The idea

Ambulatory revenue cycle centralization is the relocation of patient financial representatives (PFRs) from individual points of service to one, centralized location. This model has been in use for some time for specific functions such as prior authorization and patient call centers, but few organizations centralized other functions before Covid-19. This report examines centralized registration and point-of-service collections for ambulatory clinics. Instead of in-person PFRs collecting patient information, patients use digital channels, including kiosks or handheld devices to submit information. Centralized PFRs digitally connect with patients to confirm their information, collect copays, and route patients to other financial resources.

The promise

Centralization allows organizations to reduce the number of on-site PFRs to optimize clinical site space allocation, flex staffing across sites, and increase productivity. Other potential benefits include higher point-of-service collections, fewer front-end denials, and consistent patient experience across sites.

Why now

Hospitals and health systems have been increasing ambulatory care for years. While this led to interest in centralizing revenue cycle management, the Covid-19 pandemic drove this model to the forefront. Revenue cycle leaders looked to centralization and off-site management to minimize patient contact and combat labor shortages in the pandemic. The benefits gained can continue once the pandemic has abated.

Reality check

Despite the promise of centralization, poor execution and change management can render efforts futile. Organizations need to retrain employees for this model, educate patients to reduce trust concerns, prioritize patient engagement to mitigate any loss of in-person touch, and verify information collected digitally.

A remote ambulatory registration process locates all revenue cycle personnel off-site from where patients receive care. Digitally enabled processes allow staff to interface with patients through multiple modalities such as telephone calls or virtual video meetings conducted with a tablet or other device.

Remote models allow a patient to arrive for care and check in by scanning a QR code from their handheld device. The patient fills out their demographic information and is sent a code to verify their identity and connect any preexisting accounts. The system identifies a patient’s check in status, and a nurse is notified that the patient is ready to see a physician.

A remote PFR reviews the patient file while the patient receives on-site clinical care. After the medical examination is complete, an on-site nurse brings the patient a tablet to digitally connect with a remote PFR who confirms the patient’s information, discusses financial obligations, collects copays, and routes patients to other financial resources as needed. The patient leaves the clinic when they have been cleared by on-site staff and the remote PFR.

Why is it useful?

Centralizing PFRs can produce numerous benefits, as outlined below. 

• Reduce front-end denials: Claim denials continue to plague the health care industry. In 2019, 39% of initial denials were due to technical and demographic errors. Advisory Board’s 2021 revenue cycle benchmarks indicate that the problem became worse during Covid-19, with technical initial denials increasing by 47% from 2019 to 2021. Centralization can reduce strain on the denial management and mitigation processes, and can prevent revenue loss by improving the accuracy of patient information recorded on the front end. 
• Flex staffing: Having PFRs on-site at all ambulatory locations requires a lot of staff and leaves organizations susceptible to shortages due to absences or turnover. Centralization allows organizations to optimize PFR efficiency, adjust staffing to account for patient volumes, reduce the number of on-site focus areas, and minimize site space dedicated to non-clinical staff. 
• Enhance patient experience: In the ambulatory environment, patients’ most frequent complaints are related to interactions with office staff. Organizations that centralize PFRs can standardize patient experience and cater to patients who prefer the ease of digital tools and interactions. Centralized PFRs can improve process consistency, reduce patient complaints, standardize staff responses, and improve wait times. 
• Improve point-of-service collections: There is a narrow window to collect fees from patients in the ambulatory environment. In-person PFRs may not always communicate obligations correctly. However, with a remote model, organizations can standardize and monitor staff communication about patient obligations and collection policies. Centralized policies can ensure that staff route patients to financial resources such as financial counselors, payment plans, discounts, charity care, or eligibility options to maximize collection rates.

Overall market forces at play:

1. Staffing shortages, large turnover, and pressure on staff to have a wide range of knowledge and requirements 
2. Unpredictable patient volumes 
3. Changes in case mix and unemployment 
4. Evolving payer requirements and increased administrative burdens 5. Disparate IT systems

Non-pandemic drivers

Prior to the Covid-19 pandemic, some progressive organizations were exploring the benefits of revenue cycle centralization for ambulatory or hospital-based facilities. The trend was driven by general site-of-care shifts, acquisition of ambulatory sites, increase in front-end denials, shrinking margins, and rising costs. As a result, an efficient and effective revenue cycle became increasingly important, and many leaders turned to centralization to respond to market forces. 

Pandemic drivers

Covid-19 accelerated centralization because hospitals and health systems faced dire financial circumstances and erratic fluctuations in patient volumes. Urgent care centers experienced a 58% increase in visit volumes attributed to Covid-19 care and vaccinations. Traditional PFR staffing models were not constructed to handle rapid changes in volumes that have been experienced during the pandemic. Organizations may turn to centralization to minimize patient contact, flex staff easily and effectively, and continue to combat current market forces that impair revenue cycle performance. 

Hospitality South (pseudonym)

A nonprofit health care organization based in the South. It operates multiple hospitals and 50+ outpatient and urgent care centers.

Hospitality South centralized the registration process for their ambulatory clinics. Registrars connect with patients remotely to verify patient information, discuss financial obligations, and collect out-of-pocket obligations.

The Covid-19 pandemic exacerbated many of the hurdles that Hospitality South’s patient access process faced. The clinics did not have enough physical space at some sites to house the on-site staff required to accommodate the volume of registrations. Managing quarantined employees, high staff turnover, and preventing unnecessary exposure to frontline registrars complicated surge staffing.

To address these issues, Hospitality South initially switched from in-person to phone registrations. Staff called patients to collect their personal information, review financial obligations, and obtain consents. Unfortunately, the process failed due to poor telephone signal and patient mistrust. In response, Hospitality South began integrating their sites with videoconferencing capabilities to allow for communication between patients and the remote registration team. Covid-19 impacted implementation, but currently 9 of their 20 urgent care centers are live. To further the virtual experience Hospitality South has adopted Phreesia —a customized patient intake software— at 3 of their sites and have plans to expand both processes to all 20 sites.

Digital-enabled registration process

The Phreesia process begins when a patient completes the in-person check-in process by scanning a QR code on their handheld device to complete intake forms. The patient information is routed to a remote registrar for review. Once the provider indicates that the patient medical screening is complete, on-site staff will bring the patient a tablet on a cart (referred to as “Reggie,” for registration) to virtually connect with the remote registrar. The registrar will complete registration and collect any obligations. If a patient is unable to pay or indicates financial distress, they are triaged to prompt payment plans, any applicable discounts, or a financial counselor. 

Results from Hospitality South’s pilot

So far, Hospitality South has seen numerous benefits from centralization for patients, staff, and the health system, include:

• Patient experience: Patient satisfaction scores are greater than 98% for Phreesia sites; data is based on 7,750 registrations. 
• Staffing: To optimize staff efficiency the on-site PFR position was repurposed to a clinical support role that assists with clerical and clinical duties through flexible staffing structures that adjust to site-specific needs. 
• Performance: The organization is focused on quality of registrations completed rather than quantity, but the goal is for a PFR to complete four registrations per hour. 
• Collections: The three Phreesia sites increased collections by $113,000 in the first three months of being live.

Hospitality South plans to build on these initial efforts by integrating Phreesia software into the registration and collections process at all their clinics to boost the efficacy of the digital registration process. Phreesia allows patients to fill out personal information before they arrive for their appointments and permits the registrar to validate the entry, obtain electronic consents, and collect remotely via video on a tablet.

Centralizing revenue cycle functions for ambulatory settings is still a novel concept. Your organization might benefit from a centralization now if you:

• Have many ambulatory sites such as urgent care centers and retail clinics spread across a wide geographic area 
• Struggle to achieve performance metrics due to inconsistencies in staff training, education, and oversight 
• Encounter space constraints on-site that minimize clinical space availability 
• Suffer from process inconsistencies across clinics that harm patient experience metrics 
• Require a flexible revenue cycle staffing model to meet fluctuating patient volumes across sites and account for staffing shortages

Your organization may not benefit from a remote model if you:

• Do not have the required funds for the technology 
• Have a large patient or staff population with a preference for in-person models 
• Lack the time and resources for effective change management 
• Do not have care sites dispersed across multiple regions 
• Are not experiencing staffing shortages

Factors that could change the calculus:

• Broader care shifts to and from different ambulatory settings and the relative importance of site-specific revenue cycle expertise 
• Continuation or reversal of social distancing and/or public sentiment about in-person safety 
• Changes in staff preferences surrounding in-person touchpoints, digital safety, or general experience 
• Advancement in technological innovations that further improve the patient experience with remote revenue cycle processes

Today's tight labor market requires systems to achieve greater efficiencies, and there's no sign of the labor market changing soon. Compared to in-person models, centralized revenue cycle management can achieve comparable (or better) collection rates, reduce up-front denials, and standardize the patient experience. But it's important to note that these benefits will come only with effective change management, standardized staff education, and positive staff and patient engagement.