Monument Health revamps its revenue cycle leadership structure for the benefit of patients and the organization

Looking to break through the cultural silos that can hamper operations at hospitals and health systems, Monument Health has engineered a new brand of clinical-finance collaboration.

Headquartered in Rapid City, South Dakota, the community-based health system established a dyad leadership structure in which a clinical leader has joint oversight of the revenue cycle. It’s a rare, possibly unique, setup in U.S. healthcare.

“I don’t think this exists anywhere else in the nation,” said Ted Syverson, Monument Health’s vice president for revenue cycle.

Syverson’s co-lead is Deepak Manmohan Goyal, MD, MBBS, MBA, executive medical director for revenue cycle and supply chain. The synergy they have established promotes the interests of all parties as patients engage with the health system leading up to a care episode.

While leaving the details of revenue cycle rules and regulations to Syverson, Goyal focuses on creating and optimizing an internal communication platform that expedites front-end revenue cycle processes such as preauthorization.

“We’re cutting through cultural barriers here,” Syverson said. “We have a physician having these conversations with other physicians. We have a physician out there having conversations with administrative staff, helping lead and trailblaze the way for best practices and principles for patient financial health, for that holistic approach to patient care that we’ve been talking about for years.”

> 99%

Monument Health’s financial clearance rate 18 months after implementing its new revenue cycle leadership structure — up from less than 50%, the organization says

Identifying a need

Goyal had no background in revenue cycle when he joined Monument Health in 2018. Soon thereafter, he began chairing the health system’s utilization review committee, on which Syverson participated as a nonvoting member. The two established a working relationship that was formalized when Goyal received his current title.

Syverson said the organization’s chief medical officer (CMO), Brad Archer, MD, and the CFO, Mark Thompson, recognized the importance of having a physician leader in the revenue cycle who would go beyond the traditional review-type role to actually advocate for patients.

“People would be amazed, once they have this knowledge, at how closely these two arms are integrated with each other, how patients’ financial journeys affect their clinical care — their quality of care — and vice versa,” Goyal said. “We can write the best medication. If a patient can’t buy it, it’s all pointless.”

Goyal and Syverson quickly targeted financial clearance as an area in which their collaboration could make a difference. They thought Goyal’s perspective as a clinical leader could augment processes that include getting payer authorization for services and initiating financial transparency conversations with patients.

With respect to prior authorization for surgeries, for example, Goyal could engage with physicians to discuss whether a procedure was medically necessary. Such discussions could focus on whether the surgery should be delayed until the insurer completed authorization or whether, in the physician’s mind, it was worth going ahead as scheduled and incurring financial risk for both the patient and the organization.

“We never had those conversations before,” Syverson said. “We did not have that level of advocacy and partnership available for patients with physicians.”

Previously, Syverson might have been the one to have that dialogue with the system’s affiliated surgical groups, and it would be an exchange “I’d try to chop my way through,” he said, referring to the need to contend with physician resentment that “all you care about is finances and money.”

With the dyad leadership structure, he added, “We cut through that cultural red tape by having Dr. Goyal making those presentations [and] consistently engaging with both patients and physicians about these subjects. He doesn’t just talk about it once and walk away from it. It’s a consistent conversation.”

Establishing new protocols

Early on, Goyal explained to wary clinicians that the new approach was not primarily about optimizing cash flow. It was about optimizing hospital finances and care quality in tandem, ensuring that patients would not be scared away or placed at a disadvantage due to monetary concerns. He presented stories of patients whose out-of-pocket costs have landed in the organization’s bad-debt ledger. Many such patients end up having to choose between buying prescribed medicine and buying food.

“I think that was very touching for clinicians to hear,” Goyal said. “I told them: This is all avoidable. We can make a difference together. We can help those patients.”

In the new structure, decisions on moving forward with a service can be made by frontline caregivers such as registered nurses. At the second level, physicians can get involved if needed. The third level is the CMO, but Goyal said no case has had to be elevated that high.

If there are exigent circumstances, Syverson can make an executive decision after consulting with the CFO as appropriate.

“Everybody in the revenue cycle is aware about this process,” Goyal said. “We have created clear communication at multiple levels that this is what we are going to do for the patient. In the end, it’s the patient at the center.”

We cut through that cultural red tape by having Dr. Goyal making those presentations [and] consistently engaging with both patients and physicians.”

Ted Syverson, vice president for revenue cycle, Monument Health

Steps that guide cases

Goyal deployed a flowchart that guides the progression of cases among clinical and revenue cycle staff across the health system. When patients lack insurance, for example, issues to consider for nonurgent cases are (in order):

1. Do they have the means and willingness to pay their own way?
2. If not, are they eligible for Medicaid or subsidized insurance through the Affordable Care Act marketplaces?
3. If not, are they eligible for charity care?
4. If the answer to the previous question is no, patients should be scheduled for financial assistance.

If patients have insurance, the considerations for nonurgent cases include:

1. ‌Is the service a covered benefit? (If not, treat the case as if the patient were uninsured.)
2. If yes, is preauthorization required?
3. If yes, is the clinical team willing to follow the payer’s policies and lead time?
4. If the answer to the previous question is no, patients should be furnished with an advance beneficiary notice or notice of noncoverage.

Many benefits emerge

As Goyal has grown into his role, Syverson said, revenue cycle staff feel more assured that their decision-making processes are in accord with the organization’s mission and values.

Staff “act with greater confidence and compassion because we have a physician who’s directly participating in the revenue cycle process,” he said.

Patients also have a better understanding of why decisions are made, even if those decisions result in a postponement of care. Monument Health’s leaders have told Syverson they cannot recall a time when so few patient concerns were elevated to the office of the CEO or CFO.

“Those patients feel safe: ‘I don’t have to run away from my doctor, from the hospital, and they’re not greedy. They’re trying to help me,’” Goyal said.

The dyad concept can work even at the smallest critical access hospital, Goyal noted.

“Can every organization dedicate a physician to do this work full-time? Probably not,” he said. “But whatever you can do to engage those physicians, I think that’s where the difference-making starts.”

For Goyal, a recent exchange with a gastroenterologist highlighted the progress that’s apparent at Monument Health. The physician described asking a nurse colleague to schedule a diagnostic screening as soon as the patient was financially cleared, given that the procedure was nonurgent, Goyal recalled.

He added, “This is what I’d wanted to hear for so long.”