Why clinician onboarding matters: A physician's perspective

Read this if you are interested in building a thriving workforce.

As businesses across the country continue to struggle to find and keep employees, it is time to build a workplace that sends a clear message to employees: “We care about you as a person. Your well-being matters.” 

Many leaders will send communications that emphasize the importance of people and the value of well-being. Despite this messaging, many organizations are missing opportunities to make well-being a natural part of the employee experience. The resulting disconnect between messaging and reality can result in frustration, disengagement, and cynicism. We’ve compiled a list of some of the most common workplace factors that can disrupt an organization’s intentions to build a strong well-being culture. 

Are you missing the mark with employee well-being? 

The chart below illustrates common ways that employers may be missing the mark on providing a supportive environment to employees. As you’ll see, they can be both large things like compensation and benefits, but they can also be small, potentially easy-to-fix things such as providing healthy snacks in the office instead of junk food. Look at this chart holistically for ways you may be able to change some negative influences into positive ones.

Overcoming the challenges to your well-being goals takes time. And while it is natural for organizations to think of employee well-being as the responsibility of human resources and leadership, in reality, well-being is a product of every part of the employee experience. In other words, it’s part of everyone’s job.

Well-being program considerations

Understanding the pain points for employees is an essential element of any successful well-being program, even if those pain points exist outside the domain of traditional well-being and wellness programs. Here are some things to consider:

• Find out what matters to your employees, as every organization is different. Use surveys, interviews, and focus groups to understand priorities and do something substantive with what you learn.
• Make a plan to address operational challenges. Put simply, outdated technology and inefficient business processes stress employees out.
• Assess your well-being approach to identify strengths, gaps, and opportunities for improvement.
• Develop, document, and implement a well-being plan that aligns with your organizational culture and goals. 
• In the midst of planning a big system implementation of organizational change? Consider ways to integrate well-being as part of high-stress initiatives. 

How mature is your organization’s well-being program?

Understanding the maturity level of your organization’s well-being program can help you benchmark, assess progress, and gain leadership support by showing a clear path to improvement. This maturity model can help you assess where you are now and how to incrementally improve.

Have questions or need ideas about your specific situation? Contact our well-being consulting team. We’re here to help.

Healthcare system conversions are risky endeavors. But what is the alternative? Stay with a system you’ve outgrown and no longer meets your organizational needs? At BerryDunn, our healthcare consulting teams have worked with a substantial number of organizations as they’ve transitioned to new enterprise systems such as Electronic Health Records (EHR) systems and Enterprise Resource Planning (ERP) systems. Based on our experience, there are 10 key areas to focus on in order to have a successful conversion.   

1. Start preparing early 

If you know you’ll be bringing in a success partner like BerryDunn to help you through the conversion, bring them early in the planning as possible. The success of the entire project depends on how well you’ve planned and if you've brought in a strong methodology to approach the implementation.   

2. Assess your needs before you make a decision to change systems 

Before you even decide that you need a new EHR or ERP system, the first step is to conduct a thorough assessment of your current system and determine if you actually need a new system.  It’s possible that your current system could and will meet your needs if set up correctly.  

If you determine that you do need a new system, the next step is to conduct a thorough needs assessment that details exactly what your organization needs out of the system. It’s important not to think in terms of what your old system was capable of, but to focus on the problems that you want the new system to solve. Talking to other organizations or consultants like BerryDunn, who are solely focused on and have experience in this work, can help you determine what best-in-class systems can do.  

3. Understand and mitigate the risks 

There are risks at every stage of the process, from not identifying your needs correctly, not assessing the facility’s readiness for change, choosing a subpar vendor, having an incomplete contract, not monitoring the implementation very closely to meet the deadlines, and not addressing the risks as they appear. It’s important to manage the steps correctly at each phase, beginning with: 

• Documenting detailed requirements for the EHR or ERP system 
• Initiating a formal RFP process to include the system requirements in writing 
• Thoroughly vetting and evaluating vendors consistently 
• Negotiating a solid contract that holds the vendor accountable for support and a timeline 
• Assessing what staffing changes and training are needed 
• Providing sufficient time for testing pre- and post-go-live 
• Understanding and planning for the impacts to your revenue cycle 

4. Manage the vendor 

The vendor may be managing the project, but who is managing the vendor? Whether you hire a consultant like BerryDunn or have in-house resources, managing the vendor can be a full-time job. In our experience, the vendor wants to have a successful implementation as much as you do, and they also want to go live on time so they can move on to their next project. You will need to advocate for your organization and be able to hold the vendor accountable to what was agreed on, even if that means taking more time. If your contract was thorough, you should have enough leverage to do so. The bottom line: Don’t feel rushed to go live until you know you are ready. 

Insist on a detailed implementation plan from the vendor that shows realistic timelines for the tasks needed to be accomplished to meet the go-live date. The project should include weekly communication meetings with the vendor to ensure any problems and delays identified can be addressed quickly. 

5. Make sure your internal project team is ready 

Just as it’s important to ensure your vendor is well-staffed, prepared, and held accountable, these factors are equally important for your internal project team. Take the time at the beginning of the project to create a plan for success that takes into account roles, communication, and contingency plans. A good plan will include:  

• Establishing a project charter to formalize governance, teams, and roles and responsibilities 
• Communicating and reinforcing the project as a mission-critical effort 
• Establishing regular project meetings to follow up on and manage risks, actions, issues, and decisions 
• Monitoring competing priorities and alleviating non-project efforts for staff where possible  
• Anticipating project team turnover and having a plan for backfilling team members in advance 

6. Help your staff adopt the new system 

Even if you implement the best system in the world, if your nurses, doctors, and billing staff don’t use it (or don’t use it correctly), it won’t be effective. You need to be able to manage the people side of change, starting with building the case for why you are switching systems and how it will benefit the working staff. Having a thorough training plan and making sure people are ready for the conversion is a key step that shouldn’t be neglected. 

7. Allocate enough time and the right resources for testing 

Before you go live, you need to know the system is going to work for specific scenarios in every department that uses it. For EHR systems, that is every department that touches a patient. A solid testing plan begins with identifying the key, critical scenarios in each area and assigning the right people to be involved in testing – ideally, those who will be using the new system and have a firm grasp on the typical workflows. The plan should “follow” a patient from the point of registration to treatment, discharge, billing, and patient follow-up. A good testing plan will confirm if the system functions as intended and will drive issue resolution and any needed configuration changes. Ultimately, the result of testing will be to determine if you’re ready for go-live.  

8. Get your accounting systems in order  

Many healthcare organizations implement new accounting ERP systems at the same time they convert their EHR. It is important to determine concurrently how the operational and financial data from the EHR will be integrated into the general ledger and reporting dashboards. A study will need to be made on the ease with which the payroll information from the outside software application can be accurately uploaded. Your chart of accounts likely will need to be revamped.  Electronic invoice routing and approvals have become very sophisticated and can improve efficiency with the proper setups. Your new accounting ERP system should not be a “last minute thought” but carefully selected and planned as the EHR is being implemented to ensure accurate and state-of-the-art reporting to deliver to your internal and external audiences.   

9. Don’t neglect your revenue cycle 

Launching a new system is not business as usual. Most new EHRs introduce new complexity to the clinically driven revenue cycle. This requires different management skills and tighter coordination across the organization. Success requires advance planning around charge master structure changes, patient access, and other workflows that will heavily change. Attention needs to be paid to leveraging clearinghouse functionality, and testing plans should incorporate all charging and payor scenarios.  

In addition, no matter how prepared you thought you were, your clinicians are just not going to be able to do things as fast as usual when using a new tool. It takes time to build proficiency in any new system. When launching a new EHR, you’ll need to schedule lighter patient loads in the weeks after your go-live, allowing flexibility for fixing problems and for taking into account learning curves.  

Because of this lighter load, your revenue cycle will be impacted. Fewer patients will be cared for, and fewer patients will be billed. You need to consider these cash flow impacts and plan around legacy receivables well before launch day (ideally as much as two years prior) so you can plan for it and ensure that you’re accounting for, and finding ways around, any shortfalls.  

10. Manage the post-go-live transition 

So you went live with your new system. Congratulations! But this isn’t the end. The two weeks after your go-live date are very important. Are you meeting with the vendor to track defects? Are you getting everything out of the system that you dreamed of? Do you have a plan for addressing deficiencies and adding more functionality? Most vendors have a two-week window to help you post-go-live. You need to take advantage of that while you still have their attention. Once you transition to help desk support, you’re just not going to get the attention that you were before. Having a plan and a system in place for these post-go-live weeks is crucial.  

Is it time to bring in a success partner?  

To be successful, you need a partner who can address all of your needs and be your advocate, and expert, providing the support – and the answers – to questions you might not even know to ask. BerryDunn’s Healthcare team works with healthcare organizations every day, all year long, guiding them through EHR and ERP selection, vendor management, system implementation, testing, and beyond to mitigate risks and help ensure your investment pays off. We’re happy to discuss how we can help you with project and change management, interim or project staffing assistance, system report creation and dashboarding, and revenue cycle optimization. Contact a member of our team.                                                              

Read this if you are looking at implementing a new Electronic Health Records (EHR) system. 

Not since the early years of the meaningful use incentives have we seen such client activity in implementing new EHR systems. The primary driver for this activity is a strong desire to move away from combinations of multiple different EHR vendors across a health system toward a single, integrated EHR platform from one vendor. Continuity of care, population health, and patient-centric data are trumping a strategy of having niche EHR platforms at the department or care-setting level. Implementing an integrated EHR across an entire health system is a big, ambitious, high-risk project that comes with significant change for your people—even under normal conditions. 

Conditions have been far from normal for most workforces over the past few years. After three years of the COVID-19 pandemic, exhausting work conditions, and the unusual labor market (commonly referred to as the "Great Resignation"), staffing challenges are understandably at an all-time high. 

It is no surprise then, that when we ask clients what some of their top project risks are heading into an implementation, staffing is listed as their number one or two risk. And staffing is not just a risk for clients. EHR vendors are also facing increased employee attrition. 

So, when you combine very large and high-risk projects capable of changing every process for your people with a labor market full of turnover and vacancies, you have a higher risk EHR implementation environment than at any time in recent memory. 

This environment may lead you to think that now isn’t a good time to implement a new system. At times, waiting on the implementation may be the right call for your organization. Maybe you should hang tight for a bit and wait until your team is more stable. 

However, it may not be best to wait. Staying with a combination of legacy EHRs bolted together may not reduce your organizational risk. As viable legacy EHRs are dwindling, the chance that a change in EHR will be forced upon your health system increases. Replacing a system under duress, rather than choosing when to implement a new EHR system, would actually be more stressful and most likely introduce even more risk. 

If you are planning to or are currently implementing a new EHR in these workforce conditions, here are some recommendations to help mitigate staffing and vendor risks and manage, if not strengthen, employee well-being.

Vendor turnover

• Negotiate provisions
  During contract negotiations, address turnover and vacancies directly. Contractual terms for notification, transition plans, and timelines for filling vacancies won’t prevent turnover but will make it more manageable when it occurs.
• Meeting summaries
  Direct the vendor to use a consistent meeting summary format and post it to a project portal within a set period of time; this can also help the transition from one vendor teammate to another. 
• Executive sponsor notice
  Require the vendor to provide notice to your executive sponsor as soon as the vendor knows about staff turnover. This allows leadership to be prepared for the news and lead their team through the staffing transition calmly and from an informed position. 
• Transition plan and call
  Have vendors document a written transition plan and hold a transition call between the client and vendor resources. This can’t be accomplished with sudden departures but can be with planned departures. 
• Timeline provisions
  Vendor staffing disruption can be a project risk and can negatively impact implementation timelines. Negotiate timeline change provisions to limit the negative impact on your health system if a vendor encounters staffing turnover. 

Health system turnover

• Change management
  Focus on deliberate, intentional, and proactive change management. Active and visible sponsorship for the change will help your employees embrace the change to the new EHR. By making the new EHR more exciting and less daunting, it will give employees one less reason to seek employment elsewhere.
• Have contingency and management reserves
  From a project management perspective, increasing your contingency funds and management reserves can help you account for a higher likelihood of staff turnover, more recruiting, or staff augmentation, if needed. 
• Establish staff augmentation arrangements in advance
  Identify firms for staff augmentation before you start. Know who you will call to get the talent you need when you need it. Having expectations of contracted rates in advance can help you fill vacancies more quickly.
• Use your senior team as your coaching staff
  Some leaders and managers will find an implementation more stressful than others, decreasing their effectiveness as team leaders. Assigning senior leaders to different department heads to serve as coaches and mentors can give managers the support they need to get through the implementation.
• Address weak leaders before the implementation
  In a tough labor market, you may be reluctant to address your weaker leaders for fear of not being able to replace them. Our experience is that implementations don’t often make weak leaders stronger, and their weaknesses will hinder the project. You’ll need to determine if you can coach them up, make the tough call to replace them, or find a leader within their team to step up for the implementation. 
• Negotiate delay provisions
  While not as easy to negotiate as vendor staff turnover delays, having a defined process for changing the timeline if you need to can be helpful. Provisions of this nature can help you manage the risk and know in advance what will happen if you were to delay the project. 
• Monitor for the non-project turnover
  Often implementations will have a staffing and turnover plan for people on the project. However, a less obvious staffing risk is turnover of people in departments not assigned to the project. Those turnovers tend to put more non-project work on project team members. Having a plan to resolve vacancies quickly will help you reduce this risk.
• Have job descriptions ready
  In order to speed up the process to address turnover and vacancies, have job descriptions ready. This can allow you to go to market faster when (not if) you have turnover during the implementation. 

Employee well-being

Large-scale, complex initiatives can place new strains on employees, leading to greater levels of stress, and in some cases, employee burnout. By taking a proactive approach to supporting well-being (physical, mental, social, financial, and professional), the organization can better manage the performance, retention, and interpersonal dynamics of the project team. This can help reduce the risk of project delays and improve overall project outcomes.

• Prepare people for what to expect
  A large system implementation can be a source of concern and uncertainty. Employees may worry about how the change will affect their jobs and what will be expected of them. There may be fears around how these expectations will impact other personal and professional commitments. Transparency, proactive planning, and an individualized approach can help alleviate fears and reduce stress and uncertainty. 
• Unite project leadership at all levels
  Inconsistent messaging and decision-making can quickly undermine trust and may trigger cynicism, disengagement, and even animosity. It is imperative that executives and team leaders share a common understanding of project goals, guiding principles, and core organizational values around well-being—and communicate that understanding to the team. 
• Be intentional about trust
  Trust is a core element of well-being that is built upon authenticity, empathy, and credibility. Make sure to make trust a part of the project as it is also the foundation for the collaboration necessary among the organization, vendor, and implementation partner. 
• Pulse surveys (Stay in tune with how people are doing)
  Workload demands will shift throughout the implementation. At the same time, personal circumstances of employees will evolve. Maintaining a “pulse” on how the team is doing and being able to quickly respond when teams or individual contributors are struggling can help project leaders and managers stay ahead of disengagement, burnout, and resignation.  
• Celebrate success and show appreciation
  It can be easy to miss opportunities to celebrate milestones and recognize individual contributors when timelines are tight, and workloads are high. We emphasize the importance of appreciation, celebration, and finding moments for fun throughout the project. 
• Support for stress management and resilience
  Often, there are opportunities to help staff improve stress management with practical, research-supported activities, such as five-minute breathing exercises, stretch breaks, and environmental changes (brief walking breaks and outdoor meetings, for example) to support stress regulation. 
• Highlight wellness and well-being resources
  Employees may benefit from existing wellness and well-being resources throughout the project. There may be opportunities to work with human resources or a well-being manager to increase awareness for these resources or design custom programming in support of the project.
• Promote healthy lifestyle choices
  Implementations are often synonymous with long hours sitting in meetings or at a screen, “always-on” mentalities, and team donuts, pizzas, and bowls of candy. While these behaviors (and tasty treats) may offer short-term benefits, they degrade employee resilience and well-being over time. Small behavioral nudges can make a big difference, such as replacing (or at least supplementing) typical “command center treats“ with healthier options, emphasizing breaks (both throughout the day and PTO), and agreeing to off-hours communication expectations and boundaries. 

It takes strong ambition to take on a large EHR project in normal times. Under the current staffing stresses, it is crucial to be prepared. If you plan in advance for vendor and employee turnover, manage your people deliberately, and focus on employee well-being and change management, you can reduce the risk and increase the likelihood of a successful outcome. 

Read this if you participate in onboarding healthcare providers. 

The last several years have certainly been challenging for healthcare. Fueled by the COVID pandemic, increased provider burnout is a huge issue that has organizations grasping to keep staffing levels high enough to provide exceptional patient care. Physician turnover (per physician) has been estimated to cost an organization between $400,000 and $1,000,000 when factoring in recruiting costs and lost patient billing revenue. For smaller organizations, that can be a major challenge. 

The US Department of Labor Statistics estimates that by 2030 the healthcare industry will grow more than 16%, adding over 2.6 million new jobs. With 5% of physicians turning over each year (this number doubles when including physician assistants and physical therapists) and 61% reporting burnout, organizations should take steps now to minimize attrition and ensure a stable clinical workforce. 

Provider onboarding as a retention strategy

Provider onboarding is a window into an organization’s culture and is the foundation of the provider experience. During this period, action and inaction, both real or perceived, will set a new hire’s impressions of the organization. A positive experience can ensure early buy-in from new providers, helping employers improve retention rates and provider satisfaction. 

For many organizations, onboarding and orientation are the same. However, there are differences. Orientation is a one-time event for tasks (i.e., completing an I-9 form, new-hire paperwork, discussing benefits). Onboarding is an experience that begins once a provider has accepted the position and will last at least 90 to 120 days. The provider will have contact with human resources, IT, the medical staff office, and finance/revenue cycle departments to gather much of the same data (e.g., licensure, CV, NPI, and other demographic information).

A well-organized and coordinated organization can reduce the number of times a provider is asked for the same information or documents. Clear communication and centralized points of contact and processes are critical to a smooth process. To help organize onboarding, you can download our Provider Onboarding Checklist.

Ensuring you have all the information and documents your organization will need from the provider for privileging, third-party payer enrollments, HR, and IT has additional benefits beyond provider experience. Preparing new providers to participate on a payer panel linked to the organization can be an exceptionally lengthy process, often exceeding 90 to 120 business days. Additionally, if your organization participates with a large volume of managed Medicare and Medicaid payers, gathering the information and beginning the process early through an efficient onboarding can ensure you decrease write-offs of billable services to the dreaded ‘provider not credentialed’ denial code.

Provider onboarding and timely, quality patient care

Equally important is the connection to delivering timely and quality patient care, as the third-party payer process directly impacts these activities. An unenrolled provider lacks the ability to order, prescribe, and refer. This necessitates additional touches, resulting in breakdowns in the workflow that can lead to unnecessary expense and provider dissatisfaction. The provider enrollment process must be initiated early, and frequent communication with all involved parties can alleviate any issues. 

Organizations should offer providers robust revenue cycle-related clinical systems training as part of the onboarding process and create a mechanism to identify potential errors that may lead to write-offs and compliance risks. Provider entry errors can result in a claim ending up in a work queue, never to be identified, submitted, or paid. You can mitigate revenue loss by monitoring entry errors and providing additional training. Wasteful workforce expenditures are created through revenue cycle teams chasing information to be corrected, causing rework. Education for providers and everyone supporting them in operations will also go a long way toward reducing errors, increasing satisfaction, and minimizing barriers to care and collection challenges. 

If you would like more information or have questions about your specific situation, please reach out to our credentialing consulting team. We’re here to help. 
 

Read this if you work for a healthcare organization that serves uninsured or self-pay patients.

The No Surprises Act was passed in 2020 as part of a COVID relief package, with the goal of reducing surprise bills for patients who received medical or surgical services. One part of the act requires healthcare facilities and providers to give Good Faith Estimates (GFEs) to uninsured and self-pay patients starting on January 1, 2022. Read on for frequently asked questions about this topic, an update for 2023, and resources where you can find more information.

Frequently asked questions about good faith estimates for healthcare

What is a good faith estimate?

A Good Faith Estimate (GFE) is a document provided to a patient that details the expected charges for healthcare services provided. It is not a bill.

Who needs to provide GFEs, and to whom?

At this time, GFEs need to be provided to uninsured and self-pay patients. 

The following healthcare facilities must comply:

• Federally Qualified Health Centers (FQHCs)
• FQHC Look-Alikes
• Tribal/Urban Indian Health Centers
• Rural Health Clinics (RHCs)
• Hospitals
• Hospital outpatient departments
• Critical access hospitals
• Title X Family Planning Clinics
• Health care providers who serve uninsured and self-pay patients

How should information about the GFE process be communicated to uninsured and self-pay individuals?

Information about the availability of GFEs for uninsured or self-pay individuals must be:

• Written in a clear and understandable manner and prominently displayed:
• On the facility’s website and easily searchable from a public search engine
• In the office (such as in the patient waiting room), and
• Onsite where scheduling or questions about the cost of items or services occur, such as at the registration or check-out areas
• Explained verbally when scheduling an item or service or when questions about the cost of items or services occur
• Made available in accessible formats, and in the languages spoken by individuals considering or scheduling items or services

How does the US Department of Health and Human Services (HHS) define uninsured and self-pay individuals?

HHS has a two-fold definition:

• Individuals who have no health insurance coverage
• Individuals who do have health insurance coverage, but do not want to have a claim submitted to their insurer

Both of these groups of individuals must receive a GFE.

What content is required in a GFE?

A GFE must include the following:

Patient information

• The patient’s name and date of birth

Services estimated

• A description of the primary item or service in clear and understandable language and, if applicable, the date the primary item or service is scheduled
• A list of items or services reasonably expected to be furnished for the primary item or service

Information about services, providers, and estimated charges

• Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
• The name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the GFE, and the State and office of the facility’s location where the items are services are expected to be provided
• Lists of items or services that the provider or facility anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service. (A disclaimer should state that separate GFEs will be issued upon scheduling or upon request of the listed items or services.)

Disclaimers

• A disclaimer that there may be additional items or services that the provider or facility recommends as part of the course of care that must be scheduled or requested separately and are not included in the GFE
• A disclaimer that the information provided in the GFE is only an estimate and that actual items, services, or charges may differ from the GFE
• A disclaimer that the individual has a right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the GFE.
• “Substantially in excess” is defined as at least $400 more than the total amount of expected charges.
• This disclaimer must include instructions about where an uninsured or self-pay individual can find information about how to initiate the patient-provider dispute resolution process and state that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services that are furnished.
• HHS strongly encourages providers and facilities to include an email address and telephone number for someone within the provider’s or facility’s office that has the authority to represent the provider or facility in a billing dispute.
• A disclaimer that a GFE is not a contract and does not require the uninsured or self-pay individual to obtain the items or services identified in the GFE.

HHS encourages sliding fee discount providers and facilities to include information about the provider’s or facility’s sliding fee schedule and any other financial protections that it offers. Sliding fee discount providers and facilities have flexibility to determine how best to demonstrate the expected charges associated with each listed item or service, and to determine what additional information to include, if any.

What are the required methods for providing a GFE?

A GFE must be provided in written form either on paper or electronically, based on the individual’s requested method of delivery and within the required time frames. GFEs that are provided electronically must be provided in a manner that the individual can both save and print. A GFE must be written using clear and understandable language that can be understood by the average uninsured or self-pay individual.

If the individual requests a GFE in a method other than on paper or electronically (such as by telephone or verbally in person), the provider or facility may verbally inform the individual of the information contained in the GFE. However, the provider or facility must also issue the GFE in written form.

What is the timeline for providing a GFE?

When providing a GFE to an uninsured or self-pay patient, the following time frames must be followed.

Please note, when a GFE is requested by an uninsured or self-pay patient, a GFE must be provided not later than 3 business days after the date of the request.

How long should a provider or facility retain a copy of GFEs?

A GFE is considered part of the patient’s medical record and must be maintained in the same manner. At the request of an uninsured or self-pay individual, the provider or facility must provide a copy of any previously issued GFE within the last six years.

Update for 2023

• As of the start of 2023, all of the preceding requirements remain in place.
• As of January 1, 2023, HHS has paused enforcement on the next phase of GFE implementation

The next phase of GFE implementation, which began on January 1, 2023, requires that GFEs for uninsured and self-pay patients include expected charges from co-providers or co-facilities that are part of an episode of care for a patient coordinated by a provider or facility. However, on December 2, 2022, HHS paused its enforcement of this requirement based on comments it received during the rulemaking process indicating that compliance with this provision was likely not possible by January 1, 2023.

HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from co-providers or co-facilities. We will provide an update when HHS issues any communication about changes to GFE-related enforcement.

Helpful resources for FQHC, RHCs, and other healthcare facilities

• Code of Federal Regulations: Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.
• Code of Federal Regulations: Requirements for the patient-provider dispute resolution process.
• CMS Good Faith Estimates FAQ December 2021 (PDF)
• CMS Good Faith Estimates FAQ April 2022 (PDF)
• CMS Good Faith Estimates FAQ December 2, 2022 (PDF)
• CMS Good Faith Estimates FAQ December 27, 2022 (PDF)

If you have questions about the information provided in this article or are interested in an external review of your healthcare facility’s compliance with current GFE requirements, please contact Robyn Hoffmann or Mary Dowes.

Read this if you are interested in well-being. This will be the first of two articles. This first article will focus on awareness. 

When the United States Surgeon General, Dr. Vivek Murthy, recently announced five priority areas of focus that represented “the most pressing public health issues of our time,” workplace well-being was one of the areas identified. According to the Current Priorities of the US Surgeon General website, the priority on workplace well-being aims to address the “numerous and cascading impacts for the health of individual workers and their families, organizational productivity, the bottom-line for businesses, and the US economy.” 

US Surgeon General current priorities:

1. Workplace well-being
2. Address the impacts of COVID-19
3. Health misinformation
4. Health worker burnout
5. Youth mental health

Worker stress a growing challenge to employee well-being in many areas

The Surgeon General’s workplace well-being framework discusses many dimensions of well-being, with a focus on mental health. Research cited in the report suggests that worker stress levels grew from 2020 to 2021. In a different 2021 survey of 1,500 US adult workers across for profit, not-for-profit, and government sectors, 84% of respondents reported at least one workplace factor (e.g., emotionally draining work, challenges with work-life balance, or lack of recognition) that had a negative impact on their mental health. In most cases, the workplace factors contributing to stress can be managed or mitigated by integrating well-being into organizational planning and workforce development. 

Another study conducted by Mental Health America surveyed 11,000 workers across 17 industries in the US in 2021. It found that 80% of respondents felt that their workplace stress negatively affected their relationships with friends, family, and coworkers. The study also found that only 38% of those who know about their organization’s mental health services would feel comfortable using them. Statistics like this underscore the need for more deliberate efforts on the part of employers to provide services that support employees’ well-being. 

Well-being and human needs

At the core of the Surgeon General’s framework are five essentials of well-being and their associated “human need” components, all of which center around worker voice and equity. 

As Dr. Murthy wrote in the introduction to the report, “We have the power to make workplaces engines for mental health and well-being. Doing so will require organizations to rethink how they protect workers from harm, foster a sense of connection among workers, show them that they matter, make space for their lives outside work, and support their long term professional growth.”

Parallels with BerryDunn’s well-being consulting approach

BerryDunn’s well-being approach aligns with the framework suggested by the Surgeon General. Today’s most effective well-being programs are multi-dimensional and emphasize a culture-first approach. In our experience, the most successful well-being programs are those that emphasize well-being as both a personal responsibility and a shared value that is promoted through policies, benefits, and cultural norms. 

For more information on how your organization can create and deliver a program that supports employees in the various aspects of well-being, or if you have other questions specific to your organization, please contact our Well-being consulting team. We’re here to help.

Read this if you are working on a well-being program at your organization. 

When looking to develop or enhance well-being programs at work, many organizations don’t know where to start. A well-being survey is a smart first step to solidify your organization’s approach to supporting a thriving workforce. An effectively designed well-being survey will not only provide valuable insights to the needs of your workforce, it will also be repeatable so you can measure the success of your well-being efforts over time. Here are five tips to help you create a successful well-being survey.  

1. Include questions about organizational culture. It is unlikely you will engage every single employee with well-being programs and benefits. Some people just like to do their own thing. However, organizational culture is something that influences everyone and is the ultimate source of empowerment for employee well-being. Including at least a couple of questions that assess how effectively your workplace culture promotes well-being will give you the broadest sense of whether you are on the right track with your well-being efforts. 
2. Carefully consider wording. There is a big difference between the question “How well does our organization support your well-being?” and “How satisfied are you with our organization’s support for your well-being?” For instance, an organization may invest heavily in mental health, but that support may not be resonating with employees. The second question will provide clear insights into how well the organization’s well-being efforts are connecting with employee needs. 
3. Have a strategy to promote engagement. Your survey response rate can be influenced by who sends the survey and who sends the survey reminder. While it may be logical for the survey to come from Human Resources, we suggest having the survey come from either the Chief Executive Officer or Chief Operations Officer (or equivalent). This signifies that your organization views well-being as a business strategy. Survey reminders tend to be most effective when sent from department managers. This reinforces the messaging about well-being being a business strategy and signifies commitment at all levels of leadership. 
4. Include space for open comments. Multiple choice and basic ranking questions can help keep a survey direct and are easy to respond to. They also provide data that is easier to analyze and compare year over year. However, it’s not possible to anticipate every need with multiple choice questions, and some of the best suggestions and ideas, as well as some of the most constructive remarks, will come in the form of open commentary. 
5. Keep it anonymous but collect some demographic data. An anonymous survey will not only result in more candid feedback, but it will also avoid inadvertently collecting personal health information that may be disclosed (particularly in open comments). Having optional questions to self-identify department, office, or work arrangement (hybrid, remote, in person) can help identify high-risk groups ('high risk' meaning those who have a low perception of their well-being and the organizational culture). Making these questions optional reduces the risk that an employee will abandon the survey due to fear of being identified based on demographic responses (e.g., an employee who is the only remote employee in their department). 

A well-designed well-being survey can serve as a launchpad for a transformational well-being initiative, especially if your organization is prepared to report and act on results. For more information on how your organization can create and deliver a well-being survey, or if you have other well-being program questions specific to your organization, please contact our Well-being consulting team. We’re here to help.

Read this if you are interested in grant compliance in healthcare. 

This is a companion article to the podcast, Mitigating the compliance and revenue integrity risk of grant funded healthcare programs.

The BerryDunn Healthcare Practice Group boasts professionals who have expertise all across the spectrum of healthcare, including regulatory, revenue, integrity, general compliance, and risk management issues. This article covers the very specific arena of grant compliance affecting many of BerryDunn’s healthcare, not-for-profit, and government clients.

After starting as a newly minted MBA financial analyst with an academic medical center in Northern New England, I (Markes) worked my way into the world of grants and contracts supported by my interest in federal regulations and the non-clinical revenue streams. Fascinated to navigate through waters where it seemed no one was the expert, or really had the time or patience to figure things out, I worked to stand up a grant office in finance on the hospital side, separate from the medical school which was the usual repository for grant funding. We moved this direction because hospital leadership realized grant funding was tipping toward the clinical setting and was less focused on bench or clinical research. Put another way, less NIH and more CDC, HRSA, and CMS.

BerryDunn Senior Manager Regina Mathieson advises, “wherever there is complexity, there is compliance risk.” Whether from a federal agency like HHS, HRSA, NIH, or CDC, a state Medicaid program, foundation, or private source, grants always come with requirements, typically very specific requirements. Because the dollars are being ‘given’, those requirements for how the funds are used may be much more restrictive than loans.

Like other areas of regulatory compliance, it is reasonable to assume that grant programs often have compliance gaps that go unnoticed. For many of our clients, both in healthcare and not-for-profit, and in the government space, grant revenue has become a significant source of funding. Any kind of healthcare delivery organization, including academic medical centers, federally qualified health centers, community hospitals, behavioral health service organizations, home health providers, visiting nurse associations, and others can end up with significant portions of their income for the year being sourced by federal grants.

Grant compliance categories

We all can’t be experts in every domain of regulatory compliance, and grant compliance has a lot of breadth. Thankfully, at BerryDunn, we have a team of grant experts who work collaboratively across practice groups. When I was working on setting up the grant office and establishing a proprietary clinical FTE reporting process and system earlier in my career, I would have greatly benefited from the perspectives of other experts at the table.

When we think about grant compliance, four categories are helpful to keep in mind:

1. Restricted funding
2. Single audit
3. Indirect rate
4. Time and effort

Restricted funding

Firstly, and most universally understood and applied is that grant monies are, pretty much by definition, restricted. Aside from very specific and rare instances of monies being granted to beneficiaries who have no responsibility, all grant funding is awarded with the expectation that the funds will be expended in a specific way. 

Any funder, from the federal government to your local community organization like the Lions Club or the VFW, will likely require individuals and entities awarded a grant must promise to use the funds only for the purpose laid out in the award and proposal. Compliance with grant terms typically includes following the requested reporting requirements of that funder as well. Though this category may sound obvious, it's actually pretty far-reaching, as it usually affects sub-recipients (those entities who are partnered with the direct recipient to accomplish the grant purpose). For example, where the money goes after the initial awardee receives it, or rules about who can do the work, what type of organization, how you choose a vendor, etc.—all sorts of categories.

It should be noted that many of these grant award requirements are not dissimilar from work we already do in the healthcare compliance space to assist our clients in avoiding anti-kickback statutes and Stark risks. This is because grant compliance is grounded in the same basic concepts—no favoritism, no bribes or shady deals, and avoiding fraud, waste, and abuse. Especially if you're spending federal monies, you need to prove that you choose the vendor based on verifiable best practices, and consideration was afforded to organizations owned by women, veterans, and minorities.

Single audit 

The second category, Single Audit, is applicable to all federal funding of $750,000 or more annually. My colleague from BerryDunn’s Not-for-Profit practice group, Katie Balukas, explains: 

"The federal Single Audit Act is a requirement for entities to undergo an independent financial and compliance audit when the entity has expended over $750,000 in federal awards. These audits are conducted following guidance issued through the Governmental Auditing Standards and the United States Office of Management and Budgets' Uniform Guidance. The main focus of the compliance audit is to assess the entity's compliance with the requirements set forth by the federal agency that administered the grant funds. That includes, but is not limited to determining if the funds were utilized for allowable costs and activities and expanded within the proper grant period and that the reporting and performance objectives were met."

It is important to note that adequate, appropriately scaled internal resources are essential for any organization receiving grants and even more so with larger grants. Though the phrase has been overused, it really does “take a village”. Grant management isn't something an organization should do on the side, assigning grant accounting to someone who already has a full-time role, but unfortunately this is common and also unfortunate because under resourcing tends to lead to compliance concerns, as well as just plain old poor funding management. 

Indirect rate

Speaking of funding, the third type of grant compliance is very focused on a component of the grant world that really has a life of its own: The indirect rate. Though there is an accounting definition of ‘indirect’, the way it is defined regarding grant funding is pretty specific, and there is an entire body of work organizations undertake to get a federally approved indirect rate.

There's an awful lot to think about with the indirect rate. On the one hand, you could say it's pretty simple. For example, a lot of foundation funders and even some federal funders will offer you a 5% or 10% indirect rate without any need to make a calculation. That's because they know that if you take time to do the math, you'll come up with a number much higher than 5% or 10%. When it comes to federal grants and healthcare services organizations, the indirect rate is dependent on how an organization measures costs. For hospitals, of course, the method of measurement is driven by the Medicare cost report, and that's where we would do the fancy math to derive the indirect rate. But the reality is far from simple or straightforward. 

Time and effort

The fourth and final area of grant compliance, time and effort, is also the one I'm actually most passionate about and is probably the most minimized, or at the very least, misapplied. 

In one way, “time & effort” is exactly what it sounds like. Much of granted dollars, especially from the federal government, get appropriately spent on program staff. The challenge is to match time and effort to those dollars, but that isn't as clear as it sounds, because the standard way of measuring staff time is usually in a payroll system of some sort, which can't prove how time was spent.

Most payroll systems can be programmed to account for FTE (full-time equivalent) allocations; however, there is often a breakdown between theory and practice. Putting allocations into payroll, usually done without employee interaction, may show how an employee “should” spend their time, but it is really no guarantee that that's actually how they're spending their time.

So how does the organization typically go about assuring that? Now, I don't want to speak for everyone, but let's just say I happen to know that there's a place for two or three (or maybe 10,000) that basically put allocations into payroll, and then, unfortunately, often well after the fact and/or more than once, send that allocation to the employee to sign off on without really any option to disagree, or even to modify. We all know that is not compliant…but in the organization's defense, there really haven't been very good alternatives to that kind of woeful and frustrating process, at least none that have been widely shared or understood.

As often is the case in the compliance world, rules are not followed because there is no perceived risk, but that is not a winning strategy.

Though many people involved in grant management do not have any experience or even knowledge of time and effort violations meeting with any consequences, organization interest and grant compliance have more implications than just preventing front page news. What I find in the conversations with organizations, both large and small, is that loose time and effort management costs the organization in two major ways. 

Firstly, it is inefficient to scramble around at the close of each federal grant to fix time and effort allocations. The extra time spent by grant staff, project coordinators, managers, and the finance team to sort things out because they didn't get them right the first time is the worst kind of inefficient—poor use of time with an equally poor outcome. 

Secondly, loose time and effort is costly in direct salary dollars. Most grant staff are not dedicated to one project, so we need to consider the value of their other work. Whether that is on other grants or, for example, seeing patients in the clinic as many principal investigators in healthcare do, having inaccurate or fluctuating understandings of their ability costs the organization directly in wasted salary dollars or indirectly as the opportunity cost of those providers (or other roles in other organizations). 

Digging in and fixing these issues is the work I really enjoy. It's relatively simple to build a compliant model, whether that requires very little payroll redo and is just a simple recurring attestation process in built in Excel, or more complex integrated models with triggered attestations in PDF format in a database that manages the overall FTE of principal investigators. It might even drive the available clinical provider time. It can all be done. We just need to know what the goal is. 

Working in this space so rewarding, because like so much of compliance, it's about doing something better—not just being compliant—but setting organizations up to better meet their goals and fulfill their mission.

The compliance or accounting professional might still ask, “But why aren’t payroll allocations sufficient for meeting Uniform Guidance?” The truth is, when UG came into effect and superseded the A-110, 122, 133, and others, the bar was effectively lowered. Historically, organizations abiding by the old OMB circulars had to make an attestation at least twice a year, which doesn’t really seem helpful, as who can accurately allocate their time from 5 or 6 months ago? So UG did away with the timeframe reference, relying on the idea that the payroll allocations and distributions would be all that would be needed, and in the absence of those, a monthly ‘look back’ by professional staff would be in order.

I say all this, because as a result, the interpretation of ‘payroll allocations’ then becomes the standard and we have forgotten about the other elements spoken of in the regulation. Remember, for anyone salaried (the vast majority of physicians and most of the higher level grant personnel), the ‘payroll allocation’ doesn’t pass muster. It is a static allocation that has no mooring in actual activity. This is why UG calls for monthly “current and reasonable estimates” of time and effort.

So what can organizations do in response? They need to seek a solution, a process, and a method that will both pass audit muster, as well as help the organization properly manage their resources. Almost every organization manages their productivity and finances on a regular basis: monthly! That’s why the same standard should apply to grant time and effort management. It's much more reasonable to ask you how you spent your effort this month, asking you to make a reasonable estimate of your time allocations to the different efforts you worked on.

So to summarize, the four key areas of grant compliance are (1) grants are restricted funding, (2) single audit requirement for federal funding over $750,000 annually, (3) the indirect rate and related agreement, and (4) time and effort.

Of course, I would be remiss to not point out that undergirding all this is the organization’s approach to policy. Any organization that considers grant funding a regular piece of their annual income needs to have dedicated grant management policies, covering all of the above topics, with particular focus on those arenas that are unique to the world of federal funding, and being mindful to follow or otherwise update for changes in processes and/or regulations.

Final takeaways: 

• First, what grant focused infrastructure do you have in place? If you are subject to a single audit, there should be dedicated administrative grant staff. And I don’t mean the programmatic people actually working on the grant, but people outside the grant funding—also why you have an indirect rate. 
• Second, how are you handling time and effort? If the process relies on any long after-the-fact attestations or payroll-generated reporting, it is unlikely to be truly following the spirit…or the letter…of Uniform Guidance. 
• Third, review your policies regarding grants. You may not actually have policies focused on grant activities, leaving them under ‘general finance’. That isn’t sufficient to cover federal funding requirements. Many have grant policies in place, but are they actually being followed through the lifecycle of your grant programs? 
• Lastly, the grant world is a whole ball game unto itself. BerryDunn has some great resources internally to offer assistance in all phases of grant management and administration. 

Read this if you are at a rural health clinic or are considering developing one.

Section 130 of H.R. 133, the Consolidated Appropriations Act of 2021 (Covid Relief Package) has become law. The law includes the most comprehensive reforms of the Medicare RHC payment methodology since the mid-1990s. Aimed at providing a payment increase to capped RHCs (freestanding and provider-based RHCs attached to hospitals greater than 50 beds), the provisions will simultaneously narrow the payment gap between capped and non-capped RHCs.

This will not obtain full “site neutrality” in payment, a goal of CMS and the Trump administration, but the new provisions will help maintain budget neutrality with savings derived from previously uncapped RHCs funding the increase to capped providers and other Medicare payment mechanisms.

Highlights of the Section 130 provision:

• The limit paid to freestanding RHCs and those attached to hospitals greater than 50 beds will increase to $100 beginning April 1, 2021 and escalate to $190 by 2028.
• Any RHC, both freestanding and provider-based, will be deemed “new” if certified after 12/31/19 and subject to the new per-visit cap.
• Grandfathering would be in place for uncapped provider-based RHCs in existence as of 12/31/19. These providers would receive their current All-Inclusive Rate (AIR) adjusted annually for MEI (Medicare Economic Index) or their actual costs for the year.

If you have any questions about your specific situation, please contact us. We’re here to help.