Breaking Down Silos to Increase Revenue:

Breaking Down Silos to Increase Revenue:

Make Pain Your Motivation

We all experience various kinds of pain in life: emotional, physical, intellectual, financial, mental, and more. In healthcare we pretty much deal with all of this variety to some degree. Yet as a surgeon, I pretty much dealt mainly with physical pain. Four categories of pain are recognized: acute, chronic, acute on chronic, and subacute. Acute pain generally will cause someone to seek medical attention rapidly. Subacute and chronic pain typically hurt enough to complain about, but not enough to do something about it, and seek medical attention. Acute on chronic pain, in my mind, presents a different scenario and this has always puzzled me.

Here is a true story from when I was covering the emergency room on a Christmas day as a resident years ago. The average wait time to be seen by a doc was between 5 and 6 hours.

I walked into a cubicle, introduced myself to a middle-aged male and asked: “what brings you here today?”

His response was quite simple: “I’ve had a painful feeling of something in my throat.”

My next questions was quite expected: “For how long?

His response was totally unexpected: “Five years! It’s bothered me a lot.” I couldn’t believe what I had heard. I had various thoughts go through my mind but the one that I needed to understand was what happened that day to make this gentleman wait five hours on a holiday to be seen after five years of pain. I never really got a good answer for him nor myself but I did provide some follow-up treatment for him.

In life we see this type of scenario quite frequently; complaining of something, but no action or attempt to address it or change it. The cause of the complaining for this situation was “pain.” Merriam Webster has several definitions of pain ranging from physical, “a basic bodily sensation that is induced by a noxious stimulus, is received by naked nerve endings, is associated with actual or potential tissue damage, is characterized by physical discomfort” to “mental or emotional distress or suffering” or “one that irks or annoys or is otherwise troublesome”.[1]

Pain is hard to quantify. There are terms such as severe, mild, intolerable, intractable, and others, but these terms are only descriptive especially when it comes to mental or emotional distress. Realize that pain is totally subjective. Everyone feels and tolerates pain differently. I’ve heard it said that the pain of a root canal[2] is awful, many times requiring significant narcotics for relief. Yet, when I had mine, there was no pain after the local anesthetic wore off. There are probably many reasons for my subjective response, but mine are really not germane to the content of this writing. What is germane is how do we quantify something as subjective as pain?

As already mentioned, physical pain is prominent in the healthcare industry. Over the years, there have been multiple attempts to quantify it, whether it be in presenting symptoms or post-operatively, or otherwise. Quantifying the pain has become a mechanism for physicians to judge the pain, helping with treatment to alleviate legitimate pain, safely. There are various drug-seeking individuals that have mastered this quantification of pain for personal gratification, but that will not be addressed here.

When it comes to quantifying pain, it had been termed as the “5th vital sign” in a campaign by the American Pain Society in 1995. The Veteran’s Health Administration added to that campaign in 1999, while California’s legislature passed Assembly Bill 791 in 1991, which mandated that “Every health facility licensed pursuant to this chapter shall, as a condition of licensure, include pain as an item to be assessed at the same time as vital signs are taken. The pain assessment shall be noted in the patient’s chart in a manner consistent with other vital signs.” The Joint Commission added it to their standards effective in 2001 with a revision in 2018.[3]

There are many pain assessment tools involved with patient care available today ranging from simple to complex.[4] Yet, there are none available to investigate non-patient assessments of pain. Revenue cycle management (RCM) in healthcare is one of those areas that, today, is experiencing significant “pain.” Hospitals have been facing financial challenges for the last decade with decreasing reimbursements and increasing denials, amongst other causes. Now, with the global pandemic, hospitals are suffering escalating financial pain in the form of losses. The American Hospital Association looked at hospital costs, cancelled surgeries and services, the additional cost of personal protective equipment (PPE), and support for their workers over a four-month period from March 1 to June 30, 2020. Their analyses estimated a total impact during that time of losses of $202.6 billion, averaging over $50 billion per month for America’s hospitals and health systems.[5] According to Becker’s CFO Hospital Report[6] at least 42 hospitals across the U.S. have closed or entered bankruptcy this year, and the financial challenges caused by the COVID-19 pandemic may force more hospitals to do the same in coming months. There have been numerous closures prior to this year.

Hospitals and healthcare systems are noted for patient care and numerous other services and are valuable resources to the communities they serve. They deserve to be paid for the services they provide, period. Hospital “median operating margins reached 1.7  percent in 2018, down from 1.8 percent in 2017. A more sustainable operating margin would be around 2.5 percent, according to Christopher Kerns, executive director at The Advisory Board, who said “that’s still an anemic margin overall,” adding that (median operating margin) “was held back by low revenue growth.”[7]

Even though the industry is so severely regulated there must be a process by which they can stay financially afloat. Simple principle: you cannot have expenses that exceed incoming revenue. This process is relegated to RCM. One of the best definitions that I have found is “Healthcare revenue cycle management is the financial process that facilities use to manage the administrative and clinical functions associated with claims processing, payment, and revenue generation. The process encompasses the identification, management, and collection of patient service revenue.”[8] It is the full 360° cycle, from patient registration to dropping the bill.

When something is happening that one doesn’t like, there are three options:

  1. Change it – best option
  2. Deal with it – just complaining, may not be sustainable
  3. Leave it – what does that solve?

In my motivational speaking days, there were three principles that I espoused:

  1. “The definition of insanity is doing the same thing every day, expecting different results” (may be falsely attributed to Albert Einstein.)
  2. “If You Always Do What You’ve Always Done, You’ll AlwaysGet What You’ve Always” — Henry Ford
  3. If you want to make some changes in your life, you’ve gotta make some changes – my saying

What kind of changes can RCM make? What is the solution? The question to ask before that is how much pain needs to be endured for RCM to be motivated to change and not just use temporary patches. Don’t accept the pain. Said better, what will be the precipitating factor that will cause RCM to make some changes now.

The simplest solution is to get back to fundamentals. Think about this: Your service mix is what it is; you are not going to start a cardio-thoracic surgery department if you don’t already have one. Reducing that volume may not be a good solution either. The payer mix is not going to change either. Where is your revenue cycle leaving money on the table? How well is patient care being managed?

The solution is “Utilization Management 360®”, a revolutionary new concept consisting of the five components of utilization review (UR), case management (CM), clinical documentation integrity (CDI), the physician advisor (PA), and coding/compliance. They all funnel into the revenue cycle. The challenge is that each one tends to exist in a silo, creating a sense of territorialism which may be impeding collaboration in your hospital. What is interesting is that each one of those functions is looking at the same chart, the same documentation, but with their own lenses. That is the good news and the bad news. These components are all seated at the same table. The question revenue cycle must ask of itself is have they lost sight of what documentation really is and the role it pays? Does it adequately tell the patient story throughout the 360 cycle and support the services provided?

The PA may not necessarily be a silo since that individual(s) interact(s) with the first three components and may actually serve to gain acceptance throughout. Healthcare systems must embrace this concept, as it will help to drive optimal revenue cycle operational efficiency and performance with strong net patient revenue integrity. It will enforce standardization and accountability making it sustainable. With collaboration as a goal from the beginning to the end of a patients episode of care, breaking down the silos can provide solutions for quality improvement, improved patient care, decreasing denials, and better throughput throughout all components.

There are some challenges without this collaboration, without breaking down the silos, without integration and communication. Here are some examples:

  • If there is no medical necessity to justify the acuity of an inpatient (IP), CDI will not be needed – it is irrelevant
  • With an initial order of IP, CDI gets involved
    • Changed to observation (OBS) means wasted time for CDI
    • Time could have been spent elsewhere
  • Many coders only want to touch the patient chart once
  • Efficiency is throughput. Is everyone sitting at the same table for the same meal?


  • Does leadership understand what its component does?
  • Does each component have the right tools and staff to achieve outcomes?
  • Is there interdepartmental education to have an overarching understanding of each component?
  • Is physician education consistent across all specialties and components?
  • Are there rewards/incentives for outcomes, not tasks, key performance indicators (KPIs)?

Another key factor is to decide what your outcomes need to be, what do you want to achieve? It has been said that if one doesn’t know where they are going, they will never know when they get there. Marcela Sapone has said:  “Ticking off tasks on our to-do lists might make us feel productive. But to truly be productive, we must clearly visualize the outcomes we want and design everything we do around getting them.”[9]

What kind of results might one expect with this collaboration, this integration?

  • Education and better understanding of each department to the other reducing duplication of efforts, thus increasing efficiency
  • Sustainable front end level of care recommendations supported by compliant processes with a resultant decrease in Condition Code 44 and Condition Code W2
  • An increased focus on meaningful integrated documentation that best communicates patient care, that gives an accurate depiction of the patient story with a resulting reduction in denials and revenue preservation
    • One cannot take credit for income received that is taken back
  • Alignment of vision/mission – autocorrect past difficulties in mis-aligned functions
  • Keeping aligned with outcomes focused, in today’s world of value-based purchasing (VBP) and quality metrics, areas that can be affected:
    • SOI, ROM
    • Quality – VBP – four parts with each a 25 percent domain
    • Medicare Spending per Beneficiary (MSPB)
    • HCAHPS – Hospital Consumer Assessment of Healthcare Providers and System
    • Patient Safety indicators PSI
    • Clinical Care
    • Readmission Reduction Program
    • Hospital Acquired Conditions Reduction Program
    • Unnecessary days
    • LOS management
    • Present on Admission
    • 30-day mortality rates
  • Reinforcers of “the message” with the on-site physician advisor (OSPA) to physicians and other clinical entities

This may seem to be an overwhelming task, but do you have a solution to alleviate your revenue cycle pain, especially in these challenging healthcare crisis times. There are four basic steps to get started:

  1. Make a decision – change will not occur on its own, it may be painful but so is where you may be today
  2. Engage someone who can help
    1. Find someone who has done what you need to do
    2. Assess where you are today with a Gap Analysis
    3. What are Best practices – your end point
    4. Interview Key Players
      1. Leaders and Staff
    5. What are the missing pieces?
    6. What gaps are there in your documentation practices?
    7. This is a multifaceted process and will require
      1. Planning
      2. Education of all components
  • Getting buy-in
  1. Implement the changes
    1. Determine what are your indicators of success ahead of time
    2. Develop standardization across all components, what are the expectations?
      1. Don’t accept “no” or “it won’t work”
    3. Intermittent Reassessment
      1. Why reassess?
        1. There probably has been leadership changes
        2. There probably has been staffing changes
        3. Is the education still consistent incorporating changes that have occurred in the industry?
        4. Is everyone accountable, following an established protocol?

In summary, the implementation of the “Utilization Management 360®” appears to be a good solution. It is the solution that makes sense and produces results.

“Utilization Management 360®” provides best practice solutions for each component of the clinical documentation continuum and revenue cycle. With the proven success of bringing a holistic approach, “Utilization Management 360®” gives you the ability to identify the missing pieces in your current workflow. Once identified, it establishes a focused communication partnership between and within stakeholders of your revenue cycle and breaks down the silos impeding collaboration within your hospital. “Utilization Management 360®” builds on years of experience working with multidisciplinary teams and provides a physician-led solution to your patient-centered clinical and financial strategies.










By John Zelem, MD, FACS
President – Streamline Solutions Consulting, Inc

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