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From the Consultant’s Corner 8/7/19

Patient Access Centralization – Far More Complicated Than Anticipated
By Nancy Gagliano, MD


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

Over the last decade, healthcare organizations have implemented centralized access centers with the promise of a panacea to improve patient satisfaction, access, volume, revenue, and all that ails ambulatory operations. Numerous articles have espoused the value of this approach. Unfortunately, organizations are struggling with numerous challenges, having underestimated the complexity involved in running a successful patient access center.

The wide variety of challenges are not easily covered in one article. This article will summarize and highlight common opportunities. Over the next few months, I’ll dive deeper into these challenges, highlighting considerations and recommended solutions. Topics will include:

  • Scheduling templates and governance.
  • Technology and telephony.
  • Staffing and service level agreements.
  • Establishing a patient access center approach.
  • Self-service – where the future lies.

“Centralized Patient Access” does not have one clear definition. In some organizations, it defines the approach to registration and insurance verification. In other organizations, it includes scheduling and referral management. In some, it also includes pre-authorizations and nurse triage. Without a clear short- and long-term vision, organizations struggle with whether this is a finance or an operations unit. When the initial foundation and governance is not clear or aligned, it leads to broader challenges as a centralized approach is expanded. In some organizations, we have seen two central access groups – one for financial-related activities and the other for patient clinical activities, creating unclear accountability. Other organizations have one center but are challenged because of matrixed responsibilities and structure.

Scheduling: A common scenario includes scheduling staff centralized into pods of expertise responsible for registering and scheduling patients. Patients, in theory, will be evenly distributed to all available providers, filling any open slots, and providing access quickly to patients, resulting in increased patient satisfaction and overall volume. While organizations are aware this works best when schedule templates are simplified with clearly documented protocols, the hard work of obtaining provider buy-in and changing their schedule templates is often not completed due to provider resistance. Without simplified schedules, the patient access center often makes errors as well as ends up with unused slots in schedules. Without easy access to talk to providers, schedulers cannot fill unused slots for “different” patient types. It is often best for central access centers to start with more general specialties, such as primary care, and then add complexity associated with specialties as the foundation for success is established.

Governance: An opportunity often underappreciated is the need for a governance model that has accountability for both the performance of the central access unit and dependent clinical operations components. For a centralized unit to be successful, a collaborative dyad between the practices and the central unit is required. An organizational approach to scheduling templates, visit times, provider availability, and bump rules needs to be defined and managed. Practices, in turn, need to be assured of appropriate staffing, training, and performance of the centralized unit. Working together through joint governance creates the collaborative approach necessary for the foundation of success.

Technology and Telephony: There are numerous third-party vendors available to support effective call center operations. Many organizations leverage telephony and provider matching systems already in place. However, for efficiency and quality, additional systems can be extremely helpful. I have seen organizations have too many systems, too few systems, poorly leveraged systems, as well as a  lack of internal expertise to maximize the use of technology.

Staffing: Appropriate staffing for call centers is quite complex. Turnover is often as high as 30% – higher than ambulatory practices. Replacement staff tend to lack training, experience, or exposure to the clinical setting, and are therefore less efficient and prone to errors. Given high turnover, most centralized call centers are short staffed, particularly on Mondays and Tuesdays, in addition to most mornings, which see peak call volumes. Appropriate staffing is also dependent on which specialties are included in the access center. The more specialized the departments are, the more complex access support is, requiring a higher level of staff skill.

Us/Them Mentality: When practices have their staffing cut to support a central unit, it commonly sets up tension between the two. Practices may want all calls to be handled centrally and are often slow to respond to calls from the call center in need of support and clarification. Practices may undermine the central unit by providing patients with a “back number” to the practices. Or practices will avoid scheduling any patients, such as follow-up when leaving their visit, and refer all scheduling events to the call center. In turn, call centers voice frustration on calls they receive that may not technically be their responsibility, such as medication refill requests or complaints that the practice hasn’t returned the patient’s calls. The antagonism is typically not anticipated or realized until the center is underperforming and improving relationships is difficult.

Patient Satisfaction: While patient satisfaction and consumerism are often a core rationale for centralized patient access centers, underperforming central access may worsen patient satisfaction. Poor response times, handle times, errors, and lack of expertise may lead to dissatisfied patients who find back channels to the practices to get their problems solved. Subsequently, providers and practice leadership, vent their frustrations to organizational leadership.

Referring Providers: An effective patient access center is designed to efficiently handle referrals to minimize leakage and reduce the work by outside practices to schedule their patients. Unfortunately, many call systems are still working through faxed referrals, resulting in only about half of the requests ending in actual patient visits. To complicate matters, most organizations do not have an efficient tracking process to inform referring providers of complete or incomplete referrals.

Cascade of Challenges: The result of an ineffective patient access approach is a cascade of challenges. The central patient access center is challenged in meeting call demand and is fraught with scheduling errors. The practice staff spend time cleaning up schedules, rebooking patients, and dealing with frustrated patients. Because practice administrative staff numbers have been transferred to the central unit, the time spent in “clean-up” precludes practice staff from supporting in-office patient flow and other patient needs. Subsequently, providers are less efficient, frustrated with the central unit, and often request being removed from the central until. The overall result is frustrated patients, providers, practice staff, and access staff without significantly increasing access, productivity, or reducing costs.


If operating a superb patient access center isn’t challenging enough, most organizations initially set up their centers for phone-based interactions with patients. Now access centers are transitioning to multi-channel communications, because patients want the ability to communicate by phone, text, email, and chat. The next goal for organizations is to support patient and referring provider self-service. However, without setting the above foundations, self-service will only be a vision for the future rather than a near-term reality.

In summary, operationalizing a patient access center is extremely challenging and many organizations are looking for ways to improve performance, patient satisfaction, and provider engagement. While there are no quick fixes, organizations should assess their vision, governance, provider scheduling approach, technology, and staffing. Stay tuned for deeper dives into these topics.


Jenn, Mr. H, Lorre

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From the Consultant’s Corner 5/23/18

Single Billing Office Planning & Design
By Brad Boyd

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


Consolidating professional and hospital revenue cycle functions into a centralized Single Billing Office structure presents several benefits. The most significant include:

  • Enhanced patient experience through the reduction in statements and simplification of customer service.
  • Reduction in statement costs.
  • Improved self-pay collection performance.
  • Staffing and operational efficiencies.

The ability to capitalize on these benefits is largely dependent on an organization’s ability to manage risk associated with organizational change. An effective planning and design framework involves three separate but integrated planning activity components.

The first step is for an organization to conduct an SBO risk and readiness assessment. Based on the findings of this analysis, an organization is better prepared to determine the scope of their initial SBO capabilities. This is known as the SBO design. For many organizations, SBO represents the consolidation of patient statements and the centralization of customer service operations. Professional and hospital billing teams remain separated, with two separate leadership teams, typically reporting up to one revenue cycle executive representing the health system.

At the other end of the centralization spectrum, some organizations fully integrate their billing teams into one cohesive entity responsible for claims submission, denial management, A/R management, revenue integrity, self-pay, and customer service. This involves a greater degree of transformation – the benefits and risks of which need to be fully understood and planned for in the design process. The final step, the SBO implementation roadmap, coordinates all implementation tasks into a comprehensive execution plan.

The intent of this post is to share lessons learned and highlight tactics that have assisted organizations in effectively aligning their SBO initiative with the strategic goals of their institutions. A thorough planning process is necessary to effectively mitigate the various risks in order to enhance both patient satisfaction and financial performance.

What follows is a best-practice approach for successful SBO planning and design.

Step 1: SBO Risk & Readiness Assessment

The goal of an SBO risk and readiness assessment is to clearly identify and understand the variances, or gaps, between professional and hospital revenue cycle operations. These gaps must be addressed to diminish disruptive change and decrease risks to ensure a successful transformation effort.

There are four key risk areas to assess and evaluate:

  1. People: R the current state of hospital and professional billing team sizes, structure, job descriptions, compensation plans, and competencies to support current operations and future-state SBO requirements.
  2. Process: Review of processes, policies, and procedures related to hospital and professional billing operations.
  3. Technology: Conduct a high-level review of the system build that supports self-pay management and customer service (i.e., workqueue design, clearinghouse capabilities, real-time eligibility, including propensity to pay and payment estimation tools), and any additional third-party solutions supporting the organization’s revenue cycle systems.
  4. Culture: Conduct a cultural assessment to determine the organization’s ability to adapt to change.

The risk and readiness assessment should result in a formal document that includes the following:

A. Current-state assessment of professional and hospital billing operations:

  • Revenue cycle-related policies and procedures (small balance write-offs, payment plans, partial payment allocation methodologies, GL reconciliation, etc.).
  • Job descriptions including compensation plans, staff management structure, staffing levels, and competency.
  • Self-pay related workflows – particularly as it relates to the POS collection initiative. Examples might include pre-arrival, financial clearance, calculated patient cost sharing obligations prior to patient arrival, and notifying patient in advanced patient notifications by front office staff. These activities align with overall revenue cycle operations. They also align with new system POS collection policies and the executive vision and goals.
  • Billing system setup and functionality to support self-pay management including workqueue design, account prioritization algorithm, clearinghouse capabilities, and real-time eligibility, including propensity to pay and payment estimation tools.
  • Customer service operations (i.e., hours of operation, telephony, third-party technologies, etc.).
  • Banking relationships and lock-box structure.
  • Use of third-party collection vendors.
  • Statement design.
  • High-level review of other billing and A/R management workflows.

B. Gap analysis to evaluate the degree of variance between policies, procedures, workflows, and staffing structures between professional and hospital billing operations.

C. Risk and readiness assessment.

Step 2: SBO Design

After completing a review of the current state and completing the risk and readiness assessment, the next step is to develop a recommended future-state organizational SBO structure. This will include key design recommendations related to the following areas:

  • Governance.
  • Scope of services to implement at SBO module go-live.
  • Statement design.
  • Partial payment allocation methodology.
  • Standardized policies and procedures.
  • Workflows.
  • Staff productivity levels.
  • Reporting.

Most organizations enter the SBO planning process with one of two principle definitions of SBO – centralized self-pay management and customer service, or truly integrated hospital and professional billing operations. Both approaches provide benefits and risks. Many health systems have taken an incremental approach to SBO consolidation, initially focused around self-pay and customer service centralization. However, the risk and readiness assessment is a valuable process for organizations to make initial SBO design decisions that lay the foundation and provide the flexibility for future consolation and centralization opportunities.

Step 3: SBO Implementation Road Map

The implementation roadmap should include major tasks and milestones, resource requirements, and timeline. It should incorporate the following areas:

  • Internal and external communications strategies.
  • Staffing levels and management structure.
  • Technology configuration (revenue cycle systems, telephony, third party tools).
  • Integrated test plan.
  • Training strategy and user proficiency requirements.
  • Change management program.

Medical Group Considerations

The benefits of an SBO are real, particularly improvements to the patient experience and self-pay yield. The major concern of medical group leadership and physicians involves partial patient payments, including point of service patient payments collected within a physician practice, being applied to larger hospital balances. An effective SBO design process mitigates these concerns through the establishment of effective governance, and by designing a partial payment allocation methodology that incentivizes the collection of patient balances within physician practices. Typically, the location which collects the cash receives full credit for that payment before any funds are allocated to other balances. Not only does this incentivize practices to collect patient responsibility at the time of service, but it is also an effective tactic for alleviating the loss of autonomy over an increasingly expanding portion of the overall revenue cycle.


Jenn, Mr. H, Lorre

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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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