenue cycle leaders as a Peloton [bicycle]. We are the hub. The spokes represent the areas of integration impacting healthcare systems, and the handlebars are the consumer providing the direction we need to take to meet their needs, their expectations and their values. No point in discussing the seat, because as revenue cycle leaders, if we sit down, we are at risk of slowing down.
I have been able to be strategic, innovative and a driver to support community members before they become patients. Whether through our 38-foot "Enrollment on Wheels" RV, supporting our patients 24/7 within our four hospitals and 26 clinics in person, our tele-financial coordination or being an empathetic ear within our patient advocacy contact center, we are able to positively engage, embrace and be an integral influence for a healthier community. By sharing knowledge with colleagues, I have been able to collaborate with government relations to lobby on behalf of my hospital, which could also positively impact hospitals around the country. I am fortunate to have what I refer to as a triad of experience: clinical operations, information technology and finance. This has helped me immensely because I can understand the strengths and opportunities for enhancements throughout our healthcare system and others.
Q: What is the biggest challenge you face as a revenue cycle leader today and how do you address it?
DG: The degree of discussions around denials continues to be driven by the magic formula of what is the best software, who would be best to manage rejections, what are the most effective ways of working with payers, and, of course, how do we get paid with a single touch versus appealing. Last year, I promoted a change in our thought processes. We no longer use exploitation; we emphasize exploration. Instead of a denial management team, we have strategic appeal specialists. We no longer refer to denials. Denials are those claims with adjustments. We refer to the [explanation of benefits] nonpayments as rejections, and our mantra is, "With a little bit of SAS, we have the momentum to avoid rejections."
I also created a collaborative group with providers, management and support teams to move toward centralization. We call it the STAR Program, for Scheduling, Technology, Authorizations and Registration. This facilitated measuring what multi-diverse teams could improve and what technology could be optimized. A payer assessment report was created for our large payers so we could share the positive and negative impact their processes had on our own operations. Three major areas were: turnaround time for claims adjudication and percent paid the first time; rejections that eventually were overturned based on appeals and pure tenacity; and authorization requirements outside of CMS rules which typically set a precedent. Within one year of this program, we realized a reduction in rejections through avoidance ranging from 21 percent to 50 percent depending on the area of concentration which included infusions, physical therapy, cancer care and other outpatient services. Our payers are aware that we are collaborative and relentless. This is facilitating a paradigm shift for many of them based on promoting integrity and trust.
Q: Federal officials have been working to address price transparency. What is your take on the best price transparency approach to reduce costs and meet patients' expectations?
DG: For more than a decade or so, we have listed our charges for the most frequently used services so that patients could query those. But in 2015 we launched a self-service portal where patients can go and put in their own insurance information and get out-of-pocket estimates. It helps patients understand what their out-of-pocket cost is because charges are not helping patients understand what their risk-sharing is. The portal is very easy to use. We give estimates in English and Spanish, and patients can connect with one of our representatives anytime they want. They can do it through email or phone, but we're working on setting up chat right now as well. That's been a great experience for our patients and for us because they're much more advised.
I believe that price transparency is about being open with the patient, making sure they understand what their personal liabilities are, having the information available to them and then also having somebody help explain and navigate them through why their out-of-pocket cost is what it is. We also really work with our patients in helping them determine how to make choices.
Q: If you could pass along one piece of advice to another hospital revenue cycle leader, what would that be?
DG: Stay ahead of what's going on while managing the day-to-day tasks. You can't do one without the other. Vision and sustainability require integration – not sequential steps. With the revenue cycle, you have to be tenacious, you have to be passionate, and you have to be unyielding with vision so you're always ahead of the game. You can't be hesitant to be a pioneer, and you have to persevere. Sometimes it's very difficult when you're in the revenue cycle to get people to understand — and to help promote — the idea that efficiencies to optimize cash collections begin with everyone in the healthcare system. If awareness is not fostered with the patient prior to service and expectations are not managed by both the healthcare system and patient prior to service, optimized cash collections cannot be realized. Providing education for providers, clinical teams, management and support staff ensures consistent and clear information throughout the health system and for the patient. It's also critical to provide easy, accessible tools on the hospital website so all employees who have patient contact can quickly address questions regarding estimates, financial coordination/assistance, billing and other financial issues. The response may be as simple as providing contact information or a link to the healthcare system website. Ending thought: Collaborate with everyone to strategize, develop, execute and provide the patient with an overall positive patient experience. When a patient says "thank you" during collections or financial assistance, that's success.
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