#194 Who Does What, Who Answers, and Who Just Needs to Know

A household runs on clarity, not effort. So does a practice. Most performance problems in independent practices are clarity problems: somebody thought somebody else was handling it. This episode builds the RACI model (Responsible, Accountable, Consulted, Informed) into your billing workflow and your hiring. 

What RACI actually means.  

Four roles, each assigned to a person for a task, with one hard rule: never more than one Accountable person. If two people are accountable, nobody is. 

Mapping RACI to your practice.  

A denial slips through when the billing manager assumes the front desk verified eligibility and the front desk assumes the billing manager caught it at scrubbing. With RACI, every role is named and the gap disappears. An unowned weekly denial review at a $350K-a-month practice can run 3 to 5 percent above its potential clean claim rate, $10,500 to $17,500 a month lost in a gap nobody owned. 

Hiring into the RACI structure.  

Define the RACI role before the job description. A person wired to execute will struggle in an Accountable seat that requires sitting with ambiguity. That is a role mismatch, not a character flaw.

Three actions this week 

• Map the RACI for your weekly denial review (if you cannot name the Accountable person in thirty seconds, the task has no owner). 
• Audit your current team against the RACI role definitions: right role, right wiring? 
• Use RACI in your next hire, before you write the job description. 

Resources 

30-Day Revenue Recovery Plan (primary): 

eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan 

Book a call with Heather: 

calendly.com/heather-natrevmd 

Payment Posting Audit Checklist (supporting): 

eligibility.natrevmd.com/payment-posting-checklist 

Referenced: The Five Dysfunctions of a Team by Patrick Lencioni; High Output Management by Andy Grove. 

Transcript

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SPEAKER_01 0:04

We probably all know what good looks like at home, right? Kids have done the chores, everybody's picked up on time, things just run smoothly. But how do we know what good looks like when we're at work? So today we're going to unpack strategies to have your office run like a well-oiled machine. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signarelli, founder of NatrevMD. Let's get started. Obviously, we can all think about a dream state when it comes to your home running well. Dinner gets made on time, dishes are clean, homework gets done, bills get paid, kids know what is expected of them, and they're generally doing what they're asked. Really, the idea here is that nobody's tripping over each other. Nobody is standing around waiting to be told what to do. Everybody just knows their role, what to do, and how to do it. Now, think about what happens in a household that's not running well. We've all been there. Maybe two people are making dinner at the same time or nobody makes it at all. It's probably more likely. Folks are bumping into each other, kid says that they thought their sibling was doing the dishes when in reality they were supposed to. A bill was late because somebody else thought that they were handling it. Homework doesn't get done. Nobody checks the homework. And it's not because people are inherently lazy, it's just because the expectations around what they should be doing and who's responsible for what isn't there. So the difference between those two households isn't that in one setting someone's smarter than the other or how much effort people are putting into things. It's really because you don't have a structure. And there are recurring tasks that happen every single week in a household in an office. And if folks don't know how to do those tasks or who's responsible for those tasks, or who has to be ultimately responsible for that decision, then things just operate on assumption. And assumption in a household or in a multi-million dollar medical practice is really how things fall through the cracks. So today we're going to go over the RACI model, which is something that I have experienced working in, whether it's in healthcare or your household, great in a business of any size. And so the rule here is really explaining who's responsible for what, how to do things, what's the expected outcome, and what's the expected frequency. I do truly believe when we think about our employees that most people come to work every single day because they want to do a good job. I think inherently people want to do a good job, they want to have results that they can see and feel and be tangible, especially certain generations, maybe more than others. They want to have praise when it comes to doing a good job. They want feedback when things maybe didn't go as well as planned. And how do we set the structure around allowing people to have the knowledge, the skill set, and the ability to work independently, but knowing that they're doing a good job or that it is something that's useful for the business. So, same thing about our kids. I think kids thrive in an environment where there's structure, where they know what's expected of them, they know the frequency of that, they know the expected outcome when they don't do something, or, you know, the praise when they do something well. So whether it's parenting or a management framework in the office, the highest performing households or practices that I've ever seen use some sort of model like this. My hope today is that you walk away with a couple key strategies that you can bring to your office manager, that you can bring to your staff huddles to really lay out this framework to help your staff know their role. The thing that I see practices struggle with, and this is probably any business, is not a clinical problem. It's not a technical problem, but it's a clarity problem. So how you hire and who you hire, even if you hired the best staff member, if you don't have clarity in what they're supposed to do every day, those people will get frustrated and they may not be successful and either they quit or you feel like they're not doing a good job. This is about making sure that you have the right structure in place to keep those high performers, to identify those high performers and make sure that everybody is set up for success. So, an example of this is say somebody thought somebody else was handling an urgent issue. Maybe it was a contract or credentialing issue that never got resolved, training that actually didn't happen because you thought the lead was doing when in reality the office manager was the one that the lead thought was going to do it. And so things just sit there undone. And really that's because ownership was never defined. I'm a huge fan, and we've talked about this in the past, Patrick Lancioni. So he has truly built his entire career studying why teams fail. He says that it's not finance, it's not strategy, it's not technology, it is actually teamwork that remains the ultimate competitive advantage, both because it's so powerful, but also because it is so rare. And that's all from the five dysfunctions of a team, which we've talked about in the past. But teamwork is rare. And not because people are difficult, but because clarity is hard and leadership is difficult to do, especially because I think a lot of us just aren't trained in this. You have to seek out training when it comes to leadership, whether you do it on your own or you take classes, whatever it is. And good employees quietly stop trying because they can't figure out where they're supposed to be or who's on point or how to do a good job, or they don't get the praise or they don't get the instruction. He has got some great YouTube stuff out there. He's got uh several great books. So I recommend if you're in that world of managing, Racy is such a great tool to close that gap. So, what does Racy stand for? So it stands for responsible, accountable, consulted, and informed. These basically lay out four distinct rules. Each one has a defined scope in terms of what their part is along a project or a specific area within your practice. So basically, each one of those roles is assigned to a specific person for specific tasks. And so the critical rule here to make this whole thing work is that there is never one more accountable person per task ever. And responsible is going to be the person who does the work. They are the doer. They are the one doing the execation, execution, they complete the task, they run the process, they manage the workflow. There can be more than one responsible person to on a complex task. But so say you have somebody who's responsible for eligibility. Depending on the size of your practice, you may need two responsible people to complete that task per day. Or is say you're on a you know medium-sized practice and you only have one person assigned, maybe per day, then that is the responsible person to handle the process and the workflow of doing the eligibility. So the responsible person knows exactly what their piece is and they need to have the outlined steps of that workflow, eligibility, for example. Now, the accountable person is the person who answers if it goes wrong, not who does it, somebody who's accountable. Um, but you won't have more than one person in that accountability role. So if you have a large office and you have multiple people responsible, then maybe you pick one of those who's accountable for leading that process. So that may be your office manager, that may be a front desk lead. They are the person who owns the outcome. And this is always one person. If two people are accountable, nobody is accountable. And they're the ones who are responsible at the end of the day for the denials that occur that the responsible person is supposed to carry out. The consulted person is the subject matter expert. So maybe that's your outsource-billing team who's a subject matter expert whose input shapes the decisions before they are made. So that could be someone who is consulted to help train or write a workflow. They are the person who helps support a two-way communication. Maybe they're training that responsible person. Now, the consulted person does not own the task and does not make the final call, but their expertise is the one who's going to influence that outcome. And last is the informed person. This is anyone who needs to know what happened after it happens. So this is typically that one-way communication. So I think the big takeaway with the racey model is really that single person to be held accountable for a task. Because if you have a more than one person, then everybody thinks somebody else is accountable for it.

SPEAKER_00 8:19

And the task doesn't have a true owner. And in a medical practice, if nobody is accountable for that, then what happens if it doesn't get done?

SPEAKER_01 8:33

Revenue slips, things fall through the cracks. Really important that somebody has to be held accountable so that they're the one just checking up on things and making sure that the responsible individuals do take care of their tasks. So let's now try and map the RACI model to your practice. So here is where this goes from just some theory, but actually to a tool you can use in your practice. So every function, or whether it's your front desk, your clinical team rooming a patient, your billing and operations team, all of those workflows have four potential role holders. Start with the area that you feel is most chaotic in your practice. So is that your front desk? Is that your back office? Is that your billing team? Is that your clinical staff? Whomever it is, pick one area and let's map out the specific tasks that folks are struggling. Start with one or two, and you're going to look at one specific task and then the four columns. So race C spelled out. So responsible, accountable, consulted, and informed. And then that's where you can put four individuals in those roles. And again, if you're a small office, you may have one person show up in more than one of those columns, and that's okay. You just never want to have more than two people held accountable for something. That's the biggest thing. So if a manager leading the office has a ton of eligibility denials, but doesn't see that and fix that and have an accountability loop to address that, then their failure is not just the task that they personally complete, but it's the performance of every single person that they manage and are held accountable for. So RACI is really a tool that we can give our management or that we give our staff to make sure that accountability is something that's visible and that when an output or an issue drops, that everybody knows what role they are held accountable for, who was supposed to be doing those tasks as the person who's responsible for those, so that those individuals can sync up and identify where the breakthrough, break, you know, breakdown happened, then they can potentially consult somebody who needs to be consulted to help solve the problem, right? Maybe a subject matter expert who can help solve that workflow. And then the informed person is really the person who just needs to make sure, okay, yeah, I know manager, you've got it, you're fixing this issue. I'm informed, I'm aware that you're addressing that, and I'm going to be monitoring metrics to make sure that those fixes address the revenue problem, for example. So, for example, in a in a billing workflow, right? So say a denial comes back from a payer, right? So the billing manager assumes the front desk verified eligibility before the visit. Now the front desk assumes the billing caught the issue at claim scrubbing, but maybe the billing lead was never consulted on a diagnosis code mismatch that triggered a denial. And so then the practice owner finds out three months later when the AR report shows a denial that nobody can explain because nobody owns that gap. And so that's why in our company we create trackers because we want to make sure that we are holding ourselves accountable. And so we're working with the management team at the practice to address issues. And the informed party then becomes typically the practice owner. And so this creates an accountability loop. So another example of this could be working accounts receivable. So in that scenario, the responsible person, the doer, right, is the AR follow-up individual. They're responsible for calling the payer, getting the claim information, and helping work the denial. Now, the person who's held accountable may be the billing manager. They're the person who's held accountable for all of the metrics. Now, maybe we have a certified coder who's the person who's consulted. They're the person who's maybe managing that complex denial, helping support a resubmission, working with the physician to get, you know, new ICD 10 codes. And the person who's informed is either an office manager or practice owner who's helping make sure that they understand these things are being taken care of. Our AR metrics look good at the end of the month. Another example is maybe who is responsible for updating insurance information. And that person who's responsible for that collects the correct information. They get it verified when the patient checks in. But the person who's accountable for that may be the office manager or the front desk lead if you have a supervisor, depends how big you are. And so that's the person who is accountable for the metrics at the end of the month. But the person who is consulted may be a billing expert because maybe the eligibility was a struggle or there was a COB issue. And so that's again the person who's consulted. And then the informed person, again, tends to be that higher leadership role, office manager, COO, practice owner, et cetera. They're informed at the end of the month that, hey, these tasks got completed. Our metrics look good. They don't need the nitty-gritty. They just need to make sure that, you know, if there's an issue, that the responsible person is the one fixing it because the accountable person is the one that's holding them accountable. And so you can walk away and go through your practice and pick out tasks that you guys are struggling with and then sit with your leadership team and then assign responsible, accountable, consulted, and informed roles in each of those tasks. Again, this doesn't need to be all hundred tasks that happen every day. Pick two or three that you guys are struggling with and then work through that, roll it out, set the expectations, and then see if that helps improve the outcomes. So another example that we can go through is how to use this framework as a hiring tool and where you can avoid expensive mistakes. So maybe you bring on an office manager who's really good at execution, but has never really owned an outcome. They've never been in that accountable seat. They promote a front desk coordinator to a manager, but that person hasn't ever had that level of accountability. Can they watch for issues before they become bigger issues? Can they teach and mentor individuals in the responsible roles in order for the outcomes to improve over time? I've also seen this where we've seen individuals who are really, really good individual contributors. They're very good at doing and executing, but they're not great at leadership. They can't anticipate issues before they can't come up. They can't provide constructive feedback. If you have somebody that you're trying to groom into that accountable role, you want to make sure that they have the skill set and capabilities to do that. Again, I think everybody can be taught how to be accountable, but you want to make sure when you're hiring, is this going to be a doer? Is this going to be a leader who's going to be held accountable? Have they been held accountable for different tasks or roles? How did they do in that position? Or have they always just been a consultant where they've not actually had to make decisions or own outcomes? So I think really sitting down, if you're trying to hire somebody and understand what is their position in the company, are they an individual contributor who's going to be the person who's responsible for the doing? And then have they done those tasks before? But just really important that you have that ambiguity defined because that's really going to help you hire the right person into the right role. So the right butt in the right seat. So one of the key takeaways is before you write a job description, I want you to define the racy role first for those tasks, right? So is that person that you're hiring, that role you're hiring for, is that primarily a responsible hire, someone who executes and, you know, does a workflow at volume, or is it that accountable hire, somebody who owns the outcomes, makes you know decisions, or is it somebody who's consulted? And so I think once you know that role, then helps you frame the right interview questions. An example of those interview questions is a responsible hire is going to be somebody who should be able to describe a process step by step, right? They should be able to describe how they've executed on eligibility or executed on working a denial step by step. And the accountable hire is going to be somebody that should be able to tell you about a time that they owned an outcome that went wrong. And then what did they do about it? And you can see, are they blaming somebody else or are they showing ownership to say, I owned that? And it was my job to help retrain the responsible party so that they had a better workflow, or it was my job to understand where the process broke down. I think that that shows ownership and that shows maturity so that then those are the individuals that you know can be held accountable without pointing fingers because that never goes well. So this takes practice. So the three actions to walk away with is first, I want you to map the racing model for some process in your practice that's not going well today. Start with one task. Maybe that's uh in your back office, maybe that's eligibility in your front office. And I want you to identify the person who's responsible, who runs it, who does the task. Name a single accountable person who answers to it. And I encourage if you are the practice owner or if you are a high-level executive and you have multiple people underneath you, please don't make this yourself. Obviously, there are gonna be some things that you are accountable for. And if you have a smaller team, you may be the person who's accountable and there's no choice around that. But if you have a larger team, I encourage you to identify somebody on your team who can be held accountable. This allows you to practice delegation. Now, maybe in the beginning, you have to be held accountable while you're, you know, managing somebody up, and I get that, but I really encourage you guys to think about delegation. Now, you may need to have somebody who should be consulted. Again, that could be your outsourced billing partner, and they may be the person that is consulted when it when a decision needs to be made. And then you'll want to have the person who's going to be informed of outcomes afterwards. And so write this down. And if you can't name an accountable person in under 30 seconds, that task does not have an owner today. And so you're going to work, want to work through that because it can impact revenue. Now, the second is you're going to audit your current team against the racy role definitions, right? So look at your manager, look at your billing uh team, maybe a director of operations or a COO. So for each of those people, ask honestly, are they in a responsible role or accountable role? Are they competent at doing those roles that they're supposed to be in? Or are they acting as a responsible individual when they need to be the person who's holding people accountable? Or do you have nobody in that accountability seat? And so, really, really important do you have the right people capable of doing what you need those roles to do? And last, if you are working on a hiring process, use Ray C model in your next hiring process. So really think through okay, what is this role going to need to do? Roles may have multiple tasks. So it's not like this person may be the only person that's accountable ever for every task, right? Different tasks are gonna have different people who are responsible and accountable. But again, pick the top five things that people are gonna be doing in the office. Hopefully, this is helpful to you. Maybe you can go make somebody responsible for doing the dishes tonight. So, really key, I think, to have this laid out. You know, practice, I think it just makes things run smoother. So hopefully you guys enjoyed this. We are also always looking for specific topics that you guys would like more on. Do you like more of the coding stuff? Do you like more of the leadership stuff? Like to have a mix. We would love to hear from you. Info at Natrevmd.com. And as always, we'd love for you to um share this podcast. We do have a revenue recovery uh toolkit down in the show notes show notes. These are super helpful to help you diagnose and see what's going on in your practice and make some meaningful changes. So hopefully you guys have a great rest of your week and we'll talk soon.