Modernize your revenue cycle workforce

Kelly Gooch:

Welcome everyone to today's webinar, How Penn Medicine, Fought Revenue Cycle Staff Shortages With Efficiency Retention. I'm Kelly Gooch with Becker's Hospital Review. Thank you all for joining us today. Before we begin, I'm going to walk through a few quick housekeeping instructions. We will begin today's webinar with a presentation, and we'll have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q and A box you see on your screen. Today's session is being recorded and will be available after the event.

               You can use the same link that you use to log in to today's webinar, to access the recording. If at any time you don't see your slides moving or have trouble with the audio, try refreshing your browser. You can also submit any technical questions into the Q and A box. We are here to help. At this time, I want to thank today's webinar sponsor, Optum and introduce Morgan Haines, the senior director, Optum advisory services and Tom McCormick, the vice president, patient accounts at Penn Medicine. Morgan and Tom, thank you for being here today. I'll now turn the floor over to you.

Morgan Haines:

Great. Thank you, Kelly and good afternoon. Good morning to those of you on the West Coast. I'm very excited to share with you the presentation today and let Tom tell more about the story and his successes at Penn Medicine. I know there's been a lot of focus in the news all around the clinical workforce challenges and shortages, but as most of you are probably feeling it, the same is true of the revenue cycle. Really, the shortage of qualified dependable revenue cycle staff is driving up labor costs and is making it even more difficult for many health systems to achieve sustainable financial performance. We've seen this impact in front, middle, backend revenue cycle staff, really having those experts in short supply.

               I will let Penn talk about really their prescription for relief here and the items that they have put into place to increase efficiency, productivity and overall cash collections while really navigating some of those complex issues from staff burnout and turnover. You'll see the agenda here, but I want to start us off with a quick poll question to get a sense for what you all are seeing and feeling right now and how critical this is. You'll see on the screen now, we'll give it a few minute or two for you to answer, but really how critical to your 2022 revenue cycle strategy is improving your revenue cycle management workforce challenges? So go ahead and take some time to select one here.

               All right, let's see the results, that's astounding 65%, very important. We don't think that's probably a surprise to many of you on this line. So hopefully this webinar today will give you some good food for thought, strategies you can take, lessons learned from Tom and his team at Penn. So let's get started into just some of what we're seeing. So as you all know, providers are facing mounting pressure to maintain performance amid flattening revenue, declining funding, rising costs. According to report from Kaufman Hall back into October, 2021, revenues were decreasing month over month as volumes decline, really relative to those pre-pandemic levels. At the same time expenses continue to rise dramatically.

               We've seen hospital operating margins decrease year over year, both between 20 and 29 performance and there was about an 18.2% decline in that median operating margin just month over month. This doesn't even account for some of the federal relief funds through the CARES Act and then again, add to that, just the variability and volatility and volume, really impacting performance overall. When you take a look at this side on the left hand side, you'll see that really more 35% of US hospitals are still experiencing negative margins, really requiring just that increased focus on expense management here.

               When you look at the right, there is an even for those highest performing health systems, the cost of collecting every single dollar owed to you is rising indicating extra effort needed to really manage this, overall. We know there's a lot of factors contributing to these overall challenges. We've got unchanged or shrinking payments overall from your payers from the government, but we know at the same time, the cost of technology supplies, other items are rising, making it challenging. We also know there is not a shortage of ever changing state and federal regulations.

               A lot of ... some new ones just came into play, January 1st here in the new year and being ready and complying with those, have their own price tags. We know that pre COVID, some of these issues already created challenges in healthcare, but within the pandemic, we're seeing that the same challenges are here along with new and accelerating ones. An efficient, effective revenue cycle really is critical to financial stability, in the increasingly challenged and challenging industry of healthcare. I mentioned earlier, and I think you all are seeing it all over the news, that we're talking so much about the clinical workforce shortages, but I know in speaking with my clients each day, they're all really feeling it.

               Overall in healthcare, we've lost about half a million workers since February, 2020, which is very significant and about 18% have quit since the pandemic began and additional 12% have been laid off. In a recent study, 80% of healthcare professionals said that the national shortage has really affected them in their place of work. There's a number of reasons for these types of shortfalls, we're seeing them in revenue cycle across all of the different areas, front end patient facing, coding, billing, clinical documentation improvement, revenue integrity, you name it.

               It is there, it is happening and with some of the very recent updates on the vaccine mandate, we know it's only going to get worse before it gets better. An interesting fact here, you see, I think about some of the revenue cycle specific labor challenges. So a recent study from PELITAS here, we're expecting about a 40% turnover with patient access functions. I know some of those ... some of you are already feeling it. Some of you potentially will feel it, but if you were to assume an organization that had about 28 FTEs in the front end, so that's $56,000 in turnover costs, it doesn't necessarily account for everything else going on.

               So again, all of the training, the impact that has to the patient financial experience, some of the challenges that causes with your physicians and additional burnout and burden there. So again, it's really having an impact. We are seeing this overall just being a top issue, as you mentioned, we know the health system leaders really need the revenue cycle management teams to operate at peak performance. During this time that we're facing these unprecedented staffing challenges, overall about how half of the CFOs in a recent HFMA 2030 survey noted that it's become more difficult to recruit finance and revenue cycle workers than ever in the past. For many of you, we know that this is not new. It's just been exacerbated with the pandemic all around us. Many reasons for it, burnout, morale, mention of vaccine mandate. We have an aging workforce, you've got retirements, really just driving talent competition all over. We are about what, 22 months or so into the pandemic. I think we've got a good sense that we know this challenge is going to continue.

               Really when we think about what are we going to do better, any lessons learned, benefits that we gained, and I think part of that comes when we think about the shift to remote and that hybrid workforce, that for pretty much every organization is becoming the new normal. When we sat back and really thought about what were our clients feeling? What were some of the challenges in shifting in that virtual work environment, but also what were some of the benefits that organizations received here? We saw some of these, so again, the ability to eliminate space, some cost reallocation or savings.

               A lot of employees reported improved wellness and having that flexibility and work life balances became really important to them and a benefit for staying in organizations. Also, it gave some folks the opportunity to really expand their access to talent. So again, hiring outside of your traditional geographic area, being able to tap into talent across the country, but these did not come without challenges. How do you keep employees engaged? How do you keep workplace culture, important? Technology fatigue, I think all of us have been facing this across the past two years.

               If you weren't necessarily excelling at monitoring performance and productivity, how did you do that? So just a lot of really kind of challenges, things to think about here and I know when Tom starts talking a little bit about the Penn story, they face some of these same things and were able to really shift it and make some of these benefits to them. Before we turn it over for him to talk more about that, I want to get a sense from the audience here, what is your biggest revenue cycle management workforce related challenge today? So again, we'll give it a minute. If you all can take a second to select one that resonates most.

               All right, let's see, we've got about just over half of you responding. Okay. Keeping up with daily workloads and addressing backlogs. Absolutely, a huge challenge for many of my clients today. We'll be talking through a little bit of ... kind of what we're seeing in the industry and some of those opportunities, what's working well and then, recruitment and retention, we'll talk through that too, so interesting. With that, I am going to turn it over to Tom, to talk more about Penn Medicine and kind of their story and what they've been doing. I'm not sure Tom, how many years at this point we've known each other and worked together, but always in awe of just the kind of strategic approach that they take to their revenue cycle. So with that, Tom, I'll let you go ahead.

Tom McCormick:

Thank you, Morgan. Yes, we have worked together for quite a long time, but that's probably just because I'm old. Speaking of Penn Medicine, I've been working at Penn Medicine for 34 years. There's some people there that thought that I started under Ben Franklin, but that's not true. We are a health system steep in history over 250 years involving our ... the first nation's hospital, as well as the first nation's ... the first America nation for medical school, but the rubber really hits the road for us in 1993, when we formed the health system. Since then, we've built up our health system to include six hospitals, highly specialized practice plan, primary care, affiliated physicians group, over 24,000 employees. As you can see from the slide, six billion dollars, almost six million in revenue and the lapse in volume. We'll go to the next slide.

               So with that volume as you can imagine comes some pretty significant challenges, and a lot of those challenges around managing our most valuable resource, is our staff. We have had a longstanding history concentrating to improve employee engagement. We've had over 15 years experience of employee surveys, which I continue, all surrounding employee engagement. I want to make sure that departments who do not need certain thresholds with those surveys develop work plans to improve this employee engagement. And as you can imagine, those things come with some requests from the employees. Employees are always looking for more flexible work arrangement.

               We've been answering everything from a four day work week for employees to improvement on flex times around employees who are looking for a more flexible work schedule, and we've had a lot of requests for remote working, even prior to the pandemic. So anyway, I will say that the regional competition for labor drives a lot of this in terms of our employee engagement. We want to pay specific attention to that because in our area, we have four large health systems all competing for the same resources and we're just one of those health systems in that group that wants to make sure that we have the best employee workforce that we can. Then COVID-19 comes along and actually in terms of disruption to accelerate workforce management strategies, actually providing us with an opportunity. An opportunity that we really didn't see when we first sent our workforce home due to COVID, on a temporary basis. The governor was shutting down offices, non-essential people should have been working from home.

               We scrambled to do that early on, and then it presented us with some facts that we decided that this might be something that we may want to do on a more permanent basis. Go to the next slide. So I want to talk a little bit about Penn's revenue cycle strategy. Obviously, everybody wants to surpass cash goals and reduce collection costs while enhancing the patient experience. Those top three strategies that you see on this slide are something that we've consistently focused on and then, the next two is something that has arisen as a result of us evaluating shift in our paradigm for a workforce that was brought on by the pandemic. So in terms of managing productivity, we monitor digitally all of our staff's productivity, we did not prior to sending our staff home. They get realtime information on their productivity.

               They have standards that they're supposed to be maintaining. Everything is out in the open and honestly, this helps for an easier, more objective performance management when it's based on facts and figures and not interpersonal interactions that can sometimes lead to some ineffective performance management, and we'll talk a little bit more later about how we develop an incentive program to engage the staff up, that's unique to the revenue cycle. Strategic partnerships is very important. We have a long history of outsourcing and we've built those service partnerships to serve as an extension of our business office. We manage these as if they're exactly our employees. It's just like another section within the revenue cycle, make sure that we're meeting the needs of our institution.

               Then of course, technology and automation, we want to do everything we can to drive out inefficient processes, maximize your system capabilities. We went live with Epic in 2016, everybody was concerned about having a smooth transition and we don't really fully utilize the system when you're focusing on the implementation. So as a result, you wind up putting things aside and you're calling them optimization, which if you're not focused on those and pushing for a complete maximum use of your system, it becomes like a black hole, things that you have ... every intention you do, but you never really got around for doing it. As managers, it's up to us to keep pushing that so we can drive out manual processes and deficiencies in our system. Right-size staffing was something that really popped up as a result of the pandemic. We always thought that we had a great handle on our staffing compliment. It was very unusual for us to ask for a new staff in a higher volume circumstance because we know that volume can fluctuate.

               We utilized our outsourcing to manage capacity. What Happened when we started to send people home during the pandemic, loading to the top where significant number of non-productive employees, where technology has passed them by, they were long-term employees, all of retirement age and they really lots of technical capacity to work from home or to continue to work on things that were more digital in nature. Managers had gotten used to giving them really non-productive, paper shuffling jobs in the health system and they were kind of reps flying below the radar in terms of the efficiencies we were trying to build. That quickly raised to the surface. We approached our human resources department and asked them for some assistance in this, and we developed a voluntary separation program where we financially incentivize the retirement eligible employees to take their retirement.

               In doing that, it actually allowed us to eliminate practically 5% of the whole workforce that were really not very productive, which was a big ... It was a big deal going to senior management and promoting our work from home strategy. Then, of course, when you have this work from home strategy, a flexible workforce model, if you will. I mean, you have to seek more innovative ways to keep connection with the staff. We do MS Teams as part of our normal interaction of staff and doing that, where we have mandatory meetings between supervisors and staff, no less on a weekly basis. They can meet more frequently if they feel the need to. They're required to meet with our staff weekly. I make sure that those meetings are on my calendar because I will pop in, allow staff to ask questions, try to promote more engagement as we go along.

               We have to do more innovative things, because there were things that we used to do in the past to help celebrate successes, what have you, like pizza parties or little mini Christmas parties or holiday parties, if you will. Those things are gone and now, we need some more innovative ideas to keep staff engaged. Next slide, so a little bit about our incentive program. Sorry, I want to talk first about our productivity. So 28% increase in activities really came about when you see that line, that March, 2020 line was our transition month, but by the second week in April, we had all of our staff working from home and we've seen a continuous increase in our historical ... over our historical productivity, and a lot of that we think is result of the events that come about when you're working from home.

               So things that occur at the house that staff would usually have to take some time off on, they can actually manage better, because they are working from home. Travel has been taken out of the equation and more importantly, some of the personnel interactions that take place during the day, which supervisors would have to manage, and they are true time-wasters, are the personality conflicts that occur when you have over 400 people working at 55,000 square foot space. Those are things like, "I can't stand the smell of that guy's Cologne or this woman wears too much perfume, and why does she have to clean her desk when the cleaning solution is making it hard to breathe."

               All those things kind of go away and people are really more focused on work and in terms of getting their job done and we manage it just the way we did before we sent them home. It's a digital report that comes out. We have quality reviews associated with it and then those employees, they can see their ... in real time basis, what their productivity is against our standard. We go next. So this is a slide that I was mentioning in terms of what we've done to incentivize our employee in building this culture of accountability for better cash collections. We have a unique program for revenue cycle where employees can earn a revenue cycle incentive payment on the basis of cash collections at the end of the fiscal year, exceeding target.

               This program has been in place for over 15 years. We've actually never missed the target. We've come close in a few cases, but we've never missed a target, and it's really something that I think that keeps the employees very well engaged. We produce a daily cash report. Everybody looks at it, people are concerned about it. They're looking to make their own jobs more efficient, so that they can reach their target, and we also do something to make a better employee. We paint a certification reward for employees who obtain the AHAM certification for their positions. So in terms of AHAM certification, it's good for three years, they get an annual payment for each of the year that they're certified.

               So at the end of three years, they have to retake the test to become certified again, but for each year that they maintain their certification, they're able to obtain this certification bonus, if you will. We have excellent retention record for our employees, as you can see by this graphic here. With 14.7%, which is less than half of the turnover rate that's experienced in the rest of the health system. Something that we're very proud of, and we do think that a lot of what we do to keep our employees engaged in the medical cycle is related to that. And then when we want to really come up with some creative ideas on managing stay at home, we built an employee morale committee. We're continuing looking for innovative ways to reward staff for excellent performance during the year, not just at the end of the year.

               Continually to assess our staff engagement, to make sure that staff ... they don't feel like they're off the process because now, they're working from home. There's a big concern that people start to feel more isolated and not involved as part as being part of a team when they're doing this work from home or remote working process. So we've come up with some pretty creative ideas, during this last holiday season, we had little mini MS Teams parties for staff. With some games and challenges that we did during the work day for them, when we had some prizes that were awarded. So, like ugly sweater contest or decorating your house. Things that we try to do, become a little more innovative to keep the staff more involved and feeling like they're part of the team.

               Go to the next slide. So I want to tell you about our service partnerships because it is a big portion of our success in terms of not only our remote workforce strategy, but even a success in our processes, in the revenue cycle. We've been a big proponent of outsourcing since 2000 and over the last 20 some odd years, we've been able to, I think, really get down to identifying what are the organizational processes that should be outsourced as opposed to working internally. So in that first point where you identify your organizational capacity and threshold, you really want to start thinking about the purpose of outsourcing. Outsourcing where you think that you either cannot get to, and trust me, you can't get to everything or there are things that you don't do well that someone else could do more efficiently, then you can do internally.

               Then you want to find the right partner for that. Vet your partner. These are going to be people that share the same culture that you do in terms of how you approach the work processes. If you don't have someone to share the same culture, these are again, extension of your business office. It's not going to make for a long term relationship. These are things that you really have to make sure that you're working as if you're one department. Leverage your partnerships on flexibility. The most important thing that's in our outsourcing process is that when we have lower capacity and less get to outsourced, we keep it internal for our own employees to process. When there are times when volume is way up and we don't have enough capacity, that's the time when you change the threshold and you start outsourcing more to your partners.

               I can tell you, our partners are pretty long term because of what we've discussed before that they share that same culture that we do in terms of our approach to the revenue cycle. Of course, you need a data driven methodology to select that work, that the process should be matching, and also keeping track of that capacity that I talk to that in terms of what you're going to outsource and when you're going to outsource it. Then, develop a supportive management team that can lead to cultural adoption is extremely important. When I first started outsourcing, managers were not very happy about it, they felt like it was a stain on their performance that they were not doing their job, when I tried to explain to them that we're actually just trying to improve the process overall, they weren't buying it.

               It actually took quite a long time for the staff to begin to understand that these are true partnerships. This is a process and a system that is like getting additional resources, and don't look at as if you're no longer in charge, so you no longer get to manage this process. That's a big mistake because just because you've taken a section from a manager and outsource it, you still want that manager to manage the process. They need to be managing your outsource partner just as if they were their own employee. So that's a big culture change. That's a significant amount of time for my own management team to accept. Now, they manage the capacity very well. They know exactly when they need to change a threshold, to bring more accounts or send accounts out and it was really important for them to adopt that culture. Next slide.

Morgan Haines:

That's great. Thank you, Tom. I know it's no easy seeds on some of that culture change management internally that you all have done over the years to be successful, but another question for the audience, when you all think about a few of these revenue cycle management strategies, which ones are you planning to implement in the next 12 months? In this poll, please choose all of that apply. I'm not seeing anyone answer the poll, so I am so sorry if it's not-

Tom McCormick:

Yeah, the chat has a problem. The people are not seeing the poll.

Morgan Haines:

Well, we can, let's try going back one and here. Let's see if that works for anyone. It does not look like it, so we will keep moving forward. All right. The big question, many of you, how do you fix your workforce challenges? I think as Tom shared, there's no one single solution. It is a really strategic discussion for revenue cycle leaders to have internally to think about what is going to work best in the organization, what will be adopted, what is the breadth and kind of magnitude of your challenge. So, I want to talk a little bit about some of the ways to mitigate staffing shortages and then a little bit about more of that retention and improving staff performance. So when we think about, what we're seeing in the market, how we're working with our clients today, what strategies they are taking, there are really five here that come to mind.

               The first is around process re-engineering. So again, we tend to see a lot of variability in staff performance and kind of processes across the revenue cycle. So, how can you really standardize that, building out your standard operating procedures, policies procedures really put that workflow improvement to the test, helps to really minimize account touches. How can we have folks working via exception, especially within those shortages. The next thought is really, again, more about shared services. So again, you're having to do more with less, but how do you maintain performance? So especially important as you are bringing organizations together, whether that is physician practices, hospitals, seeing changes, but any sort of physical or virtual consolidation, really gaining those economies of scale.

               Also, there are kind of subject matter experts for kind of individuals that you can leverage across the network? So really trying to identify those individuals that can be of the utmost importance for the whole entire health system. The next piece is around global services and staffing, so both offshore and onshore smart sourcing, and I say that really being strategic with your outsourcing. So taking a look and understanding where are some of your largest gaps? Where is there performance opportunity to leverage a partner just like Tom was speaking about? Then, as they did at Penn, really, what are some of those triggers or thresholds that would allow you to leverage some of those partnerships or shift account assignments there?

               The fourth one really around robotics and intelligent automation, and I would say if there's one ... if there's an area that is of kind of unique focus and interest to organizations in this day and age, it's really moving towards automation. So, a couple of ways, so one are you leveraging your existing EMR to the best of its ability. So where can you really be optimizing that? Overall, the goal is how can you eliminate any of those manual or redundant processes? So you have your staff really focusing on what they should be. I know we've got ... think about the mid cycle space, for instance, whether that's CDI, coding, utilization review, how can you be leveraging the technology or automation such as natural language processing that really prioritizes and allows your staff to focus on the areas that they need to.

               So, essentially do more with less, allows your staff to also stretch focus on challenges that really need to be handled by an individual. So huge area of opportunity. We'll touch on this in just a slide or two. Then the last around self-service adoption, I think this became just very important as we transitioned and moved into the pandemic, so I know so many organizations struggled to get patients to register online or do things prior to service. Now, it's really a requirement that all organizations have this capability. So online scheduling, receiving estimates online, how can you streamline some of the check in and arrival services, especially knowing that there's the biggest impact from a stopping shortage on your front end.

               So again, how can we give patients the ability to leverage digital capabilities and then, do some of those easier tasks themselves in advance of care, not only helps the health system, but really improves the patient financial experience as well. If we think about the other side of the coin, how do you retain your existing staff but at the same time, improved performance, really couple of areas to think about here. So one, I know Tom talked a lot about productivity. What are you measuring? How are we do doing this, real time? How are we incentivizing staff? It is not just measuring performance, I would say many organizations did this pre-pandemic, but then how are you setting the appropriate targets? How are you holding them accountable in this virtual world? Thinking about things like incentive plans or kind of shared incentives to motivate staff?

               Again, we do this with vendors. We do it with partners, all the time. Why do we think about doing this with our own internal staff as well? The second piece, when it comes to technology infrastructure, how do we shift to measuring process efficiency? So not just what are the staff doing, but how effective and efficient are they in doing it? How do we work smarter, not harder, but really giving your staff the tools they need to succeed. So, when we shifted everyone virtual, there was a big need to think about just what did staff need. So again, shift to virtual platforms, wifi, phones, how do you do all of that? But also things like, are there workflow or productivity enhancing tools? Again, can you leverage your EMR differently? We see, again, some of our examples, we've got some technologies, from an Optum perspective, that I see organizations using.

               Again, we mentioned natural language processing, so much out there around authorization is a huge problem. How can we mitigate and leverage technology to support that, embracing flexibility, I think it's competitive for any of you that are trying to hire staff or retain staff, it is competitive market out there. So, how are you ensuring that you are meeting the demands of the market to ensure that you're going to keep your staff? So, yes, flexible hours thinking about work shifts, compensation plans. Again also, do you have an understanding of what your staff are really looking for and what they want? So really having some of those engagement conversations, and then lastly, training, retraining. It's harder to do virtually obviously than it was pre-pandemic when everyone was in person.

               There's always an opportunity to get more out of your staff as you take the initiative and spend the time from a training stand point. As Tom mentioned, thinking about incentives for certifications or things that aren't going to make them more effective and efficient at their role. Then, also cross training. Tom, I want to pause to see if you'd want to add anything from your experience about other items or things that have been ... challenges or that really helped you retain some of your staff.

Tom McCormick:

Yeah, actually I think just some commentary, particularly on how you're summarizing, these fixes on workforce challenges. Prior to the pandemic, we had lots of requests, as I had mentioned, for four day work week, which just wasn't conducive to our business. Insurance companies work five days a week. We're going to be working five days a week, but there was a thought that if I were to have a remote workforce, would I apply it to clerical staff? Now, we already had HIM coders that were working from home. We had certain staff like, high skillset people that we wanted to maintain. So, we allowed them to work from home and they were individual exempt type of employees, but a clerical staff ... and my idea was they need supervision, we need management by walking around.

               Sometimes they need shoulder to shoulder assistance for their work. I was concerned that we would never be able to maintain productivity. I was wrong. I mean, I think that what went into that thought, which was probably somewhat archaic was the fact that, I didn't trust an hourly staff person to be able to manage their time effectively to maintain their productivity. The first several months of the pandemic, proven me wrong on that, and that's what led us to making the proposal of senior management that we could maintain this productivity even after the pandemic was over, which I hope is true because I'm trying to let Spanish explore that he arrived on the beaches of Mexico and burned this ships and said, "Yeah, I'm not going back," because we gave away all our space, 65,000 square feet of space, we've given away.

               We only have a small workforce there. So it's kind of like vetting your job, but so far it's looking pretty good, and I think that that's something that everyone should consider because I know that I have colleagues at Penn that don't feel that way. They're bringing their people back in, or they're going to have somewhat of a hybrid component, but I don't know if anybody else at Penn that went fully remote.

Morgan Haines:

No, absolutely. It is interesting again, while I don't know if I've seen a real study out there, I would say, most revenue cycle executives where they can want to keep people home, if it's working, again, you've been able to shift and work in this pandemic. It also allows you to be more flexible in the future for other items. Absolutely, I want to give a quick spotlight to one of these items that I've referenced a couple times, which is just around automation. I think we have seen automation and other industries, so banking for instance, it's been around forever and we're starting to see this more and more in healthcare on the clinical side, but it's becoming a huge opportunity within the revenue cycle, just to improve efficiency, reduced dependencies on staff and bodies alone.

               There are a number of activities that we do today and our staff do today that can really be enabled through automation. So, I know there's a number of items here, but I mean, if you think about patient access, again, one of those areas hit harder from a turnover standpoint and staffing shortages, there's chatbots out there. We've got prior authorization, as I mentioned, technology and automation to help both identification and submission of those prior offs. So again, you're having staff focus on the ones that require follow up and additional information rather than more of those simple back and forth communications. We're seeing the same thing on the backend.

               So if you just take claim status and claims edits again, improving the efficiency from the billing team members on ... away from those low yield activities overall. So again, there's a number of ways to, and benefits of automation, but I think an area that we are seeing many organizations strongly consider. When you think about lessons learned, and in some conversations with Tom, some of my other colleagues and others in the industry, there are some things that I think we probably wish we knew before we enter the pandemic and had everything flipped around in a matter of a week or two weeks. But some of these, I think that can be really helpful and imperative to consider in the future.

               So the first is creating that virtual workforce playbook. So really outlining standards, expectations, policies, procedures, what tools do you have. So you do have a structured standardized way that you are managing staff that are virtual, but also if you do need to shift other positions that may make sense right now in person, you've got to shift from virtual, you've got a really methodical way to do that. Second, when you think about like developing that employee engagement infrastructure. So what does matter most to your employees across job functions, demographic segments, it's not going to be the same as you've got some newer employees. And some of those that are more tenured, but really understanding what matters most and then, does your internal infrastructure and what you are doing to engage staff match and meet those needs.

               Then really thinking about building those incentives. So I mentioned this earlier, but it's really customary to have those gain sharing agreements, the service level agreements in place with your vendors and partners. But why don't we think about setting performance based incentives for your own employees? They, again are a huge driver of success for a health system. So, how can we really focus in on target accomplishments and get them engaged in overall revenue cycle performance, like the Penn Medicine TMSM, leveraging automation. Yeah.

Tom McCormick:

That program that I have goes on trial every year and I've been doing it now for 15 years, it goes on trial every year because it is unique to the revenue cycle. There are some people in finance entity, CFOs what have you, they will say that, "Well, that's just an extra corporate expense that gets filtered down to us, why do we have it?" And it's really shortsighted when you think about it. Thank God, I have a CFO that supports it because these are some of the lowest paid people in the health system. This is a big deal for that to get this kind financial incentive. And because it is such a big deal, I think they really do put out the effort because they want to attain it every year. We haven't missed it once since we implement it.

Morgan Haines:

Again, it's fantastic. It's true, again, we've got to think for the future and that again is sometimes challenging, but we're seeing more success for those organizations that are really being strategic around, "What do I need to do? How can I fix some of my challenges," and not just succeed this year, but you know, three, five, 10 years down the road. When you think about automation and self-service adoption in general, again, it's how can you have your staff working top of license, doing tasks that require critical thinking, and for the highly skilled resources. It not only will help if you do a staff shortage in terms of callouts or overall turnover, but it's also much more engaging for staff to be leveraging their minds more in what they're doing day to day than some of those manual redundant processes that we find in the revenue cycle.

               So consumerism, is top of mind for many. Again, how do you leverage that same concept into how you can improve the patient experience with some of those self-service options? What is your methodology and triggers that you would activate partnership support across your revenue cycle? Then, finally and Tom talked a little about this, but just establishing those proactive relationship. So again, there is ... it's not necessarily turnkey all the time if you don't have those, but how can you think about that proactively? I'm sure you've got structured onboarding process, underlying MSAs in place. How can you make it easy to partner with organizations to help give you that lift where you need it? For instance, in outsourcing, but Tom, before we go to the kind of one of the next questions here and kick over to Q and A, anything else you would add?

Tom McCormick:

Actually, I think we pretty much covered it. I mean, my only advice is to ... once again, is to, to take a serious look at keeping your staff engaged, whether you're fully remote or not fully remote, because I truly believe that the more you keep your staff engaged as a team, all working towards the same goal, and there's only one goal because cash is king, I think that is really the solution to managing a workforce that wants to be successful.

Morgan Haines:

Absolutely. So we're going to try a polling question again to see if this one will work for us, but in your opinion, do you expect your revenue cycle management workforce challenges to worsen, improve or stay the same in the next 12 months? All right, good news, as we have something answers coming in, so we will give it a little bit of time here. Okay, a few more coming in. Okay, we've got some pessimism here, perhaps in the ... worsening. Again, I think what we want to do is shift over to Q and A here, so you've got the opportunity for some of these questions that you all have been submitting for Tom or myself. With that, Kelly, I will turn it over to you.

Kelly Gooch:

Wonderful. Thank you to Morgan and Tom for such a great discussion. We'll now begin today's question and answer session. You can submit any questions you have by typing them into the Q and A chat box on your webinar console, and I'll go ahead and get started with the first question and we'll try to get to as many as we can today. So one question we have here is what percentage and job functions have you outsourced versus kept internal?

Tom McCormick:

So we didn't outsource positions. We outsourced parts of our work. So if you take into consideration, you've got a high volume, load our accounts that really aren't getting the proper attention, whether that be proper follow up, resubmissions appeals, these are types of things that we outsource to our outsource partners. We do a full outsourcing, for example, auto worker's comp is a fully outsourced program for us, home care and Penn home infusion therapy. That's another fully outsourced program. They're usually longer tail, manually intensive, lower volume compared to the overall health system. We actually manage our insourcing versus outsourcing in terms of dollars and essentially close to 90% of our dollars are collected by internal resources and approximately 10% are our outsource partners.

Morgan Haines:

Yeah, I would just say overall, I think we are seeing an increase across many functions, whether that is more staff augmentation and/or full outsourcing. I think for many years, coding and some of those end cycle tasks we've seen, but we are really seeing across the board that piece really grow.

Kelly Gooch:

Great, and we have another question here from ... So I'm wanting to know a little bit more about the patient access robots and how they're used, if you would want to elaborate on that.

Morgan Haines:

Sure. I can absolutely do that. So not ... and since you were talking about for an automation standpoint, we're seeing some organizations leveraging those robots for patient registration, different way finding other tasks. So it is essentially controlled remotely by an end user. There's video conferencing and allows that to interact with the patient, has camera, OCR capabilities, that really can upload some of those photos, those patient photos or patients being seen for facial recognition, the ability to capture insurance card, credit card payments, and then interfacing directly with the EMR. So, really helpful to reduce some of that need for onsite staff given potential covert exposure, increases the ability to access that talent pool. So, yeah, again, that's one example I would say, but something really unique and really cutting edge, if you will.

Kelly Gooch:

Right. We have another question here, how are you working to address the surprise billing regulations, and either internally or with your partners?

Tom McCormick:

So we're managing that internally and I'll have to say that when it comes to the surprise billing act, some of that we've been focused on for quite a while. I mean, just the way we handle network patients in general, because they do tend to have higher balances at the end. So on the inpatient side, we already had a fairly robust program, but we did have to adjust it for the gas station as well as the estimates for our patient responsibility. So, the estimates we've already done, it's just the paperwork and getting them signed to make sure that the patient agrees. It's kind of like that ABN process, 72 hours before the services. Outpatient side is a little more challenging, not only because the volume, but because if you don't have that timeframe all the time, to get the paperwork completed signed by the patient.

               So we are creating some programs. We use our patient portal wherever we can to communicate. We have a warning for the check-in process to get the patient to sign off on a lot of the paperwork that the act requires. Then, we're building a backend strategy as well. We do outsource our customer service. We have a firm that answers our phones and we're building in a kind of like some recognition on some of the things about an unexpected balance or a balance that maybe they weren't expecting, or they were told, they were not told that they have this balance. Those are the things that we're going to escalate internally, get to a work, to do some further investigation and all that is to really try and avoid any of the problems for when they actually do start to implement penalties.

               We know this is going to be a work in progress. We've done the best we can with the things that we have in place right now, but we're certainly not covering everything, and we have a separate strategy for emergency room services. Again, a lot of that will be backend driven because that's pretty much when we're going to be able to catch these accounts after they're processed and get paid by an insurance company. So work in progress but I think that we have a good start on it.

Kelly Gooch:

Great. Thank you, and we also have a question here about what tools does Penn use to measure productivity and quality targets?

Tom McCormick:

So we're going to ask the client and they have a tool in their system that you do have to kind of build in your unique aspects that you're tracking for your employees. We do do it by section because there are some things that are payer specific that we want to make sure they are being captured, when our employees are working on accounts. We have some separate productivity things for our claims adjudicator and our cash posters that we track, but for the most part, we're using Epic. Then, we do the scorecard, we add quality components. We sample cases to make sure that people aren't just selling in the boxes to get credit, that system will see them as being highly productive. That the things that they do have to be of a quality nature, to have it show productivity, and we even track the cash that's coming in.

               So we're always suspicious of an employee that has a group of accounts that they're following up on has fantastic productivity, but none their accounts are getting paid. So those are the types of things, but still these are the reasons why we have supervisors that can be more strategic in managing their staff as opposed to managing time-waster type of things.

Kelly Gooch:

Thank you so much. Looks like we have time for maybe one more question here, and one question we have is what is the number one most valuable AI for revenue cycle right now?

Tom McCormick:

Well, in my personal opinion, it's something that I've kind of evaluated some vendors on. I haven't seen one out there that I think is up to par, but prior authorizations. We can make prior authorizations more efficient. By that, I mean that we're kicking off a process and then the computer takes over in terms of getting the prior authorization, answering questions on medical information you already have in your system, possibly providing records and then, what only floats to the top is your exceptions to the rule where you're just not going to get that prior approval, unless you have some kind of medical provider to provider intervention or peer to peer intervention. I do think that that's a doable thing.

               I've seen some people who are working on it and I've seen some people who think they've got it, but I haven't seen one that I think is a solid product as of yet.

Morgan Haines:

I think ... again, it's a hard question. I think prior authorizations probably are a huge, huge pain point for many organizations, but again, just across the board, we are seeing automation, and intelligent automation just function across. So I'll let Tom leave it with the prior off as maybe number one.

Tom McCormick:

Well, it's my number one pain point.

Kelly Gooch:

Well, that is looks like is all the time we have for today. I do want to thank Morgan and Tom for an excellent presentation and Optum for sponsoring today's webinar. To learn more about the content presented today, please check out the resources section on your webinar console and fill out the post webinar survey. Thank you for joining us today and we hope you have a wonderful afternoon.

Tom McCormick:

Thank you.

Morgan Haines:

Thank you ...