A discussion with one of MGMA's Better Performers

Graves Gilbert Clinic, Bowling Green, Ky., achieved something rare in 2020. After MGMA evaluated 3,864 organizations that participated in three data surveys (Compensation and Production, Cost and Revenue, and Practice Operations), there were 1,036 organizations that stood above the rest in at least one of four MGMA Better Performer categories (see Table 1).

Graves Gilbert Clinic was the only practice out of those 1,036 Better Performers to attain Better Performer status in all four categories.

By the numbers

When it comes to where the 1,036 Better Performer practices reported their success:

• 57.7% were Better Performers in profitability (379 practices)
• 36.6% were Better Performers in operations (598 practices)
• 28.8% were Better Performers in productivity (298 practices)
• 27.1% were Better Performers in value (281 practices).* 

* Figures do not add up to 100%, as 466 practices were Better Performers in more than one category. 

Steven K. Sinclair, CPA, CMPE, chief financial officer, discussed the group’s successes and provided insights during the 2020 Medical Practice Excellence Conference.

Q. When you were first filling that information out and then tracking it, did you think you were going to be a Better Performer? Did you have an idea what was going through your mind at that point?
A. Well, our group has been recognized as a Better Performer for many years. So I wasn’t surprised that we were recognized based upon our 2019 performance, which was a very good year for us. I’m pleasantly surprised that has happened.

Let's talk about the size and scope of the practice and any specialties you have there.
We're a physician-owned, multispecialty clinic in south central Kentucky, and we're approximately an hour north of Nashville, and one and a half hours south of Louisville. We have approximately 200 providers: 117 doctors and 82 [APPs]. We’re a primary care subspecialty clinic, so we have primary care that you would expect to find — a family practice, internal medicine and an OB if you consider that primary care — and then most of the medicine subspecialties and many of the surgical procedural-based specialists. [Our APPs] function in primary care as well as specialty areas. We have ancillary services provided by the clinic extensively, with a large and comprehensive lab, X-ray and physical therapy departments, and extensive ancillary services provided within the physician offices. We have the largest network of walk-in clinics in south central Kentucky. And additionally, we have a significant presence in providing care within the workplace.

Q. Let’s talk about you specifically: What is your day to day like?
A. Most of my colleagues can relate to this statement, but it seems that as each year passes, what you will face on a day-to-day basis becomes less and less predictable. Perhaps this year with the COVID-19 pandemic thrown into the mix probably highlights it very well. As the clinic’s chief financial officer, there’s a constant focus on revenue cycle matters that generally center upon registration, coding and billing. Achieving excellence in these areas is important to maximize the management of the financial aspects of our patient experience with the clinic. Patients can receive great medical care, but if we don’t have their accounts, well, then they haven’t received the best possible experience that they should.

Overseeing the accounting function is crucial because this provides the basis upon which we report to our board and committees about the financial performance of the clinic through budgets and forecasts. It’s crucial in helping to estimate the provider compensation, which is crucial in our group. As an independent, physician-owned group, maximizing provider compensation is critical to our success. I am also responsible for the computer services aspect of our organization, and there’s challenges there in an uneven way. Sometimes you’re dealing with projects that involve the computer services that take a lot of your time. We’re very fortunate to have a great [IT] team.

Payer contracting is a constant issue … trying to maximize what you can get on the commercial side. Then you have purchasing, retirement plan management, banking relationships and physician recruitment. You keep your diary pretty well occupied with those — what you would typically expect in the occupation of a chief financial officer of a medical group.

Q. You were talking about being involved with the IT team. What differences did you have in 2020?
A. We had to switch on a dime to providing several telemedicine visits through both the normal clinical relationships that our patients have with our physicians, and then also from the occupational side. We had to quickly ramp up our capabilities there, and our IT staff did a great job of doing that. And while that really helped us through the initial three months of the COVID-19 pandemic, as we’ve gotten back to “normalcy,” that has been a supplement we still use, but patients have tended to want to actually come in and actually be in a one-on-one relationship with physicians. So we’ve kind of reverted more to that, where our patient counts and billings have almost reached a normal level for us.

Q. Looking back at 2019, that was a particularly good year for the practice. What was happening that helped lead you to Better Performer status?
A. First of all, the productivity among our providers is excellent. We have a definition of full-time practice for physicians that is based upon the MGMA survey data of median work RVUs for each specialty. This is very helpful in keeping everyone pulling their own weight, which contributes to maintaining financial stability … and the numbers from the survey show that. Controlling overhead cost is quite important to us being an independent group, and the MGMA Cost and Revenue survey reports are very helpful. It helps us to understand the trends in cost management. We can make better-informed decisions about what we need to do on the expense side of the revenue-minus-expense-equals-compensation equation.

The big part is the revenue. That’s the area that you can hopefully contribute to growing that. You have to go deeper than just maybe what’s in your practice management system, we actually have a third party … that helps us to analyze our revenue cycle processes, and that’s yielded a lot of positive results for us. It goes into very specific details of that revenue cycle process. ... That has helped us focus on areas that we can improve on so that we can maximize the cash flow into our organization.

Q. What has been your success in cost management?
A. The biggest expense item that we have, outside of physicians, is support staff. So in our compensation formula, the physicians are responsible for support staff who work directly for them. So that helps to provide a way to control that aspect. Then we can look at other departments, for example, billing/coding, accounting, [IT], X-ray, etc., to look and see if the staffing models reflect the costs that are incurred by other groups, or those divisions within the organization. If we do a good job of managing those, that gets us a long way down the road in maintaining cost control.

Q. You mentioned getting third-party revenue cycle help. What was the decision-making behind that outsourcing rather than keeping things in-house?
A. By having someone on the outside looking at our revenue cycle, that person is incentivized to tell us all the bad news. If you have the revenue cycle person in-house, they’re incentivized to make it look like they’re doing a good job. [Outside help], they’re going to tell you all the warts, which is what you need to hear. … I think having that person on the outside was a good financial decision, because we have been able to engage with that person at what I feel is a very fair cost. I think that person is really pushing this very hard to get better. And that’s what we need.

Q. What were some of those warts that you needed help with that you’ve been able to address?
A. Denials are always a huge struggle. We were able to get a better handle about our denials, where they’re coming from and where we need to focus on them. In this process, we learned a great deal about eligibility benefit denials, and how your clearinghouse or practice management system can, at times, not really help you a lot in that regard. Even if you’re on the 5010 format for 270 submissions [as part of the Centers for Medicare & Medicaid Services’ HIPAA Eligibility Transaction System (HETS)], you may not be giving all the information you need, or when you get information back from the payers, the 271s may not be applied appropriately. ... You’re getting denials from either the clearinghouse level or the payer level. We really have learned a lot and improved that dramatically. That’s been a big plus for us.

Q. What were the biggest opportunities to maximize revenue for the group?
A. Trying to eliminate denials: Our goal was — and this is obviously an overstatement — to have no denials. But we wanted to set the bar high so that we could achieve some strong results and eliminate denials. Denials tell you a lot about failures in your processes. And in that attempt to eliminate those denials, we have found so many things that could be improved. For example, we have about 700 authorizations a day within our group. That’s a big task for people. And we’ve gotten the authorization denials down to an average of seven per day. … We’re also trying to automate that process — we want to get it less than seven. But at the same time, we want to reduce the time [and] money spent in obtaining that many authorizations on a daily basis. We’re working with a company [on] a pilot project … to get an interface in place [with our EHR] that can then take advantage of that for all of our departments.

Q. You mentioned your practice were Better Performers before: You’ve been benchmarking. As you’ve done this year to year, how has it made you a better practice? How’s it made you personally a better manager and have a better grasp and understanding of what you guys are doing and where you need to raise the game a little bit?
A. Overall, the Better Performer reporting has done more to validate our thinking. And I think that validation is essential. Once we’ve established a thought process, having the third-party revenue cycle manager in place, and then going through some of that work … will either help to validate we’re making good decisions or we need to rethink what we’re doing.

By being a Better Performer and seeing the results that we’re getting helps to validate that some of these meaningful decisions are good ones. That doesn’t mean that we’re done — the goal line is always changing. It’s always moving. What worked for us a few years ago now needs to be modified or perhaps even scrapped. One of the areas that we’re working on right now to improve on is upfront collections. We’re in the process of implementing a patient engagement platform, and this can be a really good tool to help us to do that. One thing that we’ve stumbled across is that it appears that patients are more apt to pay a balance on their account from a computer telling them that than a human.

Q. For practices that are considering going through this process, what’s some advice you’d give them since you’re a veteran of going through Better Performers for several years now?
A. I would tell them to spend time looking at your group’s processes, in particular revenue cycle, with the goal of eliminating all denials. It will take a considerable amount of time and effort to do that. This is not something that’s a quick fix. In fact, it’ll probably take a few years to realize your goals. … Every aspect of your operational failure is summed up in denials. In the end, eliminating denials ends up maximizing cash flow. It’s almost like finding a hidden treasure when you do that. So that’s helped us tremendously. In 2019, we found a lot of hidden treasure that the work had begun years ago.

MGMA Insights

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Thanks to Sarepta Therapeutics and R1 RCM for sponsoring this episode.