As value-based purchasing takes root, the revenue cycle looms large in the quest for high marks on the Hospital Consumer Assessment of Healthcare Providers and Systems, which makes up 30 percent of the score governing payment. HCAHPS problems could undermine stellar results on core clinical measures making up the rest of the score.

"Everybody's kind of got the core-measure thing down, and they're getting up there in the 98s [percentile]," says Anthony Spezia, president and CEO of Covenant Health in Tennessee. "But the differentiator right now is in HCAHPS, because it's patients telling you their experience—and you can blow the whole thing with a bad approach in the revenue cycle. You can do a great job in taking care of the patients, but if somebody's getting a bad surprise about what they owe, or they're being handled inappropriately by some financial counselor, forget it."

A project started by the Healthcare Financial Management Association found that "financial communication was as important as the clinical discharge information," says Richard Gundling, vice president for health care financial practices. "It wasn't necessarily the satisfier, but if it wasn't done well, it was a big dissatisfier."

Communicating expectations affects more than the bill. Instructions executed poorly in the discharge process can ding HCAHPS scores, but also have serious financial and clinical consequences. "From a revenue-cycle perspective, we really want patients to understand their discharge information because if they don't, depending upon the patient's condition, there's a better-than-even chance that the patient is going to wind up back as a readmission," says Gregory Meyers, vice president for revenue integrity at Integris Health in Oklahoma City. "I'm not being critical of nursing, but still that's probably a good example where the nurses don't understand that maybe taking an extra five or 10 minutes to really go over things ... can have a huge impact on the readmission rate."

The impact can be especially high at small hospitals. At 25-bed Chowan Hospital and six-bed Bertie Memorial Hospital, two critical-access facilities in North Carolina, contracts and information systems are managed by the larger system to which they belong—University Health Systems of Eastern Carolina—but "we still have to stand on our own finances," says Jeffrey Sackrison, president of the two hospitals. "A blip in our numbers here probably wouldn't make a big difference to our 800-bed teaching hospital, where to the smaller hospitals it's going to have obviously an impact," Sackrison says. "For us, revenue cycle really starts at the front door with patient registration and making sure that, first of all, we're getting all clean information."

From there, the operation stays attuned to patient-satisfaction readings to monitor where processes are slipping, and determine ways to improve—for example, in emergency department waiting time. "I think, every hospital in the country probably is looking at how we can improve those waiting times," Sackrison says. "A lot of it shows us that we may need to do a better job of keeping the patients informed as to why they're waiting. Making sure we have good communication with the patient solves a lot of problems."