Charge champions: How the Mayo Clinic got back to baselines amid an EHR rollout

By Jill Ludowese Skinner, project manager; Carolyn (Carrie) Macken, MS, unit manager; and Kassandra Young, senior health system engineer, Mayo Clinic, Rochester, Minn. 

Mayo Clinic, a not-for-profit healthcare organization focused on clinical practice, education and research, employs more than 4,500 staff physicians and scientists and has more than 60,000 total employees. There are three main campuses — Rochester, Minn., Jacksonville, Fla., and Scottsdale and Phoenix, Ariz. — and the Mayo Clinic Health System, which includes more than 50 clinics and hospitals throughout Minnesota, Wisconsin and Iowa.

Throughout the enterprise, a variety of core and ancillary EHR and revenue cycle management (RCM) systems were used. In 2014, the organization decided to implement a single EHR/RCM system. Implementation was staggered by region, with four separate go-live dates.

As part of the planning process, Mayo Clinic interviewed academic medical centers that recently implemented new EHR/RCM systems. One of their frequently cited major challenges was their ability to timely and accurately capture charges. To proactively address this risk, Mayo Clinic decided to leverage charge champions who were identified by clinical practice leadership to assist with the reconciliation of charges for their respective practice areas. Each charge champion was responsible for the reconciliation of specific cost centers (hospital revenue) or bill areas (physician revenue) in the EHR/RCM system.

Charge champion role and supporting team

Charge champions were operations representatives selected by leadership to be knowledgeable about and accountable for their area’s revenue. Having charge champions assigned to individual cost centers/bill areas made it possible to identify issues regarding charge capture workflows, missing charges and revenue routing. Previously, these issues were not identified until financial summaries were released each month making cleanup less timely and more difficult.  Charge champions acted as the eyes and ears of revenue integrity at the cost center/bill area level. Their responsibilities were to:

• Help make the transition to the new EHR/RCM system as smooth as possible for patients, staff and revenue metrics to support Mayo Clinic’s mission.
• Become familiar with how charging in their area works and help ensure that others follow best practice workflows.
• Collaborate with revenue and finance analysts to identify and analyze issues, then help solve those issues.

Charge champions partnered with designated revenue analysts from the finance department, who had knowledge of the baseline information and worked closely with the practice on fee schedules, billing practices and much more. Revenue analysts were the charge champion’s first contact for charging questions within their areas of responsibility. Forming this relationship prior to implementation ensured collaboration as issues arose during go-live and was a key factor in the initiative’s success. This team approach was critical at go-live and for ongoing operations. 

Furthermore, charge champions designated delegates to assist with these responsibilities. These individuals were selected by the charge champion or operations leadership to be knowledgeable about their area’s revenue, help answer questions related to charging and fill in as a charge champion when necessary. While the delegate could fill in for them, the charge champion remained the point of contact and was ultimately accountable for identifying issues regarding charge capture workflows, missing charges and revenue routing for their assigned cost centers/bill areas. 

Training

To prepare charge champions for their role and ensure success, a thorough training program was needed. Training on the revenue cycle, charging mechanisms in the new system and understanding the reporting capabilities and results were critical. Training began by introducing the new role and explaining the financial value charge champions would bring to the organization. Information sessions were held and dedicated web pages were created to provide resources for charge champions.

To aid in the understanding of how charging occurred in different clinical settings, charge readiness guides were developed by specialty area by those individuals doing the system configuration, with input from the EHR/RCM vendor. Familiarity and training on these guides was imperative and needed to be completed prior to the second phase of preparation: just-in-time training (JiTT).

While charge readiness guides provided charging execution methods based on specialty/department, JiTT guided charge champions through the steps of creating revenue monitoring reports. The reports built during this final training session were used by charge champions and revenue analysts to monitor daily performance. With each go-live, the training strategy was modified to improve effectiveness and charge champion satisfaction.

Go-live

During go-live, charge champions were instructed to:

1. Ask themselves three basic questions each day:

• Do clinicians or nurses in my department have questions on their charge capture workflows?
• Am I seeing the charges I would expect in my cost center/bill area?
• Is revenue in my cost center/bill area where it needs to be?

2. Review revenue tracking tools to understand posted and pending revenue from the new EHR/RCM and the legacy system, monitor charging performance and identify trends in the area’s revenue relative to expected baselines
3. Run reconciliation reports if low revenue was identified, using revenue analyst support as needed
4. Work on high-dollar, high-quantity and service dates out of range errors
5. Join the daily revenue tracking calls to discuss top risks, trends, causes and resolution plans
6. Follow up with staff and develop plans to address revenue issues

Revenue analysts facilitated the daily charge champion calls during go-live. The frequency and length of the meetings varied based on the complexity of the service line and meetings became more infrequent as service lines reached baselines.

Early in the go-live process, charge champions found significant issues, including:

• Providers failing to close encounters, which is required for charges to trigger
• A workflow problem that prohibited charges from triggering
• Revenue routing to inappropriate cost centers/bill areas

Ongoing support

Thanks to the success of the charge champion/revenue analyst partnership, Mayo Clinic decided to operationalize the charge champion construct as an ongoing way to improve and maintain satisfactory charging performance.

An oversight group was formed to provide consistent, effective and timely support to the charge champions and revenue analysts in the following areas:

• Communication and implementation of institutional policies, standards and practices
• Adjudication of issues and execution of approved solutions consistent with standards and policies
• Resource planning, monitoring and evaluation to optimize limited resources
• Education and communication regarding the integrated revenue cycle and charge-related updates and issue resolution (including system upgrade communication)

Clinical practice, nursing and revenue cycle leaders made up the oversight group. The remaining membership consisted of charge champions (two per region) and a revenue cycle manager from each region.

Results

Charge champions were interviewed four weeks after each go-live to identify areas for improvement. Based on these surveys, the team was able to improve education, set clear expectations and optimize go-live meeting cadence.

A key measure of success was the amount of time it took Mayo Clinic to get back to its revenue baselines, which were established using legacy system data for the six months prior to go-live. Throughout the go-lives, the organization continued to reduce the number of days it took to get back to baseline revenue.  The first implementation took approximately three weeks before revenue baselines were achieved. However, the subsequent two implementations resulted in a return to baselines of less than 10 days. 

Preparing for the unexpected and bracing for the complications that may arise in a large EHR/RCM implementation is an important part of any system change. For Mayo Clinic, having an established charge champion program was a critical part of the effective EHR and RCM system roll-outs. The partnership between the clinical practice and revenue cycle has been a key driver in the successful implementation.