American Association for Physician Leadership

Finance

Non-Fee-for-Service Revenue Cycle Management: Tools of the Trade—Clinical Call Center

Ronald B. Sterling, CPA, MBA

February 8, 2021


Abstract:

From proactive analysis of patient health status to facilitating patient treatment recommendations, contact with at-risk patients is more frequent and intense under the non-fee-for-service models. Continuing attention to patient services will challenge most practices and healthcare organizations. The clinical call center is a critical tool to effectively and efficiently monitor and manage patients.




In many practices/healthcare organizations (HCOs), the patient service strategy is based on paper medical records. Typically, patient calls are taken by an answering machine, front desk staff, or triage staff. In many cases, the patient issues are recorded and passed to the doctor for an answer. In some cases, a triage line is staffed by nurses who offer basic information and advice to the patient and have the authority to manage the same-day appointments for the doctor.

In many cases, patient service strategies are managed within each location. For example, a practice with 10 offices typically has patient service staff in each location. The patient service process is a vestige of paper charts: patients cannot be served without being able to look at their chart. Indeed, some practices are creative about ensuring that patient service staff have the chart before talking to the patient. For example, some practices put the patient service staff in the middle of the medical records room so they can access the chart while speaking with the patient. In other situations, practices take messages or have the patient go to voicemail so the patient service staff can retrieve the patient chart before calling the patient back.

Often, practices/HCOs incur the cost of a clinical call center but do not benefit from the investment. For example, the 10-office practice mentioned above had 12 full-time staff (1 or 2 per office) dedicated to patient calls that added little to patient care, but controlled access to priority appointments. Practices in this situation may be able to create the clinical call center by redesigning the current process and relocating the current staff.

In other situations, the clinical call center will be an entirely new expense. For example, many practices/HCOs funnel all calls to the front desk staff to manage same-day appointments but offer no clinical advice. This strategy also keeps people in the office waiting to check in or out while the front desk staff addresses the phone traffic. In that situation, a call center would require new staff and space.

The non–fee-for-service (FFS) model changes everything about how practices serve patients through direct and indirect requirements that affect payments to the practice. Under some non-FFS arrangements, the practice has an incentive to control the cost of care using its own proprietary strategies and techniques. For example, an incentive payment may be tied to lower expenses, which may be achieved with frequent non-physician contact with patients.

Regardless of how patient issues get to the practice, the information must be triaged by appropriate clinical staff on a timely basis to assure that the patient is properly managed and served

Evolving industry requirements also point to a call center strategy. For example, Advancing Care Information includes measures to gather information from patients outside of the clinical environment and use secure messages to maintain contact with patients. Regardless of how patient issues get to the practice, the information must be triaged by appropriate clinical staff on a timely basis to assure that the patient is properly managed and served. For example, what good will remote patient information on their weight serve if no one is available to review the information outside of tolerances over the weekend?

If clinically appropriate, addressing patient issues without an office visit is allowed and encouraged under many non-FFS models. For example, a drug prescription can be refilled based on documenting a discussion with the patient over the phone, and a patient can be checked on through a Skype-like conversation with a clinical call center.

The clinical call center can address the explosion of real-time traffic from patients over the phone and over the Internet while freeing up the providers in the office to concentrate on the patients. As important, the clinical call center is instrumental in meeting patient care and services to earn and/or qualify for non-FFS revenue.

The clinical call center strategy addresses several important challenges:

  • Response to Patient Issues: Many non-FFS arrangements include requirements to respond to patient issues on a timely basis. Such actions may be instrumental in providing effective patient care and avoiding unnecessary costs. For example, directing patients to a hospital if the doctor is not available may not be the most cost-effective or timely way to address a patient issue. These issues may evolve during business hours as well as outside of business hours. The current off-hours call strategy of connecting the patient with the doctor may prove inefficient and disruptive. For example, a constant stream of information from remote blood pressure devices may have to be analyzed 24/7. Interestingly, 24/7 access to clinical advice is a MIPS clinical improvement activity.

  • Patient Management: Non-FFS arrangements may include incentives to proactively manage patient care and patient adherence to clinical recommendations. Such activities will require current information on patient treatment issues and strategies as well as tools to encourage patient adherence. Patient portals, outgoing patient calls, and monitoring overdue treatment recommendations may be managed through the clinical call center. Additionally, any call to the clinical call center would be an opportunity to encourage adherence as well as raise awareness of treatment plans that need adjustment. For example, frequent patient calls and/or too many alerts from remote patient monitoring (RPM) systems may trigger an internal call center escalation to a mid-level provider in the call center.

  • Monitoring Patients: A wide range of tools and processes are designed to more closely monitor patient care and status outside of an office visit. For example, payers may pay for telemedicine visits with patients by nurses and other professionals. Similarly, remote patient services may be part of home health visits, therapy programs, and patient wellness strategies. For example, home health episodes of care that include call center checks with patients in place of home health visits are more cost-effective and convenient than home visits alone. Such strategies will increase in importance and require an organized strategy to address evolving patient issues without disrupting office clinical operations and physicians.

The clinical call center allows the patients and the practice/HCO to fully benefit from the instant access to patient information as well as more communication through the Certified Electronic Health Record Technology (CEHRT), patient portals, and other tools to serve and monitor patients.

The key to effective clinical call centers is a structured and controlled process to establish, manage, and monitor patient issues. The following key issues should be addressed.

Call Center Tools

Many CEHRT products lack the tools to effectively manage a clinical call center. CEHRT limitations include the lack of management tools to track and assign issue flows from patient portals, incoming calls, incoming readings from remote devices, and even incoming referrals. Call centers also require routing and coordinating incoming calls to the available call center staff. Such requirements may be handled by your phone system.

In some cases, you may be able to create workarounds to support the call center or use software from a vendor allied with your CEHRT publisher. For example:

  • CEHRT messages and/or clinical note tools may be used to structure, track, and document clinical call center activities.

  • A third-party RPM system may be needed to monitor patient subjective and objective information submitted from patient homes or through smartphones.

  • Third-party patient portal software may be used separately to manage and monitor incoming messages and even remote patient information. Patient portal software programs have varying degrees of interfacing with their CEHRT partners.

Operational and Clinical Protocols

The practice/HCO medical leadership should develop supporting clinical and operational protocols to frame and empower the call center services. Clinical standards should specify issues to be handled by the various call center staff as well as documentation templates customized for the situation and disease. Call center protocols should define the escalation strategy within the call center staff as well as physician monitoring of call center activities. For example, the problem type and/or patient health status determines whether the issue is managed by a nurse or PA, as well as triggers for immediately contacting the doctor on call.

The call center design will be built on the functional and clinical framework of the CEHRT. For example, the practice/HCO should verify that call center activities can be viewed and managed within the context of other clinical services and information.

The call center is a key strategic asset to support non-FFS requirements and enhance general patient contact and engagement under MIPS. In many cases, these capabilities will involve dramatic enhancements to current triage strategies or a new capability that requires new clinical guidelines and protocols.

Call Center Staff

The call center staffing requirements may differ dramatically from the current triage strategy. For example, many practices currently route all issues directly to the patient’s doctor. Non-FFS strategies may require more clinically capable staff to advise and guide patients in an environment that will be receiving more information than current triage staff receive. Indeed, the call center may receive information at any time that could indicate a change in patient status and health risk without patient awareness. For example, the RPM information may indicate a problematic change in patient status that generates an alert message to the call center. Such a situation may trigger an immediate call to the patient to further assess the situation and initiate an appropriate strategy to mitigate a problem.

This centralized approach to triage and the development of staff capabilities as well as changes to practice/HCO cultures may take a fair amount of time and resources. For example, call center staffs can include PAs and LPNs as well as nurses to allow for escalation of patient issues within the call center. As important, the call center staff must develop a patient-oriented service culture that integrates with the rest of the practice/HCO operation.

Call Center Monitoring

Call center activities should be monitored to ensure quality and timely response. The monitoring function includes checking average response times, patient contact activities and patient service advisories, as well as providing physicians with proper notification of significant events and changes. Of course, all events should be documented in the patient’s medical record. Clinical call centers are an important tool to address the non-stop patient service and management needs of many non-FFS arrangements as well as accommodate the increased velocity and frequency of patient contact. However, call centers are not developed overnight and require an effective and clear clinical mandate driven by medical leadership as well as proper resources to fulfill its operational and patient service mandate.

Clinical Call Center Checklist

  • Inventory sources and types of patient information received and sent by the call center such as secure messages, incoming documents, RPM information, and telemedicine sessions.

  • Establish clinical standards for treatment and clinical advice available through the call center.

  • Design staffing model and requirements.

  • Implement CEHRT-based documentation tools for the clinical call center.

  • Reassign and acquire staff to meet call center requirements.

  • Train staff.

  • Continuously monitor performance and issues.


This article is available to Subscribers of JMPM.

Log in to view.

For over 45 years.

The American Association for Physician Leadership has helped physicians develop their leadership skills through education, career development, thought leadership and community building.

The American Association for Physician Leadership (AAPL) changed its name from the American College of Physician Executives (ACPE) in 2014. We may have changed our name, but we are the same organization that has been serving physician leaders since 1975.

CONTACT US

Mail Processing Address
PO Box 96503 I BMB 97493
Washington, DC 20090-6503

Payment Remittance Address
PO Box 745725
Atlanta, GA 30374-5725
(800) 562-8088
(813) 287-8993 Fax
customerservice@physicianleaders.org

CONNECT WITH US

LOOKING TO ENGAGE YOUR STAFF?

AAPL providers leadership development programs designed to retain valuable team members and improve patient outcomes.

American Association for Physician Leadership®

formerly known as the American College of Physician Executives (ACPE)