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From the Consultant’s Corner 12/19/17

Revenue Integrity – A Critical Factor for Revenue Cycle Success

Most healthcare organizations recognize the need for improving the efficiency and effectiveness of their revenue cycle operation. Efficiency refers to reducing the operational costs associated with billing and collections. Staffing and systems are the major expense categories. Effectiveness relates to maximizing cash collections and improving the timeliness of which that cash is collected. Revenue Integrity adds a third dimension to the discussion of revenue cycle performance. Revenue Integrity refers to the thoroughness, timeliness, and accuracy of the charge capture and coding processes.

An effective revenue integrity program ensures that every billable clinical activity is properly captured, coded, and billed in a timely manner. This starts the process by which clinical services are converted into cash.

The benefits of a revenue integrity program include:

  • Reduction in lost or missing charges resulting in enhanced charge volumes.
  • Reduction in charge and claim lag resulting in accelerated cash collections.
  • Improved clean claim rate resulting in reduced costs of collections and accelerated cash collections.

Traditional revenue cycle operations have historically been split between “front-end” or patient access-related activities (i.e. registration, scheduling), and “back-end” billing and A/R management functions. A revenue integrity program incorporates clinical workflow, and the actions and concerns of physicians and nurses into the revenue cycle. Clinical documentation, diagnostic and procedural coding, and the submission of charges are all generated within the clinical workflow, yet performance often appears on back-end revenue cycle reports. The result too often is that accountability falls on the billing office, yet the real performance improvement opportunity rests outside of a billing director’s direct control. Engagement of clinical staff into the overall revenue cycle truly integrates clinical operations and financial performance, assigns accountability to the proper source, and provides appropriate and actionable education to capitalize on improvement opportunities that benefit the entire organization.

As revenue integrity programs have matured, revenue cycle and financial leadership have incorporated new Key Performance Indicators to monitor the integrity of their revenue. These metrics provide a more granular analysis of common measures such as denial rates and A/R days, in order to address performance improvement opportunities directly at their source. Examples of metrics used to measure revenue integrity performance include:

  • Medical Necessity Denial volume and charges.
  • Charge lag and claim lag, and the degree of manual intervention to resolve pre-bill coding and claim edits.
  • Discharge Not Final Billed.
  • Documentation that supports 100 percent of all charges.

As referenced earlier, monitoring these indicators would be a fruitless exercise if physicians and nursing staff were not engaged in the process. Billing managers alone would have minimal ability to reduce medical necessity denials resulting from lacking diagnosis information. Reviewing this information with physicians, informing them of the financial impacts of lacking information, and engaging the EHR teams to optimize clinical documentation tools would be a much more effective approach that benefits all parties, including the patient.

To develop a sustainable revenue integrity program, or to improve the effectiveness of an existing RI program, I recommend the following activities:

  • Define goals, objectives, and scope for the program.
  • Develop a project plan.
  • Track and implement the project plan.
  • Design the organizational chart, with resource requirements.
  • Define roles, skillsets, and workflows within RI.
  • Create relevant RI job descriptions for human resources.
  • Identify and acquire tools needed for the department’s optimal performance; e.g. software coding references, library of coding books.
  • Develop RI workgroups and a steering committee to include key leaders from IT, clinical operations, compliance, RCM, and finance. (Depending on specific objectives, you may want to include RI SME’s and analysts.)
  • Identify and train RI charge capture resources (Charge Guardians) by departments and/or clinical product lines.
  • Develop best practice RI policies and procedures, to be reviewed annually and revised as needed.
  • Define baseline benchmarks and performance indicators to measure and trend performance over time.
  • Develop and implement RI training program content and timelines for RI analysts and auditors.


Brad Boyd is president of Culbert Healthcare Solutions.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 10/12/17

Addressing Physician Burnout – It’s Not Just the EHR

Physician burnout continues to rise in all specialty areas. Fifty-five percent of family medicine and internal medicine physicians who participated in the 2017 Medscape Lifestyle Report reported burnout. Fifty-nine percent of emergency medicine and 56 percent of all Ob/Gyn participants reported burnout. While EHRs are often credited as a major contributing factor to physician burnout, a deeper analysis of the root causes of physician burnout is necessary in order to address this challenge.

Administrative burdens placed on providers have accelerated with a variety of regulatory requirements including MU, ICD-10, and now MACRA. Population health management, value-based reimbursement, and coding scrutiny will continue to influence clinical workflow design and EHR usage. A poorly developed or executed EHR implementation approach will absolutely magnify these challenges. Practice leadership should engage their physician community to separate those EHR-related issues, which can be improved upon through optimization initiatives, from the administrative burdens that require alternative solutions in order to have a meaningful impact.

Up until the past two years, our EHR optimization engagements primarily focused on client goals of improving physician productivity. Increasingly, a common driver of most recent engagements is to reduce or eliminate the time physicians spend on administrative, non-clinical tasks, which contribute to physician burnout. These client administrators recognize the administrative burdens placed on their physicians, and they are keenly astute to the costs and disruptions of recruiting and onboarding new physicians. It is simply more cost effective to address physician burnout proactively, than to replace them.

I recommend several tactics below for provider organizations to start the process of addressing physician burnout. There is no silver bullet, but engaging physicians and making real, sustainable efforts to improve their satisfaction will have meaningful impacts.

1. Inefficient workflows and poor EHR design/navigation are far too common. Unfortunately, many vendors accentuate this problem by well-intended yet unproven “best practice” workflow recommendations. Engage your clinicians to understand the bottlenecks and redundancies of their current workflows. Clinical workflow optimization comprised of using all clinical resources to the maximum level of their licensure is a good first step.

2. EHR personalization, focused on enhancing clinical documentation, order entry, results management, and messaging is another best practice. Additional benefits of EHR optimization include enhanced revenue integrity and reduced charge lag, which accelerate cash collections.

3. Provide continual training opportunities for physicians and nurses to introduce and reinforce advanced tools that accelerate clinical documentation.

4. The use of scribes is not a new concept; however, it is a relatively high-cost solution for shifting the administrative tasks off a physician’s plate. Several models of virtual scribes have started to gain traction and are worthy of consideration as an additional tactic to ease burnout for your most at-risk providers. There are different flavors of these services, each with different value propositions and cost considerations. By offloading most of the EHR data entry to a virtual scribe, more face time is spent with the patient and encounters are closed (and billed) at the completion of the patient visit.


Brad Boyd is president of Culbert Healthcare Solutions in Woburn, MA.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 8/3/17

Crossroads Between Physician Productivity and Burnout
By Nancy Gagliano, MD

The scenario is all too common. Practice expenses are rising while physicians are asking for reduced clinical sessions and productivity requirements. Everyone is worrying about physician burnout. Increased and shifting regulations have dramatically increased the complexity of delivering patient care. MACRA, EHR adoption and usage, coding compliance, quality monitoring, and prior authorizations have all amplified the administrative burden that has fallen disproportionately into the hands of physicians. Physicians, particularly, primary care doctors, are spending close to half of their time performing administrative tasks including documentation. This article reviews physician motivators and dissatisfiers, and provides concrete suggestions for improving physician satisfaction while setting up a foundation to enhance productivity.

Physician burnout has three core components – emotional exhaustion, depersonalization, and a low sense of personal accomplishment. It is estimated that close to half of physicians today are burned out. Burnout is associated with depression, substance abuse, suicide, and divorce, as well as reduced patient satisfaction and quality.

Understanding core motivators that affect physician satisfaction is essential to enhance the work environment to support physicians. We all have intrinsic and extrinsic motivators that contribute to our job satisfaction. The intrinsic motivators for physicians are the “Why I went to medical school.” A typical physician finds satisfaction in providing high quality care, learning and discovery, delivering excellence and “making a difference.” Certainly, all healthcare organizations value these core elements, which are often highlighted in mission statements. However, is it possible that these values are not communicated and reinforced frequently enough to providers? Instead, is communication from business lines focused on regulations, revenue, quality reports, and the multitude of demands facing healthcare today? Organizations should step back and commit to a balance of communications focusing on business imperatives and embracing, highlighting, and recognizing its core mission.

In addition, business units should be aware of these attributes when working with physicians. For example, the revenue cycle team may think of EHR documentation as a tool to support compliant coding and charge capture. However, physicians value their documentation as a mechanism to share clinical information with their colleagues to enhance patient care, and view coding and charge capture as a burden. It is important for coding experts and the billing staff to acknowledge and reinforce documentation’s core purpose when working with physicians.

Let’s move on to external motivators that affect physician satisfaction. These factors include autonomy, resources, community, leadership, and appreciation.


Autonomy should be broken into three areas – financial, environmental, and clinical. We have come a long way from the independent physician running their own practice, determining how hard they want to work, where they work, who works in their practice, and the care that they deliver. Today, many physicians work in practices managed by administrators and arrive for their assigned session hoping that the same medical assistant is there to support them. Standardization is essential for efficiency. No longer are diplomas or family pictures hanging in exam rooms. Physicians have lost their environmental autonomy.

Although physicians can impact their earning potential through specialty selection, many physicians are now salaried with only minimal ability to control their earnings. Overall, they have lost their financial autonomy as well.

Finally, they are losing their clinical autonomy in having to deal with quality programs reports, guidelines protocols, and prior authorizations. We are telling physicians that the quality of care they provide, without these programs, is inadequate. Given that a typical physician spends a decade on education and training, we should be careful when communicating these programs and requirements, as they can be perceived as insults. When working with physicians and asking them to change behavior, it is important to be aware that autonomy is important and standardization is not cherished. Prioritizing those activities that truly require standardization and presenting the value of standardization is critical.


Unfortunately, with the complexity of healthcare increasing, tasks falling onto physician shoulders have increased. In addition, the EHR, because of increasing documentation requirements and inbox tools, has increased the time physicians spend doing tasks previously done by others. There are numerous opportunities for organizations reduce the administrative burden and increase productivity, including:

  • Clinical workflow and EHR optimization.
  • Virtual scribes.
  • Centralizing access.
  • Appropriate use of clinical support staff.


Although many physicians are independent by nature, the importance of community is often overlooked. Gone are the physician-only lounges and lunch rooms, which were eliminated for political correctness. Dining with colleagues has been replaced with catching up on notes and paperwork before the afternoon session. We have lost sight of the fact that these venues gave physicians opportunities to discuss emotionally and intellectually challenging cases. Physicians no longer have easy access to their colleagues to unburden themselves from the weight of patient responsibility, which, arguably contributes to burnout.

Look for opportunities to reinforce this in the physician community. Consider holding physician team meetings to share information, whether it is coding review, financial reports, or other administrative issues. It provides an opportunity to support physician community as well as learning from one another. While a physician group meeting may be viewed only as opportunity for venting and could potentially be difficult to manage, the venting may, in the end, result in greater buy-in.


While organizations acknowledge needing excellent physician leaders and champions, many physicians do not excel in leadership roles given their autonomous and independent nature. Typical challenges include consensus building, active listening, inspiring, dealing with conflict, and mentoring. Organizations should resist putting the “physician IT geek” in technology roles or solving a productivity reduction request by giving a leadership position. Another common mistake is selecting a physician leader based on how their peers perceive them. While it is vital that their peers respect their clinical leaders, being respected for high quality care, research, or productivity are not necessarily the attributes that make the physician an excellent leader.

Once physicians are selected to be leaders, organizations need to focus on leadership development through external and internal programs. There are numerous external programs available that can provide a boost in learning. However, for larger healthcare organizations, it is advantageous to develop an ongoing internal leadership forum that will provide physician leaders with skills reinforcement and an opportunity to interact with peers in leadership roles across the organization.


Physicians are similar to others in valuing appreciation. Although a full waiting room provides a sense of satisfaction, appreciation from colleagues is very gratifying. While balloons, candy, and flowers may not be appropriate recognition tools for physicians, peer and colleague recognition programs are. Regularly highlighting and celebrating clinical excellence, compassionate caring, teaching, and research should be an integral part of an organization’s culture.

In summary, physician burnout is a real phenomenon that we should all take seriously, particularly in an era of physician shortage. Understanding internal and external motivators of physicians is important when working with physicians. We should reflect on how we work with physicians to make sure our approach taps into their intrinsic motivators. In addition, there are numerous opportunities to create a positive environment to maximize physician productivity and satisfaction.


Nancy Gagliano, MD is CMO at Culbert Healthcare Solutions in Woburn, MA.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 6/6/17

Leverage MACRA to Support Long-Term Strategic Goals

MACRA is largely understood throughout the healthcare industry, and the majority of provider organizations are in the process of implementing their go-forward strategies. With 2017 being a transitional year, it is an essential time for healthcare organizations to think of the bigger picture and develop a long-term roadmap for 2018 and beyond.

A truly strategic approach to MACRA leverages the program to reinforce the broader goals of an organization. For example, the Clinical Practice Improvement Activities (CPIA) category details over 90 activities that can not only be used to determine your MIPS Composite Performance Score, but more importantly, support the strategic objectives of your practice. Many of these activities are likely on your project wish list.

CPIA is the area in which there is greater flexibility to utilize the MACRA program to drive operational and cultural changes. Although CPIA will only account for 15 percent of the overall MACRA score in the first year, these activities provide real opportunity to differentiate and grow your practice. For example, Expanding Patient Access is a priority for most organizations. These activities benefit the patient, but also increase practice revenues and resource productivity.

Within the nine CPIA categories, there are over 90 activities an organization can utilize, each earning a “high” or “medium” weight. The nine categories include:

  • Expanded patient access.
  • Population management.
  • Care coordination.
  • Behavioral and mental health.
  • Beneficiary engagement.
  • Achieving health equity.
  • Emergency preparedness and response.
  • Patient safety and practice assessment.
  • Participation in an APM.

An example of a CPIA activity within the Expanded Patient Access category is the use of telehealth, which is rapidly gaining popularity. While today’s reimbursement landscape regarding telehealth poses some ROI challenges from an investment perspective, it is a major patient satisfier and it also provides an organization with a real learning opportunity.

Within the Care Coordination category, CMS’ Transforming Clinical Practice initiatives are highly-weighted initiatives that also support other MIPS categories, such as quality. These are additional examples of how to strategically identify performance improvement activities to support the betterment of the practice – not just MACRA compliance.

How can an organization be sure which CPIA activities are right for them? The best approach is to identify which activities are aligned with the strategic goals of the organization. Every organization faces limited resources and competing priorities, so select activities that will achieve a strategic purpose. Also, many organizations are likely pursuing many of the CPIA activities independent of MACRA. Continuing these initiatives will not require a re-allocation of funding.

Healthcare providers have been inundated with federal regulations over the past several years (Meaningful Use, PQRS, value-based care, etc.). Selecting CPIA activities that are aligned with the strategic goals of your practice is an optimal approach that helps minimize the operational and financial burden of MACRA.


Brad Boyd is president of Culbert Healthcare Solutions in Woburn, MA.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 4/6/17

Getting the Lay of the MACRA Land This Year and Next

Despite the change in administration, MACRA, with its Quality Payment Program, is here for at least awhile, having received tremendous bipartisan support in Congress. Because there is significant upside and downside Medicare payment risk, it is essential for all providers to prepare for this new QPP.

Who Participates

If your organization is actively participating in advanced Alternative Payment Models, then the participation in this QPP is covered. However, only 10 percent of providers fall into this category. If there are few Medicare charges or patients, or a new Medicare provider, you do not have to participate. Therefore, most physicians and practice groups will fall under the category of participating under the Merit-based Incentive Payment System program.

Core Components

While MACRA is very similar to the PQRS, Value Modifier, and Meaningful Use programs, it attempts to align all three programs via four components:

  • Quality (numerous metrics to choose from)
  • Resource Utilization (cost will not be a factor in 2017 and only 10 percent in 2018)
  • Advancing Care Information (use of an EHR, with numerous metrics to choose from)
  • Clinical Practice Improvement Activities (process improvement – demonstrate core capabilities plus a few additional metrics to choose from)

Performance in these categories is weighted and begins with 60-percent quality, 25-percent advancing care information, and 15-percent process improvement. In two years the weighting will change to 30-percent quality, and 30-percent resource utilization, while advancing care information and process improvement will stay the same at 25 percent and 15 percent, respectively.

Just as with PQRS, there are still multiple ways to report. You can report as an individual provider with an NPI/TIN or as a group of physicians under one TIN. Reporting can take place via claims, registry, CMS website, Qualified Clinical Data Registry or through the EHR system.

There is a significant upside and downside to starting at 4 percent of fee scheduling and ending up at 9 percent over the next four years. This will be based, in large part, on balance budget. Therefore, there will be winners and losers, and providers will essentially be competing against one another. Above all, there is a $500 million pool of money to be shared by the exceptional performers.

What is Important for 2017?

In recognition of the complexity of a new program, many individuals and practices that have not previously reported will begin reporting. CMS has decided that the threshold to avoid a negative penalty should be very low for 2017. As long as one metric – a quality metric, performance improvement project attestation, or the minimum standard of EHR use – is met, the provider/group will not be penalized for their 2017 performance. Because very few will be penalized, there will also be little upside gain. Providers can use 2017 as a year to develop overarching strategy and infrastructure, rather than worry about whole-scale reporting.


Typically, many practices put their finance and IT departments in charge of selecting measures that are feasible to report on, reporting, and ensuring accuracy. However, this is a good time for organizations to step back and take a broader look at their organization, which typically includes:

  • CIO – Meaningful Use
  • CFO – PQRS
  • CMO – Quality
  • Population Health Lead
  • CMIO – EHR Deployment and Optimization

This program provides an opportunity to pull together these leaders and consider organizational strategies. It allows the leadership to then pick metrics and projects that will support their long-term vision, and focus resources on those areas that will most likely help the broader quality goals of the organization. This would create sustainable improvement and optimize performance.

This year is a great one to select a few metrics that are easy to perform to get one’s feet wet and develop a strategy and infrastructure to support MACRA and QPP for the long run.


Nancy Gagliano, MD is CMO at Culbert Healthcare Solutions in Woburn, MA.


Jenn, Mr. H, Lorre

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