Rising to the Challenge: How Leading
Healthcare Organizations are Thriving
in an Evolving Revenue Environment
The views and opinions expressed in this white paper are those of the authors and do not necessarily reflect
the official policy or position of Ingenious Med or any other agency, organization, employer or company.
WHITE PAPER
Lower volumes, changing case and payer
mixes paired with greater uncertainty
about positive operating margins make
revenue optimization more essential
than ever for healthcare organizations.
But what are the best approaches in
healthcare reimbursement for thriving
in today’s uncertain financial environment?
We’ve asked leaders from several
physician management organizations
and healthcare systems to share their
strategies for overcoming the considerable
challenges of this altered landscape.
They describe how they used data and
analytics to better manage capacity,
coordinate care, optimize revenues
and adapt to changing reimbursement.
The Pandemic Has Made Managing
Healthcare Finances Even Harder
Operating health systems and physician
practices has always been hard, but the
COVID-19 pandemic has created new
challenges to profitability in 2020 despite
significant federal subsidies. Before the
pandemic, healthcare financial cushions
were already thin. In 2018, health system
operating margins were 30 percent lower
than 2015 levels.1 And Kaufman Hall found
that more than 30 percent of U.S hospitals
had negative margins in 2019.2
(See Figure 1.)
COVID-19 only made it harder to operate
in the black. A July 2020 HFMA survey
of 174 healthcare leaders found that 89%
of respondents expect 2020 revenues to
How Leading Healthcare Organizations are Thriving in an Evolving Revenue Environment
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be lower than pre-pandemic levels, and 62%
project that those losses will be 15% or greater.3
Hospitals and physician practices have both
experienced financial pain. During the spring
of 2020, hospitals lost $60B per month as
surgical volumes declined by 61%, discharges
by 30%, and ED visits by 43%.4 While volumes
are rebounding, an American Hospital
Association (AHA) report projects that hospital
financial losses will deepen by an additional
$120.5 billion in the second half of 2020,
bringing total losses to at least $323.1 billion
for the year.5
Figure 1.
The AHA report states, “Experts have
warned that the recovery pace for hospitals
and health systems will be slow and that
normal hospital volume will not come back
quickly even as states lift moratoriums on
non-emergent procedures.”
1 LaPointe, J. (2020, March 5). Hospital Revenue, Margins Improved in 2019 Despite Rising Expenses. RevCycleIntelligence. Retrieved September 25, 2020, from https://
revcycleintelligence.com/news/hospital-revenue-margins-improved-in-2019-despite-rising-expenses
2 The Effect of COVID-19 on Hospital Financial Health (Rep.). (2020, July). Retrieved September 25, 2020, from Kaufman Hall website: https://www.aha.org/system/files/
media/file/2020/07/KH-COVID-Hospital-Financial-Health_FINAL.pdf
3 Ibid.
4 Kacik, A. (2020, May 11). Deferred procedures drain hospital revenue by $60B a month. Modern Healthcare. Retrieved September 25, 2020, from https://www.modernhealthcare.com/operations/deferred-procedures-drain-hospital-revenue-60b-month
5 Hospitals and Health Systems Continue to Face Unprecedented Financial Challenges due to COVID-19 (Rep.). (2020, June). Retrieved September 25, 2020, from
American Hospital Association website: https://www.aha.org/system/files/media/file/2020/06/aha-covid19-financial-impact-report.pdf
On the physician side, the picture was also
bleak. In April 2020, physician practices shed
243,000 jobs6 and lost an average of 55% of
their revenues.7 As a result, 53% of physicians
reported feeling very or extremely concerned
about the pandemic’s long-term impact on
their practice.8 Data from the Ingenious Med®
application show that this concern may still be
warranted. Billings dropped a massive 40% by
April 2020. After rebounding in July and
trending back up to 90% of pre-COVID levels
by August 2020, bills created per day dropped
off again to around 75% of typical volumes in
September 2020.
Effective Strategies for Optimizing
Revenues and Resources
How have leading healthcare entities risen
above COVID-19’s myriad challenges to
maximize productivity, cope with dramatic
volume and casemix changes, and optimize
revenues? Using examples from American
Physician Partners (APP), US Acute Care
Solutions (USACS) and a major medical group
at a southwestern health system, we asked
healthcare leaders to share the strategies that
have enabled them to succeed in an evolving
revenue environment. Their ideas for optimizing
the revenue cycle focused on using data and
analytics to manage capacity, coordinate care,
optimize resources and adapt to changing
reimbursement models.
- Manage Demand by Tracking Real-Time
COVID-19 Volumes
Having accurate and timely data is critical
to success. Key data includes census data
and real-time COVID-19 patient volumes that
can be viewed across the organization at all
locations. Sharing data from these sources
enabled these organizations to gain insights
into volume fluctuations that have been
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helping them right-size their resources during
the pandemic.
Dennis Deruelle, MD, FHM, APP’s Executive
Director of Hospital Medicine, noted, “After
seeing a roughly 45 percent drop in ER volumes
and a 35 percent drop in hospital medicine
volumes this spring, we had to make rapid
staffing changes to match the lower demand.
Fortunately, we use a staffing grid developed
internally plus performance dashboards that
include encounters per day and total encounters
to calculate our productivity. We could review
our census on a daily basis for every practice,
and track the trends to help us project the
upcoming week. That allowed us to identify
hotspots and shift resources accordingly.”
“We could review our census on
a daily basis for every practice,
and track the trends to help us
project the upcoming week.
That allowed us to identify hotspots
and shift resources accordingly.”
Dennis Deruelle, MD, FHM, Executive Director
of Hospital Medicine at APP
USACS also used analytics to adapt its budget
and staffing as patient volumes fluctuated
during the pandemic. An administrative
dashboard proved helpful for spotting spikes
in census, LOS, readmissions and more.
It enabled administrators to focus additional
resources on sites that were receiving an influx
of COVID-19 patients.
Leaders at APP, USACS and the southwestern
health system took advantage of new automated
COVID-19 identifiers and trackers developed by
Ingenious Med to check COVID-19 patient
volumes multiple times a day. Clinicians at each
site used this real-time data to spot potential
6 King, R. (2020, May 8). Healthcare jobs declined by 1.4M in April as physician practices shed 243,000 jobs. Fierce Healthcare. Retrieved September 25, 2020, from
https://www.fiercehealthcare.com/practices/healthcare-jobs-declined-by-1-4-million-april-as-physician-practices-shed-243-000-jobs
7 LaPointe, J. (2020, April 15). Physician Practice Revenue Cut in Half Due to COVID-19 Crisis. RevCycleIntelligence. Retrieved September 25, 2020, from https://revcycleintelligence.com/news/physician-practice-revenue-cut-in-half-due-to-covid-19-crisis
8 Sullivan, T. (2020, June 16). Study Finds Outpatient Practices Hit Hard by COVID-19 Pandemic. Policy & Medicine. Retrieved September 25, 2020, from https://www.
policymed.com/2020/06/study-finds-outpatient-practices-hit-hard-by-covid-19-pandemic.html
How Leading Healthcare Organizations are Thriving in an Evolving Revenue Environment
capacity issues due to physician staffing
availability and allocate resources accordingly
to support their sites while minimizing waste.
Having daily census data also enabled their
physicians to better plan their daily schedules.
“We could review our census on a
daily basis for every practice, and
track the trends to help us project
the upcoming week. That allowed
us to identify hotspots and shift
resources accordingly.”
Dennis Deruelle, MD, FHM, Executive Director
of Hospital Medicine at APP
Andrea Funk, VP Integrated Acute Care
Operations at USACS, also found this data
helped identify areas where it needed to deploy
its telemedicine backup plans in case providers
got sick and were unable to work onsite. “Having
Ingenious Med helped us stay focused during
this crisis,” she explained. “The platform made
it much easier to reassign physicians from less
busy areas – like the emergency department and
anesthesiology – to help staff our critical care
areas, where we greatly needed the help.”
APP used telehealth as a backup for
managing overflows. “When you cut staff,
hospitalists worry that there could be days
when they get overwhelmed, even though that
rarely happens,” stated Dr. Deruelle. “So, we
put virtual visits in place to manage any
overflow, which was invaluable in reducing
physician concerns.” - Plan for a Potentially Longer Length of Stay
The unique aspects of COVID-19 meant that all
three organizations had to prepare for a much
longer LOS for patients with the virus. Funk
said, “Managing co-morbidities was critical to
managing LOS in COVID-19 patients. In contrast
to our average LOS of 3.8 days, their average
LOS was closer to 20 days and sometimes
lasted over 100 days. Even when COVID-19
patients are stable, we often can’t discharge
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them to long-term care because they’re still
on CPAP [continuous positive airway pressure
devices]. That keeps them stuck in the hospital
and creates back-ups.”
USACS used its COVID-19 dashboard to receive
an accurate daily update of these patients by
location, which enabled administrators to
anticipate which facilities would need to get
temporary privileges for a pool of physicians
and APPs who were helping to manage
the surge.
The southwestern health system used the
platform’s analytics dashboard to help practices
track the higher LOS for COVID-19 patients and
the much lower census. Two key measures, LOS
and readmission rates, flow from the Ingenious
Med app into that scorecard, enabling medical
directors at each site to drill down by physician
to see which ones needed help managing LOS. - Use Analytics to Manage Productivity and
Modify Physician Incentive Compensation
APP and the southwestern health system found
that being able to use indicators to identify
COVID-19 patients also helped to manage
productivity without overburdening their
physicians. Since these patients consumed more
physician time, administrators could determine
when to reduce the number of patients assigned
to a hospitalist.
“We were able to track
productivity by patients per
shift and see whether we were
‘green,’ which meant we were at
100% productivity.
Dennis Deruelle, MD, FHM, Executive Director
of Hospital Medicine at APP
The southwestern health system’s medical
group had to cancel all elective surgeries in
March, contributing to a loss of about 50%
of volumes and over $620 million in revenue.
It sought to avoid layoffs by developing
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by patients per shift and see whether we
were ‘green,’ which meant we were at 100%
productivity. We could view our productivity by
site every single day. That was extremely helpful
because then we could tell our site medical
directors, ‘This is the staffing that we want,
and this is what you’re shooting for.’”
As part of its provider engagement efforts,
Adfinitas provides coding education to its
physicians and advanced practice providers
and requires them to monitor their performance
using Ingenious Med’s reports. “It’s very easy
for them to do and they can get reports in just
a few minutes,” said Dr. Mitchell. - Capture Charges Efficiently and Accurately
at the Point of Care
To optimize revenues, Perkins recommended
going back to basics while taking advantage
of efficient technology. Prior to the pandemic,
the southwestern health system was wellpositioned to capture charges because it had
switched from highly inefficient manual revenue
cycle processes to using both Ingenious Med
different staffing structures, offering voluntary
severance packages and reducing hours and
schedules.
The group used Ingenious Med data to adjust
its productivity targets and to enable physicians
to easily track their performance against the
new compensation targets.
Derick Perkins, Managing Partner of Metis
Advisors, LLC, worked extensively with this
health system’s medical group.
“Over-communicating to physicians and
clinical staff was critical,” he said. “Doctors
were upset because they know volume losses
impact their RVUs. Reassuring them that their
compensation targets would be adjusted
helped to allay concerns.” When volumes
began rebounding to about 70% of normal
in July and August, the group could
modify staffing and targets accordingly.
Dr. Deruelle noted that APP used its analytics
dashboard to track the hours cut as well as total
hours. “We were able to track productivity
Having a dedicated physician charge capture and practice
analytics platform focused specifically on your practice’s needs
and goals can be the key to success in this environment where
managing scarce resources, controlling productivity and billing
for every service rendered is essential for survival.
Healthcare organizations must be able to evaluate and
standardize performance between individual providers as well
as across teams andpractices. They also need to deliver timely,
actionable insights to the front-line clinicians who directly affect
productivity, performance and revenues.
Doing so relies on capturing revenues accurately at the point
of care. Real-time data enables clinicians and administrators
to identify issues and spot trends, as well as underlying causes.
When an intuitive interface that can deliver insights without
impacting workflows is combined with a mobile, point-of-care
application, organizations can extend practice analytics to all
stages of the patient.
The value of a dedicated physician charge
capture and practice analytics solution
www.ingeniousmed.com 6
and its EHR system, Athena Health, to capture
all charges efficiently.
“The health system leveraged the power of both
systems to identify the most appropriate codes,”
Perkins explained. “It helped reduce charge lags
and got claims out the door faster, so we could
get paid quickly and correctly.”
“Before the new system, inpatient
physicians had charge lags as long
as 30 days. Afterwards, charge lag
went down to six days as a result
of capturing charges accurately
at the point of care.”
Derick Perkins, Managing Partner of Metis
Advisors, LLC
He added, “Before the new system, inpatient
physicians had charge lags as long as 30 days.
Afterwards, charge lag went down to six days
as a result of capturing charges accurately at
the point of care.” The health system’s medical
group used the Ingenious Med MasterCoder tool
to help improve coding speed, accuracy and
compliance while reducing coder workload
and the amount of coding staff required. It also
reduced the number of denials resulting from
filing claims late. - Educate and Support Physician
Charge Capture
The pandemic has made it more essential
than ever for hospitals and physician practices
to collect all the revenue to which they are
entitled while minimizing the cost to collect.
Coding accurately is an important step
in avoiding undercoding and lost revenue
while improving the allocation of back-office
resources and using them more efficiently –
both important actions given today’s
tighter margins.
The southwestern health system also invested
heavily in ongoing physician education to help
avoid undercoding and overcoding at the point
of care. Instead of performing charge entry,
coders could focus instead on reviewing and
reconciling charges to increase compliance.
The platform enables quality assurance staff
to pull the missing bills report from the system
(as well as other reports) to monitor each
practice and identify any missing charges.
APP used a similar approach. “We believe
that the physician should pick the code, not
a coder,” said Dr. Deruelle. “We use coders
to provide oversight or make suggestions to
ensure documentation and coding are accurate,
but physicians deliver the care and they know
exactly what services were provided.”
USACS used the tool to stay current with
each site’s activity from a practice management
standpoint. “Our physicians were amazing,
and we pride ourselves on them capturing
their charges the same day or in real time,”
Funk explained. It also used the platform
to quickly create superbills for staff temporarily
assigned to care for COVID-19 inpatients,
such as emergency medicine physicians who
weren’t used to submitting their own charges. - Reduce Denials by Holding Claims to the
Point of Discharge
The southwestern health system learned an
important lesson along the way. It was initially
reluctant to hold claims until the time of
discharge, and instead continued releasing
claims as soon as they were received in the
practice management system. The health
system eventually switched when it realized
that holding claims to clear inside the platform
helped to catch certain issues and avoid
duplicate charges. - Create Payer Report Cards
To ensure that payers are reimbursing at
the contracted rate or at the advertised
telemedicine rate when the pandemic first hit,
Perkins recommended keeping a report card
for major payers to track this data. He stated,
“For example, we found that some payers are
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not reimbursing for telehealth as much as
they had promised, so I truly believe every
organization should have a payer report card.
At a minimum, that report card should track
how much you’re collecting versus your
contracted rate as well as your denial rate
with that particular payer.”
“You need to hold payers
accountable.”
Derick Perkins, Managing Partner of Metis
Advisors, LLC
Perkins added, “The need for payer report
cards pre-dates COVID-19, but the pandemic
has made it essential to go back to the basics
and make sure you’re getting paid according
to your contract. You need to hold payers
accountable. You could consider partnering
with an underpayment firm on a contingency
basis, and make sure you regularly update
your fee schedules and track denials closely.
We found that payers may say their systems
are ready to take certain codes, but then
deny them. This causes more work for
collectors and ultimately increases A/R Days.” - Develop a Comprehensive Self-Pay Strategy
The pandemic dramatically swelled the ranks
of the unemployed and accelerated the trend
of patients paying for more care out of their
own pockets. Continuing a practice it had
started before COVID-19 hit, the health system’s
medical group developed a comprehensive
self-pay strategy that included offering patients
financing options through a medical credit
card company.
Perkins noted, “COVID has increased the
percent of self-pay patients and patients today
have higher out-of-pocket responsibilities than
they used to. Several government programs
have provided some relief for self-pay balances,
enabling health systems to file those claims
to this program and receive reimbursement
if they meet certain criteria.” He also noted
that organizations can provide patients with
other options, such as internal payment plans
including working with patient financing firms
for extended payment options. - Make More Informed Bundled Payment
Decisions
APP and many of its hospital partners
participate in value-based models such
as bundled payment programs. Dr. Deruelle
commented, “CMS has given bundled payment
programs a reprieve, so we could just push
this year if we want to avoid losing money.
Or we have the option of pulling every COVID
patient out. Thankfully, our platform allows
us to identify all our COVID patients and pull
them out of the model if we wish, so we can
determine which is the ideal option for
our organization.” - Improve Throughput Across the Continuum
The highly infectious nature of COVID-19 meant
that fewer patients could be discharged to
skilled nursing facilities. The Ingenious Med
platform’s COVID-19 identifiers proved useful
in helping organizations proactively identify
infectious patients so they could better plan for
discharges and improve coordination with case
management departments. That, in turn, helped
reduce bottlenecks elsewhere in the hospital
and improve throughput.
“The reports enabled us to quickly
improve communication, discharge
patients timely and decongest
emergency departments that
needed it.”
Andrea Funk, VP Integrated Acute Care
Operations at USACS
Funk explained, “We used the anticipated
discharge flag identifier to send a daily report
to our site hospital case managers so they knew
in real time each day who was going home.
We found that some hospitals had perhaps
20 patients in the emergency department that
needed inpatient care but were boarded in the
ED because no inpatient beds were available.
How Leading Healthcare Organizations are Thriving in an Evolving Revenue Environment
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The reports enabled us to quickly improve
communication, discharge patients timely
and decongest emergency departments that
needed it.”
Another strategy that proved effective for
USACS was partnering with one of its hospital
systems and state officials to open a specific
treatment facility to care for infected patients.
“When the skilled nursing facilities couldn’t
admit new COVID-19 patients or take their own
patients back, we deployed a team of providers
to expand an empty facility to care for COVID
patients exclusively, which took pressure off
the other hospital system inpatient units and
relieved local emergency department
backups,” Funk observed.
Lessons Learned
When the healthcare world is turned upside
down by a pandemic – and when collecting
every dollar has never been more critical –
organizations with point-of-care charge
capture tools and accurate, real-time analytics
will be better positioned to weather the crisis
than those that lack insights and are flying blind.
Predictions about what the coming year
holds for healthcare organizations in terms
of volumes, revenues, casemix and payer mix
vary widely. Having the right tools to manage
capacity, optimize revenues, adapt to changing
casemix and reimbursement, and coordinate
care across the continuum, will help
organizations to more accurately predict
and more nimbly respond to that future.
While it’s ideal to have these tools in place
before a crisis, it’s never too late to get started.
Mobile tools that deliver cutting-edge analytics
based on timely and accurate data that
physicians themselves can enter at the point
of care make monitoring key metrics such as
LOS and productivity far easier for clinicians
and administrators alike. When such solutions
can be easily integrated with existing EHRs and
IT systems and when they are designed to be
intuitive for physicians to use, organizations
can quickly get up and running before the
next crisis hits.
For more information about Ingenious Med
or to request a free demo, call 770.799.0909
or visit online at ingeniousmed.com.
About Our Contributors
Dennis Deruelle MD, FHM, is Executive Director
of Hospital Medicine with American Physician
Partners (APP) in Nashville, TN. He supports the
management of APP’s hospital medicine program
and provides clinical oversight to its hospital
medicine physicians and advanced practice
clinicians in support of the company’s ongoing
quality efforts. Dr. Deruelle has over 15 years of
hospital medicine leadership experience, having
served as the owner of a private hospital medicine
practice and CEO/Founder of a boutique
healthcare consulting company.
Andrea Funk, RN, MEd, CPHQ is Vice President
of Integrated Acute Care Operations at US Acute
Care Solutions. She applies her more than 20
years’ experience in nursing, quality management
and patient safety to supporting hospital
administration, physicians and staff in their
daily practice and quality improvement initiatives.
Ms. Funk provides expertise in site practice
operations, including improving quality metrics,
through her commitment to the professional
development and support of all clinical and
operational staff.
Derick D. Perkins is a Revenue Cycle Leader
with over 23 years of experience working with
large health systems across the country.
He has performed successful revenue cycle
optimization projects at Ascension Healthcare,
Allina Health, LifePoint, Christus Health and
oversaw the unprecedented growth of the
Memorial Hermann Medical Group from less
than 200 providers to over 800 providers.
Mr. Perkins is the founder of Metis Advisors LLC,
a consultancy that improves the financial health
of rural and smaller practices through revenue
cycleoptimization and recovery.