The 229 Podcast: Exploring How Emory Cut Denials in Half with Carla Haack, MD

0:00 Today on the 229 podcast, >> everybody wants to do the right thing and everybody wants to do a good job, but despite the fact that we work within the same system, we live in such different worlds that it's really difficult for people to understand each other. My name is Bill Russell. I'm a former health system CIO and creator of This Week Health, where our mission is to transform healthcare one connection at a time. Welcome to the 229 podcast where we continue the conversations happening at our events with the leaders who are shaping healthcare. Let's jump into today's conversation. All right, welcome to the 229 podcast. Today I am joined by Carla Hack, Dr. Carla Hack with Emory Healthcare out of Atlanta and she is the chief financial informatics officer and we're going to talk about that because it's very distinct. Carla, welcome to the show.

0:53 >> Thank you so much for having me. It's an honor. I'm I'm looking forward to this for a couple reasons. One is you were talked about at 229 project meetings several times before I actually met you and then we met recently at the Atlanta City Tour dinner and your role is so fascinating to me and it's fascinating to others some of the things that that you've been able to do in that role with the team that's there and it's it's just really fascinating. talk a little bit about the role and the focus of the role and then I think I'm then I think I'm going to go backwards and ask you how you got into that role.

1:30 >> Fair enough. So the role is is very exciting and very fun for me and it mainly consists of being a facilitator of multidisciplinary collaboration in the pursuit of helping everybody in the organization have a better day and allowing us to fulfill our mission of serving the community, improving lives and providing hope more effectively. I can go into a lot of detail about what that looks like and what that means, but I suspect that you will ask questions that will take us there.

2:05 >> Well, you know, so you multid-disciplinary, you're sort of a somewhat of a liaison between finance, IT, and clinical >> perfectly described. and you identify those areas where there are inefficiencies and it could be in a lot of different ways, but a lot of them happen to be directly tied to reimbursement and physicians getting paid and the system getting paid and they're not small numbers. >> They are not small numbers. It's amazing how quickly the numbers add up and at the same time it's really alarming how quickly the work that our frontline clinicians how that work can be lost the work that our frontline clinical teams can be lost by miscommunications inefficiencies in the revenue cycle poor processes and I am fullon acknowledging that I am getting into the question of how did I end up in this role But the reality is is that when you have a lot of leakage in your revenue cycle, the way to make that up is to be more productive on the end of the revenue generating team members. And when you're at the end of the pandemic, I had done emergency general surgery throughout the pandemic and we had stayed busy, but all health care systems were struggling financially and there was a message sent to clinicians that we weren't productive enough and acknowledging that we had shut down elective surgeries.

3:43 >> How how was that received? >> It was a bitter pill to swallow. I will not lie. And I am not, it is not a criticism of our leadership at that time because if you don't know, you don't know, >> right? >> And that was sort of where I started peeling back layers of the onion. And there were circumstances that I don't believe in coincidence. Let me say it that way. I believe that the universe is too elegant for coincidence. And there were a series of things that happened in my personal life with my parents and my husband's parents, none of whom were in Atlanta, that forced me to take a step back from the operating room so that I could be where I needed to be from a family perspective. That ultimately led me to having bandwidth during hours that would normally be clinical and operative prime time that allowed me to show up to revenue cycle process improvement meetings that I would have never gone to if I'd been in the operating room or the clinic. And that was where I started learning more about the inefficiencies that arise from lack of communication, incorrect assumptions. And let me be clear, I am not criticizing anybody.

4:56 Everybody wants to do the right thing and everybody wants to do a good job. But despite the fact that we work within the same system, we live in such different worlds that it's really difficult for people to understand each other. So I start showing up to these meetings and I start analyzing denials and I realize that people are assuming things about the mechanism of a denial because they cannot interpret the clinical documentation to figure out whether what we put on the claim is what we said we were going to do when we saw the patient in the office and whether that's what we actually did when we went to the operating room. So, I first really started sliding down this slope when I started becoming a translator for clinical documentation for people who were analyzing denials in the revenue cycle and just realizing that by helping people work together and understand each other, we could really make a big difference. And the digital team is where the rubber meets the road. The digital team is where you can make it easy to do the right thing and hard to do the wrong thing by setting up your enterprise architecture and your workflows and your processes in a way that makes sense. But it requires you to get people together end to end and to share their screen and to have the first person show their workflow and then for the second person to show their workflow and figure out what clicks the first person made that will translate to the second person and how that looks and how it is that we need to set ourselves up so that the information that we need to flow flows to the right person at the right time with the fewest number of clicks. So you've given me a lot to go off of here. So the first thing to note is in a lot of these cases the work was being done. The clinicians were doing the work and still you had it goes through the process and the clinician ends up not getting credit for doing that work because it's not that something breaks in the process and then the system doesn't get credit for doing that work because something breaks in the process. If I could clarify one thing, >> please.

7:03 >> At our shop, and I can't speak for other major academic centers, but at our shop, the clinician gets the RBUs independently of whether or not the system gets paid. >> >> and I have interesting feelings about that because on the one hand, the work has been done, the stress has been felt, the effort has been made. And yet on the other hand, if the system doesn't get reimbursed for all of that work and that effort, then it does not it's not sustainable. And we did historically a very poor job of closing the loop with physicians and clinicians, meaning yes, giving them credit for the work that they've done and saying, "You took care of this person and you did this work and we also didn't get paid and here's why."

7:53 We just kind of left that as a black box. And then you had some of your most engaged, passionate, intelligent, committed people out of the loop and unable to help. >> Interesting. I want to take you back and and this is more of a a case study because I will tell you that when in our 229 meetings you have you have 15 CIOS sitting in that room and Alistister would stand up and he would tell some of the stories of the amount of revenue that was captured and amount of you know and the things and he would talk a lot about the fact that having someone focused on this your role is very focused on this this intersection that a lot of times it's just broken there there's just And I'm going to get to that in a minute. But he would talk about this. And I'll tell you, the 14 other CIOS would be sitting in the room taking notes furiously going, I wonder what our percentage is. I wonder I wonder how, you know, like who's and they were literally saying, I I'm not sure who's responsible for closing these gaps. And so there there's a certain sense in which just having the role and the focus is valuable in and of itself.

9:00 But before we go there, I want to go back to, you know, you start sitting in on the revenue cycle process improvement meetings. Who's in those meetings? I'm curious. I'm back in the day. I'm sure it's probably different today, but back in the day I because what I'm picturing is a silo. I'm picturing a bunch of people trying to figure something out and they're the right people aren't in there to help them figure it out. >> You're spot on. And what's interesting is that we often actually start at the wrong end of the problem. So I actually first started dipping my toe in the revenue cycle in 2015 when I became the medical director for care coordination at at our university hospital and I was doing a lot of the statusing denials. So you admit a patient, you make them inpatient and the insurance company comes back and says no that's observation doesn't meet medical necessity criteria for inpatient. And I would do a lot of those peer-to-peers with the insurance company. That started sort of opening my eyes a little bit to how it was that the insurance companies worked etc. But at that time before the pandemic, we'd actually started our revenue cycle process improvement meeting talking about denial management, which is in fairness a really good place to start because it helps you figure out where it is that's not going right. The key though is that fixing the denial starts way upstream of the denial.

10:15 So if you start at the end, you're not actually able to fix the root cause of the problem. So the denials value stream analysis sort of ended up with okay well we need a we actually need a presert value stream analysis because that's where this all starts and that's where a lot of these denials start. So that was then the rep cycle process improvement work that I started getting involved with after the pandemic. And I'll give you a really simple example of things that would happen. Sometimes you didn't have an off and when you don't have an off well that's easy. You don't have a leg to stand on. So there was a lot of process stuff that we needed to do with Epic and our EMR and just operations that needed to be strengthened and solidified. However, once we fixed that problem, we still found that we had a lot of denials that related to the fact that we would have an off for something that was different than what we ended up putting on the claim. And there was little to no reconciliation happening in between. And they would assume, people who were looking at those denials would assume that it's because the surgeon did something different in the operating room and didn't tell anybody.

11:29 when we started looking at those cases one by one. There is no glamorous way to do it. The way that we and the way we started doing it is that we had a bunch of rev cycle team members in the room and we had a bunch of denials people in the room and they would look at these denials and they were having these conversations. I was like wait a minute wait excuse me sorry stupid question. Did we read the note? They were like no.

11:49 I was like okay well let me read the note and let me figure out whether or not what we did is what we said we were going to do and whether that code matches. So I started doing that and realizing that a lot of the time we actually did what we said we were going to do and the codes were different for other reasons and there were a bunch of different reasons why the codes could be different. You could have posted it wrong. You could actually have your system built wrong. There were situations where we would order a study or a service and the CPT code would be attached to that order and we kept getting denied. And when we looked up the CPT code, it was the wrong CPT code attached to the order.

12:28 >> People forget, I mean, when you're doing those builds, in a lot of cases, you're doing a lot of work at a in a very compressed time, and some of that stuff just does. There's just errors that are made. >> It's easy to fat finger something. It's very easy to make a mistake. So, trying to fix all of the root causes was like playing whack-a-ole. You can get to a certain number of them, but you can really only get to so many of them. The place where they all come together though is right when you finish the procedure. So this is kind of where I'm going to get into what the job does because the way that I think about this is how do I set our digital infrastructure up such that the work that happens during the course of clinical care translates efficiently and effectively downstream to the revenue cycle without making our clinical teams do anything that they're not already supposed to be doing for quality and safety purposes. So, what we did, and this took a while to stand up, but what we've ultimately ended up doing, and I'm thrilled, and it's it went live on May 21st, so it's still relatively new, and it's still my little baby, is that we've partnered with our quality team who was doing a reinvigoration of our universal protocol, which refers to the series of things that you do in the operating room for quality and safety purposes, like pausing before you cut skin to make sure that you have the right patient, the right diagnosis, the right imaging, the right equipment, and Everybody knows what operation we're going to do and on what side. After the case is done, we should be debriefing. We shouldn't be rolling out of that room without everybody agreeing what we're going to call the operation we just did. That is a magical moment to actually capture what you did and put it into the system in a way that allows us to notify the payer if what we did is different than what we had authorized. So that's how we set our system up. We partnered with the quality team. We told everybody, hey, you're debriefing. You're supposed to be debriefing. Everybody needs to debrief.

14:26 This is a quality and a safety thing, and we will not compromise on that. We're also going to supercharge your efforts to make it so that what you say at the time of debrief actually helps you get credit for the work that you have done. And that is those are important words because it's really important to make sure that everybody knows that we're doing this so that credit is given where it is due. And it's not just because of the money. Yes, no margin, no mission, but that's not necessarily what drives certain groups.

14:54 And so for the physicians, it was really important to know that we're doing this for quality and safety, and we're doing this so that you can get credit for your hard work. And so at this point, everybody debriefs, and we change the field in the intraoperative record, which is the the document that the circulating nurse documents on. And if there is a change in the codes in that procedure field, those codes autopop populate based on what was preserted.

15:21 And if we if we put something different in that field, that account automatically routes to a work cube that's worked by a nurse that's that works for our central presert department. And she submits those cases to the insurance company on a same day, next day basis. The insurance companies will usually give you about 24 hours to submit a postservice request where you say, "I did this operation. and I pre-serted this other thing, but this is what I actually did and this is what I need authorization for. And it took a million dollar bite out of that particular denial mechanism in the first 21 days of being live. It made a huge difference and it didn't make anybody do anything that they weren't already supposed to be doing for quality and safety reasons.

16:02 >> There is no easy button for this, is there? I think people hear, "Oh, I heard a vendor who said we're going to have ambient listening in there during the surgery. It's going to capture everything and everything's going to sort of work." I mean, that's that's the dream, right? But there really isn't an easy button because that's just one challenge. There's several challenges that that have to be overcome. >> What's interesting is that it's also not that complicated. It's not easy, but it's also not that complicated. It's a lot and I don't want to I don't want this to sound disrespectful in any way, shape, or form, but it's it's less stressful and less scary and a lot simpler than actually doing the surgery because what this is about is this is about making sure that you understand who needs to know what and when do they need to know it. And if you can understand that in a technology agnostic manner, you can then build your enterprise architecture in a way that supports and facilitate that communication. But if you have no idea and you haven't thought about who needs to know what when, you're shooting in the dark, >> right? Now that's beautiful. One of the things you said earlier on, I do want to go to use cases if any that you could share I think are going to be really powerful. One of the things you said earlier was from a digital standpoint.

17:18 You can change the tool, change it so that things are easier and you could change it so that they're harder. And both of those things are in your toolkit because there's some things you want to make sure people don't do and there's some things you want to make sure that they do. Talk about that a little bit. >> I could give you a couple examples. A denial example that I'll give you is the Z00.0000 code for as a diagnosis code for labs ordered during an annual primary care visit. So we call it affectionately the zoo code because Z00.0000 looks like zoo. And we had a ton of denials for that. And basically, it's because that very few payers will actually pay for services that are associated with that diagnosis. But it was also the top diagnosis that was listed in the order when you opened up the order for to associate the diagnosis.

18:11 So, we did a couple different things. One of the things that we did was well, we worked with our primary care team to make the zoo code harder to find, but we also set up an ABN light type of workflow where we loaded the NCDS and LCDs from CMS into the system and we asked the system to fire an alert to a physician if they were ordering tests that were and associating them to a diagnosis that was not covered. just saying, "Hey, that's not going to get paid if you associate that diagnosis. Is there a diagnosis that is clinically appropriate to relate to that order that's not the one you just picked?" And by flashing that alert, we encourage them to pick another diagnosis. Now, people may say, "Well, they're going to get alert fatigue." But the reality is is that most physicians are quick studies. By the time they see an alert once or twice, they're like, "I'm not picking that one. That one's not that one's gonna get me a popup." And they pick another one, right? So you do the thing that makes it hard to do the wrong thing. You hide the zoo code and you let them know. And if they really insist on wanting to associate them, you make them type something in a field, right? You just make it ownorous and painful. At the same time, you know, the example that I gave you about the debrief is an example of making it easy to do the right thing. and you don't even have to do anything different because what you're already doing in order to take really good care of that patient is going to turn the rev cycle over downstream. So those are some of the use cases and I can get into others where novel procedures. So we are an academic center. We do a lot of innovative things. We are advancing the field and that means that some of the procedures that we perform will be evidence-based.

19:56 meaning that there are articles that support this as an evidence-based plan of care, but the insurance companies don't necessarily have these procedures integrated into the fabric of their coverage system. So, if you're going to be doing one of these novel procedures, you usually have to explain to the insurance company what you're going to do because you're going to have to use an unlisted code. And if you use an unlisted code and you don't tell the insurance company what you're trying to do, they're going to deny you and they're going to say, "You need to do a peer-to-peer because I have no idea what you're trying to pre-search here." So, one of the things that we did was we built the order set with the unlisted code because one of the other things that was happening is that you would submit the unlisted code, you'd get denied, you'd get a peer-to-peer the so then the next time the surgeon would say, "Well, the last time I submitted that unlisted code, I had to do a peerto-peer, so I'm not submitting that code anymore." just submit the old open code. That's another surefire way to get denied because if you submit the open code and then you go to the operating room and you do the minimally invasive approach that you plan to do from jump, you did a bait and switch on the insurance company and you do not have a leg to stand on. So what we ended up doing was we built dot phrases that would say things along the lines of there despite you know based on my assessment of this patient would b would be best served by having a minimally invasive pancreatic deb breedment despite the fact that there's ample evidence to support that this is a a superior approach for this patient based on the following factors the code remains unlisted. We will perform this procedure. We will submit the unlisted code. However, the resources, competencies, risks involved in performing the unlisted code are similar to this comparable code. Therefore, we will submit the unlisted code and expect to be compensated in a way that is consistent or along the lines or in the ballpark of this comparable code. And if you really want to get fancy, you can add some article citations to your dot phrase. And now you've made it so that the physician can include that in their note as a dot phrase or their note template when they see that patient.

22:04 That saves them the peer-to-peer a lot of the time. You submit the unlisted code and then you've you've got documentation that supports what you did front to back. Another example is when we found out that we had a lot of denials because we were preserting the diagnostic maneuver without preserting the therapeutic maneuver. There are situations like when you have lower extremity eskeeia where you have to do a diagnostic maneuver an angio so that you can understand what therapeutic intervention is most appropriate to perform on that patient. And so what was happening though is that if we tried to preserve the angio and all the possible therapeutic interventions, the stent, the endarderectomy or the bypass, we were getting a denial from the insurance company saying, "Well, which one of those three are you going to do?"

22:57 So we wrote a dot phrase that said, "This patient has lower extremity eskeemia and they need intervention for the following reasons. When we go to the operating room, I'm going to perform an angagram first so that I can then decide what therapeutic intervention is most appropriate. Therefore, I won't know until I get there. I'm going to presert all the possible codes and we will only bill you for what is actually performed. And that went a long way towards helping us be able to presert all of the possible codes that we might perform and make it easy for the physician to capture that in their documentation. I hope people are picking up on the fact that I said earlier there's like a triangle. There's there's IT, there's finance, and then there's clinical. You speak clinical very well. You speak finance and I mean from a finance standpoint, you speak the insurance codes and all that stuff extremely well.

23:52 I I don't know if you speak it very well, but I mean you understand the digital aspects and the tools that are available. I I see you waving your hand like I I can talk to them. I can translate to them from a reporting relationship. Where do you sit in the organization? >> I have a very diverse FTE. So I still have a a a toe on base in the department of surgery, but my FTE is mainly actually split between digital and finance. Currently digital is the majority shareholder by a small margin and the rest of it goes up through finance.

24:27 >> Finance. Interesting. We talked about a million dollars in 21 days in the O. Are there other examples that you can share? >> Oh man. So there are a lot of examples around plan mapping, cleaning up the plans, establishing so when we when a patient would change their insurance, we would not pick up on that. We wouldn't follow up on that. So making changes to the system such that if the insurance changed the RTE would run and it would capture those things. just making simple changes to the system like empowering people to call a patient and ask them things if there had been changes or if something wasn't adding up for us and in based on how the RTE was running because that was another thing that we found is that there were some groups that felt like they were empowered to reach out to the patient and there were a lot of groups that did not and that made it really hard to give our patients the information that they needed so that they could navigate our system effective effectively and and with peace of mind, frankly, because that's the other part that I'm really passionate about, which is that when you could be taking great clinical care of a patient, but if you're not actually attending to the business side of their experience, they can suffer quite a bit and they can end up with big bills that, you know, result in the leading cause of bankruptcy in this country. So trying to make sure that we are thinking about the patient first and making sure that everybody in the health care system regardless of their job description understands that they are a healthare worker and every time you do something in this patient's chart you are taking care of this patient or not. So making it easy for people to reach out to a patient to say hey can we talk about your insurance can we talk about how it is that you know did anything change what's your plan finding our out of network patients was another really big issue that we actually had so we had a ton of patients that were out of network that were getting care in our system and that was bad for everybody there were a lot of those patients that needed to be cared for in our system because we offered services that weren't easily accessed in the community. So, finding those patients, grouping them into buckets of who's got something weird that they need to see us for versus who can be safely cared for by our colleagues at other organizations in the city because they have great doctors and great teams that take great care of patients.

26:57 >> In network matters to me is the patient. >> In network matters to the patient. Absolutely. So then can we make it really easy to actually or can we make it easier to work out these single case agreements and I remember we talked about this at dinner at one of the uses for AI but every time you're going to advocate for a patient to get a single case agreement so that they can be cared for at your organization if they're not in network somebody's got to write a letter of medical necessity and those can take a really long time to write and they're extremely painful when they're timesensitive you got a patient full you got a clinic full of patients or an o full O day and now you have to write this letter and it's going to be really hard to find the time to do it. So leveraging AI to actually help write these letters of medical necessity so that we could more easily navigate securing a single case agreement for a patient or appealing a denial for that matter was another gamecher for us where it made it easier for us to do the right thing and follow the process that the insurance company has laid out for us to avail ourselves of those services. I assume there's a scorecard or a set of metrics that you're looking at on a fairly regular basis. What What are some of the metrics that you look at to say, "Okay, something something's broken over here. This percentage is out of way." I mean, are there certain metrics that mean more to you than than others?

28:16 >> I will admit freely that I have been fairly obsessed with denials since I've made this transition. And Epic told us point blank that our denial rate was the blemish on our implementation in as many words. When we went live, our denial rate was something obscene like upwards of 20%. >> Wow. >> It was outrageous. Now, some of those were real denials like some of the things that I shared where we had CPT code mismatches or we didn't have an authorization or the insurance was wrong, etc. I could go on. And some of those were denials that weren't real.

28:52 Some of those were denials because we were trying to doublech charge the insurance company and they would just deny the whole thing. That was actually a real denial by the way, which we fixed because what would happen is that we would if we had a patient so many things that I want to tell you so hard to be cogent and coherent in trying to tell you all of these things that I'm so passionate about. Some of the denials that we had were deni what we called affectionately dinos denials in name only where we found that we were submitting charges for things that we knew were not going to be paid and we should just stop doing that. There's no reason to do that. So there was a lot of that kind of cleanup happening and there was also cleanup of self-inflicted wounds. We had this workflow for our third-party sites. So when you submit a request for O to certain insurance companies, you don't submit directly with them. You submit to a third-party site. And that third party site will often say approved and give you a number at the end of your submission. That does not mean that the insurance company has approved the service. And that number that it gives you is not an actual off number. It is a reference number. So what was happening is that we were taking that reference number and putting it in the O field which was then making that case drop out of the work queue and then that number would populate the claim and that would be an automatic denial because that number is not a real O number. What ends up happening is that a few days later, somewhere between three and seven days after you submit your request for off, the insurance company will come to that third party website, update that number with the actual off number if they in fact approved the care. So, we didn't have a way for us to go back and check that website unless somebody remembered that they had to go back and check the website, which wasn't necessarily the best use of our team members time. So, this is where we're talking about automation. Can we have a bot go ping the website and import that number when it changes? However, first of all, you have to have a rule that is thou shalt not put anything in the offsert field that is not a bonafide verified authorization number.

31:12 >> So there's an awful lot of this that is organizational change management. It's meeting with teams. It's helping to understand where the process is fixed, educating moving, you know, changing behaviors, potentially changing some systems. And I mean, so there's a you started this off by saying multid-disiplinary. I mean, your job every day is working with a lot of different departments and a lot of different teams, isn't it? >> Everybody. Everybody. I do not recognize lane dividers in my role. I will partner I'm currently partnering with identity management which is an interesting one and it typically rolls up through the CISO but we found that we are having issues with the taxonomy of how it is that the specialty and the subsp specialty are documented and so if you document the subsp specialty before the specialty that actually makes it so that the subsp specialty is recognized. If you document the specialty before the subsp specialty, then what ends up happening is that two different people in the same specialty, the different subsp specialties may not be able to see and bill for the same patient as a new patient because the system perceives them as being in the same specialty and you two people in the same specialty cannot both bill for a new patient visit for the same patient. And so working with identity management to get our taxonomy set up properly so that the subsp specialty is what is recognized.

32:36 Therefore allowing those two different subsp specialists to bill for a new patient visit with that patient the first time that they see them. So I'm partnered with identity management. I'm partnered with training with the digital training team because you have to be able to help people use the tool efficiently and effectively and you have to help them understand why. I've been partnered closely with the revenue cycle leadership team, partnered closely with the financial planning and analytics team and partnering with anybody who will help compliance. I mean, it requires everybody and it often requires you to get lots of people in the room who who will touch that continuum of care but may be far away in terms of that continuum of care such that they may not actually realize that they need to talk to each other and work together.

33:26 So the job really consists of looking at the problem, trying to understand who you need to get together to solve the problem, getting all of those people in the same conversation, and then just making it easy for people to work together to fix stuff, which is incredibly satisfying. >> Yeah, I would imagine. And incredibly hard because the motivations of some are not the same as the motivations of others. Everybody wants to do a great job for the patient and whatnot, but certain words in one room create a different response in another room. I mean that as a CIO, I would go to different rooms and I thought, well, you know, I I said this in this last room and it really resonated and you say it in this other room and all of a sudden it doesn't resonate would be the wrong word to say.

34:09 It resonates in a way that that is visceral. So you really have to I mean there's a lot of discernment. There's a lot of emotional intelligence to understand who you're in the room with and what is their motivation and you know and what their pain points are as and they're different. >> That is a very insightful comment. You are exactly right. So you don't go talk to the surgeons about MPSR and Ebida. That's not going to get them excited, right? They're going to glaze over if not have a visceral response. You talk to the surgeons about quality. You talk to the surgeons about efficacy. You talk to the surgeons about bankrupt patients.

34:46 You talk to the surgeons about making it easier for them to get credit for the work that they are doing. You talk to finance and rev cycle about MPSR and Ebida. And you talk to RevCycle about your denial rate. And then you have to kind of come back and circle back around. And then a lot of my job also includes unpacking certain functional elements of the revenue cycle and of finance to physicians in a way that just helps them understand what you need to do about it in the way that takes up the least amount of your bandwidth possible, right? How do I give my clinical colleagues a working understanding of how it is that their work gets credited or not just so that they can maneuver more effectively? Because what ends up happening is that there's almost this hidden curriculum in our clinical training that suggests and I again I mean this very respectfully but a lot of us carry around this impression that our job is to become very well-versed on the latest and greatest evidence-based treatments out there. and becoming a little too knowledgeable about the financial side of medicine almost represents a conflict of interest to designing and delivering the best evidence-based plan of care when the reality is is that if you are ignorant of the rules of engagement of the system that you function within, it is not helpful for anybody. So I don't need my physicians to understand every nuance of how the revenue cycle works. I really need them to be focused on providing highquality clinical care in a sustainable manner, but they need to understand what words are going to get them credit and what words aren't. And if they don't know, they need to know who to call. So, I do a lot of unpacking this with my clinical colleagues and I'm really grateful to have really strong relationships with the vast majority of my clinical colleagues, which helps tremendously because when I they know they can call me number one. So now I get, hey, they're telling me that my case for tomorrow isn't preserted. Can you help? Or, you know, they're telling me that that we're not productive enough. Can you help? And there's also the, hey, I don't understand this. Can you help me understand this thing and what's happening here? And there's also, hey, this is really hard. Can you help me understand how I do this in Epic such that it's easier for me to schedule these cases or it's easier for me to write these notes? And I consider all of those in my purview and anything else that they can come up with that I can do to make their lives easier and better.

37:16 Because in order for me to make the decision to stop operating, which I ultimately made, I really needed to feel like I was not just serving the population that I had been serving as a clinician, but a broader population. I needed to make sure that I was able to serve my community even more powerfully if I wasn't in the operating room. And that means that if there is a problem and I can be helpful in solving it, I'm in.

37:44 >> We're going to close this out with three questions. Two of them are are pretty straightforward. Denial rate was 20%. I assume that has gone down. >> We are looking at about 2% right now. >> I can only imagine how much money that represents and angst and all those other things. re would it matter to an organization if rev cycle were outsourced? A lot of organizations have outsourced their rev cycle and I'm wondering if your job would be harder in in those scenarios or it just have to have the right relationships and you just make it work.

38:18 >> It's about the relationship. I really think it's about the relationship because you can have a brilliant RevCycle team, but if you don't have great relationships between your RevCycle team and all of the stakeholders that are involved, it's it does it's not going to work. At the same time, if you have a vendor that maybe hasn't been around for 20 years, but is is engaged and willing to to put in the work to make the relationship work, I can see that working well. So I really do think that it is about the relationship, but I will also say that there is a lot to be said for having a degree of organizational knowledge and wisdom around who do you have to go to to get this information or to get this done, who owns that, who who oversees that. And there's value in having people who have been around for a while that know how things work. That is also a double-edged sword though because that's where you can also find the people who say, "Well, this is the way that we've always done it, so this is the way that we're going to do it." And it's helpful to have that balance of organizational wisdom and knowledge and experience combined with a culture of continuous improvement, if you will.

39:25 >> The final question, this is the exit question. I'm I'm trying to figure out if I'm going to do it as a two-parter. I think I am going to do it as a two-parter. the first part being, so I'm listening to this and I'm going, "Oh my gosh, I we we've got to we've got to hire for this role. we've got to we've got to put this program in place. And that's the two questions really. It's like what am I looking for when I'm going out to hire for this role? I' I've decided I this what did we call it before? Chief financial informatics officer. See, I even have to learn the role name. Chief financial informatics officer. I'm going to go out and hire for this. What am I looking for? And then where does that person start to get a program off the ground? I will say that I have been very well served by having a strong reputation amongst clinicians. So you you want somebody who gets along with their colleagues and I think that I have an advantage because I'm a surgeon and I get along with the surgeons really well especially because I did emergency general surgery for such a long time that they called me for their issues and so they I enjoyed that relationship. So I do think that having somebody who can have healthy relationships with your clinical team is an important characteristic. That doesn't necessarily mean that they have to be a surgeon. You just want somebody who's respected by the community. You also need somebody who has, and I, this is something that I learned the hard way, so I'm not going to pretend like I always knew this, but who has enough emotional intelligence to bring a spirit of humble inquiry to conversations. You know, in surgery, you get extensively trained to do something and you become really expert in this one thing. And usually it's people who are smart who pick things up and they are disadvantaged when they don't understand something. And the revenue cycle is a little bit of a black's box. And finance is a little bit of a black box for some of these really smart people that admittedly may or may not have developed dysfunctional coping mechanisms to deal with the pressure and the chronically unmet basic needs of food and sleep and going to the bathroom and seeing your family. And so there's u that can actually make relating with people outside of that group more challenging. And you can come into the revenue cycle in a conversation and say, "Well, what the heck is wrong with you people?" And that's not going to go well. It's going to go very differently than if you say, "Gosh, I don't actually know very much about what you do. Can you please help me understand your job and your pain points and how it is that we might partner to help everybody have a better day?" Totally different conversation.

42:00 >> Totally different. Yes. And good words of wisdom for the home, too. Just >> fair enough. >> Humble humble inquiry goes a long way. It's like why what is making you upset is probably a better question than what's wrong with you. Anyway, I want to thank you for your time. I want to thank you for your work as well in sharing it with the community here today. It's exciting and I'm going to keep following up with you because I'm sure there's going to be more you now that you're at 2% on on denial rate. What are you focused on next?

42:29 >> So, we're still chasing our denials. I think that we will always be chasing our denials and there will, you know, you're going to fix one mechanism of denial and there's going to be another one possible. >> So, if you don't stay on if you don't stay on it, it's going to go from two to 5%. >> Exactly. It's going to creep back up because the rules are going to continuously evolve. So, there's that's always an element of it. Right now, we're also working on making it easier, improving the experience that our clinicians have in our system. We're still relatively young in Epic and we still have a lot of opportunity to really optimize the workflows for a lot of our team members in a way that aligns it with the revenue cycle. I think that our clinical informatics team has done a really great job of thinking through how can we make these workflows make sense from a clinical perspective and harnessing that and hooking it into the revenue cycle so that all of that work is really aligned. I think will also give us plenty of work to do going forward. We've acquired a couple of hospitals, so bringing them onto Epic and and all of those things are also large on the radar. We're talking about doing an ERP, and I don't even know whether I was supposed to say that or not, but that's a huongous thing on everybody's radar right now because what I've heard about implementing an ERP is that it's going to make our Epic implementation feel like we downloaded an app on our iPhone.

43:51 >> It is a it is quite the lift. And I don't think you're announcing anything that isn't known in the industry. Just about just about everybody after they did their EHR implementation then turned their eyes towards ERP and realized we've got to tackle that as well. So >> absolutely. And the last thing that I would say that we're focusing on right now is that we've implemented strata. We never had a tool like strata before in terms of timebased activity based costing. And there's a a treasure trove to be uncovered with the information that we're getting from this strat. I love I love how excited you get about this.

44:26 >> It is really exciting because we've never been able to do this before. It's always been this sort of it was just excruciating to sometimes to get the data and it required multiple people for a long time whereas now you can run these reports easily. So there's the bottom up thing of all the people texting me and then there's the top down thing of the financial planning and analytics team looking at what strata shows us and saying, "Well, we've got opportunities here, here, and here.

44:51 here's what our contribution margin is. What are we going to do about this? And so taking that information down to where the people the work is being done and the people are doing the thing is is a very exciting thing that I'm enjoying a great deal right now. I will be quite frank with you to say when I came into this industry and realized that we don't really have a good handle of our costs, I was sort of dumbfounded like because every other industry I've been in a lot of other industries have a I mean they have a laser focus on their costs and so they're able to tell you it it cost that to deliver that service or to do this thing it cost X Y or Z and I remember the first time I asked well well how much does it cost to do that? They said well it depends. Exactly.

45:36 >> It was a learning curve for me to understand why that's a challenge. But I think a lot of health systems now are looking at, hey, do we really have a good idea of what it costs to have this here or to do this in this way? >> And you know, now that you mentioned cost, I I'm remiss in failing to mention that we're also implementing Cardinal Wavemark as far as our inventory management system in recognition that our supply chain is also a major driver for our costs. So, lots of work going on there. That's that's >> I would be.

46:06 >> So you're you're not worried of working yourself out of a job is what you're telling me. There's always opportunity. >> There is always opportunity and there's I think that there it's honestly now that I've been doing the work and finding so much satisfaction in doing it to your point. It's kind of surprising that I'm the first one with this title and I certainly hope that more people will want to get involved because it's a powerful way that you can make your health care system more effective in serving everybody in the community.

46:36 >> Absolutely. Carla, thank you for your time. >> Thank you so much for having me. It's been an absolute pleasure and it is a privilege to be here. Thank you so much. >> Thanks for listening to the 229 podcast. The best conversations don't end when the event does. They continue here with our community of healthcare leaders. Join us by subscribing at thisweek.comsubscribe. If you have a conversation that's too good not to share, reach out. Also, check out our events on the 229pro.com website. Share this episode with a peer.

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