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Empowering effective revenue cycles in rural health care

Staffing stability is one of the top four factors ensuring long-term revenue cycle business continuity. Staffing remains a top industry challenge, with shortages having a significant negative impact on reimbursement.
From prior authorization to collections, a health system’s ability to maintain steady, dependable staffing fuels team efficiency and mitigates risk of cash flow setbacks. For many hospitals, the ability to find and retain experienced revenue cycle personnel remains a significant challenge and expense, as experienced revenue cycle professionals garner higher salaries and remote work enables the poaching of knowledgeable personnel by more affluent health systems.
These issues are even more acute in rural America, making revenue cycle outsourcing the only solution for many smaller hospitals and health systems. However, outsourcing carries negative connotations and possible reputational harm for rural providers in communities where the hospital is often the largest or second-largest employer.

Finding a workable balance between competent revenue cycle staffing and satisfying community demands represents a fine line to walk for many finance executives in rural hospitals.

Three revenue cycle leaders recently convened to discuss these issues and share their best practice solutions for staffing stability during a virtual expert panel. The bottom line: Revenue cycle outsourcing is the optimal solution, but it doesn’t have to be all or nothing; it can be a flexible proposition. Here’s what they had to say.
Biggest staffing issues in rural revenue cycle leadership
Staffing challenges varied across panelists, but the outcome was the same: an inability to find and keep competent revenue cycle staff. For Leticia Rodriguez, CEO at Ward Memorial Hospital in Monahans, Texas, a recent EHR conversion had led to dramatic spikes in accounts receivable –  up to 284 days at the height of the crisis. The facility simply could not find enough local resources to assist. Another panelist reported the inability to find knowledgeable staff to process difficult, complex claims. For another executive revenue cycle leader at a Louisiana hospital, retaining qualified personnel was the largest challenge as decades of knowledge walked out the door for higher-paying, remote positions.
Going forward, panelists suggested that additional staff will be needed to sustain day-to-day processes as internal teams are trained and upskilled. This includes the use of new revenue cycle automation tools such as machine learning, robotic process automation, and artificial intelligence on the front, middle, and back end of the revenue cycle process.
Address community pushback
Panelists also discussed community concerns and those from the board of directors related to using outsourced revenue cycle teams to remedy staffing issues. For Susan Shreve, executive director of revenue cycle at Boone Memorial in West Virginia, the ability to save costs by purchasing fewer technology applications alongside reassigning current employees to other tasks tipped the scales in favor of revenue cycle outsourcing. “We performed a six-month pilot project to demonstrate the cost savings, and our CFO reinforced the decision,” Shreeve says.
Another revenue cycle leader at an Oklahoma hospital was able to find expert talent for complex cases through a patient revenue cycle outsourcing project and recoup $2.1M in payer reimbursement, which thoroughly convinced his board of directors.
Other best practices discussed included rebadging internal staff to the outsourced vendor or finding new positions for existing staff, including training positions and other internal operational processes. Early retirement options were also offered by some of the panelists’ organizations.
Establish a people-first culture
Both the facility and outsourced revenue cycle partner should embrace a people-first approach. This approach continually instills a growth mindset and culture of learning for all staff (internal and external) and throughout the partnership.
As previously mentioned, new automated revenue cycle processes are ahead. Today’s skillset may no longer be required in future revenue cycle functions. Teams should be upskilled to prepare for the future. Upskilling offers positive operational and strategic impacts for both internal and external employees.
Finally, the introduction and use of smart-tech tools enhances the work experience for all involved, which drives staff adoption of tech-enabled revenue cycle workflows.
Ensure a smooth implementation
A thorough assessment of current people, processes, and technology is the first step for implementing either complete business outsourcing or partial revenue cycle outsourcing. The best practice is to conduct a seven-to-ten-day onsite assessment and incorporate as many of the organization’s policies as possible into the new outsourced team’s workflow.
Other departments and relevant stakeholders should also be included in weekly meetings. These meetings may include representatives from the business office, clinics, medical record coding, health information management, charge description master, clinical documentation improvement, and patient access or registration areas. Once outsourcing is underway, meetings move to monthly strategic planning with data review of performance and outcomes.
Keep partners on track
All panelists shared valuable advice to monitor the performance of outsourced revenue cycle teams. Here are four of the main best practices discussed:
  • Contractual penalties: Include penalties for the outsourced vendor if a dip in performance occurs to keep costs aligned with revenue. Consider metrics such as cash collections, A/R days, gross revenue, DNFB, and multi-year cost savings. Savvy vendors will also incentivize their teams on hospital performance to drive shared ownership of these results.
  • Consistent costs: Aim for consistent versus fluctuating costs. Subscription models for revenue cycle outsourcing should include all training, existing and future technology products, software enhancements and updates, ongoing maintenance, and support. Hospitals can rely on the outsourced vendor for internal staff training to ensure both teams work consistently and collaboratively.
  • Multi-parameter analytics: Use scorecards broken down by multiple parameters. Boone Memorial Health expressed appreciation for the outsourced vendor’s cash waterfall and denial management reports.
  • Communication: Build a strong relationship with the outsourced vendor and work with them as if they are down the hall. Your vendor partner should be readily accessible and flexible as new needs arise or priorities change. For example, Ward Memorial uses a local phone number to reach their outsourced partner.
Upskilling today’s team for tomorrow’s requirements
According to Lindsey Hall, people partner at CPSI, there are three steps a health care organization should take to upskill their workforce in preparation for new AI-based technology and workflows.
  • Categorize skills needed for the future: Imagine all possible scenarios around what processes and systems will be in place. Consider the necessary skills needed to deliver the work as we see it today with an eye towards the future. Defining roles, career pathways, and upskilling opportunities will create stability, opportunity, and readiness in the workforce.
  • Ensure career mobility: Talent mobility comes in many shapes and sizes. Providing employees with defined career pathways and having conversations around how to achieve goals can allow employees to progress in their current positions and find new roles in an organization that fuel their passion and interests. Partner with local educational institutions or other online partners to offer employees training to obtain necessary skills. If not already in place, encourage employees to advance their education through incentive programs.
  • Reduce dependency on recruiting:  Building the workforce from within whenever possible drives an enterprise mindset and achieves a greater level of satisfaction, loyalty, and maximized potential within the employee base. Consider recognizing and rewarding leaders who develop their staff, promote internal movement, and provide opportunities.

Debunk the Myths
According to a 2022 report by the American Hospital Association, the ongoing closure of rural hospitals threatens health care access for 14 percent of the U.S. population. Rural hospital closures are also bad for local economies. The same report mentions that one in every 12 rural jobs and $220 billion in economic activity for rural communities is driven by rural hospitals.
The perseverance of our nation’s rural hospitals is essential, yet they continue to close, according to the AHA report, with 136 closures in 2020 and 2021 alone. Many more are in dire financial straits due to rising costs and lower reimbursements.
With so many small hospitals on the brink of closure, now is the time to debunk outsourcing myths and consider new business operation possibilities to ensure long-term revenue cycle continuity. Whether hospitals have difficulty recruiting staff to their rural location, are reeling from a new system implementation, or are losing staff to higher-paying positions, revenue cycle outsourcing may provide short-term relief or a long-term solution. The health of your community may depend on it.

NRHA adapted the above piece from TruBridgea trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.

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