Continuing my series offering best practices and tips to address the many challenges executives at health centers face, this month I am addressing the topic of key performance indicators.
I hear it all the time. How do we compare to “the benchmarks”, Karl? How do we know if our results are “right”? I think it’s important to let “industry” benchmarks inform an assessment of your organization, but I do not think that industry data on a stand-alone basis is the only guiding light to follow. Metrics mean something different for everybody. Everybody has different goals, values, positioning initiatives, and they are all in different places within a business’s life cycle.
With that in mind, I encourage organizations to assess what are your goals? Is hitting a certain benchmark the endgame? Why are you striving for a certain benchmark? Is it for a financing? Hitting that goal will be a litmus test for hitting another benchmark? Will achieving a certain benchmark allow you to invest in a new program? Those are the questions to be asking. Are you achieving those goals?
For example, I have worked with organizations that had a low amount of cash compared to industry benchmarks. However there’s always a reason though, and it is not necessarily bad. Perhaps the organization is in a period of new program development, and the new program is not fully “cash flowing” yet. Monitor and respond!
My advice to companies that are asking about benchmarks is to ask company leadership to engage in a process to help them gain some perspective around benchmarks:
I want to clarify, though, that I do think metrics in the proper context are important. With the proper perspective, metrics do tell a story.
The following lists a few metrics that are indicators of operating effectiveness and liquidity:
The following lists a few metrics commonly monitored as indicators of capital usage, and financing “readiness”:
Of course never forget loan covenants! Loan document covenants have very specific definitions, reporting requirements, etc.. Rigorous monitoring is a must!
If you would like to understand any of these metrics, please reach out, and I would be happy to have a conversation about how these metrics are calculated and/or how they may add insights into your organization.
W. Karl Baker, CPA, spends his time thinking about ways to help organizations with sound financial decisions, including improving revenue cycle management, and access to capital. Find more information at www.BakerCFOadvisory.com and www.InfinityCommCapital.com.
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Continuing my series offering best practices and tips to address the many challenges executives at health centers face, this month I am addressing the topic of the chart of accounts and accounting for grants.
This topic seems basic and a bit granular, but when you understand the premise, “What gets measured, gets managed”, these are important topics. I set out to do a series of topics on themes that I routinely see. I continually encounter scenarios where analysis is limited due to poor use of data often due to poorly designed chart of accounts structure. If data isn’t accumulated in a way to help measure your organization’s finances, then it will be challenging to use the data to make good decisions. I think many executives try to understand their organization’s financial reporting and conclude it’s all gibberish simply due to a poorly designed chart of accounts.
I summarize the chart of accounts data shortfalls as follows:
These shortfalls contribute to poor data analysis, and limit management personnel’s ability to understand where problems are - activity by service line (revenues, costs, and margins), not capturing all costs for grants, etc.
With that in mind, I offer the following basic setup recommendations:
It may be impractical for many companies to discard a chart of accounts and set up a new “company” but there may be egregious situations that warrant the change. Without that change, companies should consider how to set up their reporting to align as closely as possible with the above recommendations. This can be done by utilizing your accounting software custom reporting features, using a grouping approach.
Ultimately, the important premise is to align your reporting with the way you think about your operations, for example reporting revenues that aligns with service activity data.
Next month, we’ll discuss some operational reporting matters such as utilizing key performance indicators to manage the enterprise.
W. Karl Baker, CPA, spends his time thinking about ways to help organizations with sound financial decisions, including improving revenue cycle management. Find more information at www.BakerCFOadvisory.com and www.SolvereAdvisory.com.
Continuing my series offering best practices and tips to address the many challenges executives at health centers face, this month I am addressing the topic of revenue cycle, particularly evaluating the accounting for your revenues.
In my travels and discussions with health care executives throughout the years, some of the top questions I am asked include: Are we billing for everything? Are we accurately completing claims? Are we collecting what we bill? Are we collecting what we are supposed to collect? Are our rates appropriate? Why does cash collections seem to be lower than our revenues? Are our revenues as posted in our financial statements accurate? Health care executives struggle to understand the correlation between their financial reporting, cash flow, and their general sense of the business. Does this sound familiar? If you are reading this, my guess is that you have had similar questions.
You probably need to assess your revenue cycle if you are uncertain about the answers to these questions. There are of course many factors. In order to answer the questions above, you need to address:
The concentration of this article is the actual accounting for revenues. Just as important as producing timely financial data is producing accurate data. Accurate revenue recognition in a health center is very important, contains significant estimates, and can have a material impact on the organization’s financial results. The accounting estimate for contractual adjustments is likely the most significant estimate within your financial statements and is prone to error. Get this calculation wrong and the health center’s financial statement results could be materially misstated.
Accounting for your health center’s revenues is made complicated by the number of moving parts - multiple service lines, dozens and dozens of insurance contracts, all with different requirements, coupled with tight resources to tackle this complicated area.
I recommend aligning the accounting with your business, meaning your financial statements should present revenues first by level of service and then by payor source. This allows for appropriate analysis compared to visit and encounter activity. That may seem obvious but many health centers have not set up their chart of accounts this way. Many health centers are simply accounting for revenues by payor source. I have even seen revenues presented in total, not by service line, which makes it difficult to assess lines of business.
Another concept that may seem obvious is that revenues should be recorded on an accrual basis, as opposed to cash basis. I write that advice because some health centers are presenting financial statements on a cash basis. The problem with this approach is that if the health center has a bad collections month, revenues will appear to be inappropriately decreased. A bad collections month is a problem for sure, but collections is a financing issue, not revenue. It may be a leading indicator of other issues as addressed above.
Of course the key to accurate revenue recognition is properly converting gross revenues to net revenues. Ideally the health center should input fees into the electronic health record and billing system (EHR) so that expected collection rates can be easily assessed and also expected reserves can be calculated. Additionally, the accounting department should integrate the EHR system and the accounting software, but many health centers have not made that investment.
Revenues should be recorded based on gross charges, and a separate calculation of contractual adjustments should be performed. This approach allows charges to be more easily reconciled to visits as a first test of accuracy. It is important to understand and properly apply accurate discount percentages against revenues and accounts receivable. If the accounting system does not have the tools to perform this calculation using the EHR system, and instead calculates reserves manually, the approach is prone to material error and needs to be monitored closely. Best practices are to check the allowance percentages by service line and major payor two to four times per year. It is important to compare cash collections to understand the correlation between collections and revenues.
I find that many health centers are challenged with this very important area of financial reporting, oftentimes relying on the year end audit process to “clean up” revenue recognition. A good monthly systemic approach will minimize year end work but more importantly the health center’s monthly financial reporting will be accurate and management can use the data to make informed decisions. It can be disastrous to make decisions based on materially overstated revenues because the money simply will not be there. The good news is that a proper assessment can identify the path to improved information. I would welcome the opportunity to have a conversation about these matters with you.
Last month I started a series offering various best practices and tips to address the many challenges
executives at health centers face.
This month, I’m going to write about a topic that is a major challenge to many executives: how to
improve the accuracy of monthly financial statements, and do it in a timely basis. Numerous clients over
the years have told me they either never receive monthly financial statements, relying on year end
audits, or they take two to three months to receive them and even then, the accuracy is questionable or
the usefulness is limited per the executives I’m speaking to.
I’ll start by saying that your organization should be generating accurate financial statements prepared in
accordance with generally accepted accounting principles (GAAP) on a monthly basis. I have had some
organizational senior leaders tell me that their financial leadership tell them it’s not possible to prepare
financial statements monthly. Not true, and that’s a red flag. There are many schools of thought as to
timeliness, but not too many different views as to whether it’s possible to generate GAAP-basis
financials on a monthly basis. It’s possible. Some organizations are able to generate their financial
statements within 5-10 days after month end and some take longer. Some take MUCH! longer. My rule
of thumb would be that in no circumstances should it take longer than 30 days after each month end to
generate monthly financial statements.
If you’re reading this and you are thinking, “We’re not getting financial statements out the door before
60 days. What is the disconnect?” Very simply, it’s leadership overseeing bad processes. Often times it
is due to the perception that all the work done at year end in order to close the books for a year end
close and for the independent audit needs to be done monthly, and therefore the conclusion is that it
takes too long. However, I would flip that around. As a practical approach, it is important to perform an
accurate monthly close process in order to generate the financial statements, and with a good monthly
process, the effort needed to perform the annual close is much less of an undertaking.
The quicker an organization needs its financial statements the more likely they will need to either have a
robust and accurate purchase order system or a strong system of recording estimated accruals.
If 25-30 days is an acceptable time frame, then the accounting department needs to choose a final day to
“cut off” each of the major accounting cycles: revenues and disbursements/payables. The primary
reason for the stated delay provided by accounting departments is receiving invoices with dates of
service related to the prior month.
A typical approach would be the following schedule if we use the 25 th as an example:
Some companies use cash basis for recording payroll, which is an inaccurate approach. Those 2-3
months per year where there are “3 payrolls” cause results to dip. Since most payroll is paid in arrears,
accruing payroll based on dates of the payroll period will fix these spikes in payroll expense.
How do companies generate financial statements with a quicker time frame than the above, for example
8 to 10 days? Most companies do not receive enough of their invoices from their vendors within a day
or two of month end in order to post accurate accruals. One approach is to use a purchase order (PO)
system that records accounts payable transactions and expenses based on their internal PO system. This
allows them to record expenses without waiting for invoicing. If they do not have a PO system, they are
simply using an estimated accrual system. They have studied trends and identified major expenses to
accrue and use an estimation process. This is quite an effective approach. Once past a learning curve, it
allows the team to issue materially accurate financial statements within a few days of month end. There
may be a need to keep the books open longer for year end in order to rely on hard data for the year end
close but it is an effective approach throughout the year.
In the next article, we will continue discussing the month end close by discussing tips for accurate
revenue recognition, which also impacts A/R.
What lessons are you taking away from these thoughts? I hope at the very least it is that a professional
approach to monthly financial statement production can help executives have the information they
need to run their health center effectively. Additionally, a second set of eyes can be immensely
Executives need information to run their health care organization. I talk to CEO’s all the time about their challenges, and I have put the broad challenges into the following categories simply to apply some framework:
I consistently get the following feedback: I don’t have the financial leadership support I need; I need information; the board needs to be educated about the complexities of our organization; I am not even comfortable that the monthly information is accurate; cash flow seems to be low; we frankly have no idea if the billing department is doing a good job; any financial surprises in the near future may cause some pretty big problems for us, but we don’t really know; the results from the annual audit don’t correlate with monthly data I receive and I have no idea why; we think we’re fine, and then the audit comes along and the results are remarkably worse; we receive offers to sign capitation contracts, and yet we don’t know how to evaluate them; and many, many more comments like that.
I think it’s possible for you to know what you don’t know. Over the next several months, I’m going to offer a series of articles to give some tips, feedback and pointers on several of the challenges you are facing. I’ll address topics such as board governance and education, strategic planning, financial reporting best practices, business office best practices, technology, billing and collections, financial management, contracting, evaluating lines of business, and cash management.
This month, I’m going to start with a topic that is a major challenge to many Chief Executive Officers (CEO’s): board oversight and education. This is a common challenge that I frequently encounter with organizations.
Board members are typically voluntary members, recruited to the health care center for various skill sets they may have. As a general rule, the board of directors is responsible for overseeing the planning and direction of the health center, oversight of legal and ethical compliance matters, and ensuring resources and plans are in place to have an effective operation. This latter component is especially accomplished by hiring the CEO to carry out the management of the organization.
CEO’s want their volunteer board members to better understand the business but time is tight during board meetings, and the business is complicated. So how to make the complicated simple in a short time is a big challenge. Certain members of the board may participate in certain subcommittees such as finance/audit, compliance, etc. Members of these committees will likely dive deeper into understanding keys to success.
I’ve found board members first need to understand the various components of the reporting package: the statement of financial position (balance sheet) and statement of activities & change in net assets (income statement & change in retained earnings), and statement of cash flows, along with the important metrics and line items to pay attention too. This being a broad article, I’ll not go into the details but I do find that I often need to explain in basic terms the basics of each statement, what they mean, differences between accounts receivable (A/R) and revenues, etc.
After a financial statement 101 training, the issues that cause the most complexity usually involve liquidity and working capital, revenues and their connectivity to visit and encounter activity, along with collections.
I’ll talk in a future article about managing revenue and A/R valuations, but board members need to understand the key drivers of success. As an aside, I’m often asked about industry benchmarking, which I do think is important, and is why I’m in process of rolling out some benchmarks for health care providers, but I also always emphasize that benchmarks need to be studied in context. It’s important for health centers to develop their own target metrics that will help them measure results compared to their goals. For example, I’ve seen certain health centers target certain metrics such as “days cash on hand” or “days sales in accounts receivable” in accordance with their strategic objectives, even when their targets varied from industry benchmarks.
Certain key drivers include knowing the health center’s cash position (days cash on hand), working capital, how long it takes for average claims to be paid, revenues by service line (in “total” and “per visit”) as well as visits/encounters by service line. I usually also advise reporting on monthly cash collections, as this will give you some correlation to revenues and A/R. Other important matters that make a difference in month to month results include number of days the organization was open for the reporting period. Number of clinic days can make a 5-10% swing in activity and revenues in any given month. Additionally, I think it is imperative for organizations to understand their margins by department and/or service line. Correlating with cash flow and financial results, it is important for boards to be educated on issues such as staffing, productivity, compliance matters. Of course, if the health center has incurred debt, it is imperative for the board to understand how the paydown of debt is impacting cash flows, along with the health center’s standing relative to any financial covenants in place.
When presenting to boards and committees, it will be important to assess the most effective way to convey these matters. I’ve found that charts and graphs help board members visualize the story being conveyed in the metrics. Members of the finance committee may want to see more details, and they may actually want to see “the numbers”.
I could go on and on about topics to cover in board meetings. Running a health center is a complicate venture. It takes time but as the title of the article suggests, it is imperative for board members to “learn” what they likely did not know when they first joined the board. I’m currently the president of a non-profit organization in my community. I’ve been on the board for over 10 years. I’ve personally spent time learning the keys to success for that organization by listening to many, many presentations and soaking it in one meeting at a time. I’ve worked with many clients over the years, and I am convinced the more the board of directors is given the right information, the better management and the board are able to work together to steer the health center in the right direction.
If you spend any time receiving daily alerts for job wanted postings, you likely know there are numerous companies looking for new finance leadership. Lots of opportunity out there.
So I wanted to give a few tips for a younger person that may be looking for a promotion to their first Chief Financial Officer (“CFO”) role, or perhaps you have landed that job and could use a few tips, especially for accounting professionals that are transitioning to the CFO role.
Every company handles various tasks differently, and “pushes” down responsibility in different ways depending on the size of the company, available resources, management style, etc. Therefore, the following is a list of a few things to think about, keeping in mind there are no “bright” lines:
CFO’s can fail because they stay in the weeds, either due to style or necessity due to limited resources. I believe in a very under-appreciated best practice that a second set of eyes can provide enormous benefit. It is difficult to analyze a given set of facts if you have to compile the facts first. For example, if a CFO has to compile a financial statement from scratch or has to trace numbers from financial reports to the underlying supporting documentation as a first review because the review has not been performed by a controller, then it is very difficult to perform a higher level “smell test” of the financial statements, which is key for ensuring accuracy and to begin to draw conclusions from the data.
The CFO role is a key role; it is very exciting and very challenging. I encourage any new CFO to embrace the role and develop the habit of continuous lifelong learning.
I work with a number of health care and other types of clients. In the last two years, I’ve been blessed to work with more clients than I can count on my two hands. One thing I continually encounter is a very dry but important subject - chart of accounts (“COA”) structure.
Too many companies know their books do not capture financial information in the way they should but they avoid the challenge of changing their COA. That’s not a very interesting subject but it drives financial reporting so thoroughly, I thought we should talk about it. Very often, the COA was originally developed from a canned package or frankly by somebody that simply didn’t plan well enough. As businesses grow in size or complexity or simply seek to increase their level of sophistication, a change in the COA structure may be warranted.
The following is a short list of leading indicators that there may be a need for a change:
If any of these questions trigger further questions, it may be worthwhile to invest in the time necessary to revise the COA. The following is a short list of things to consider:
These are a few thoughts addressing wholesale changes. Maybe the health center does not need a wholesale change; perhaps an effective change would be to simply add some accounts or departments. I’ve seen that approach work very effectively to enhance the reporting.
What’s most important is to step back away from details, remove oneself from the resistance to spend the time, and think about the gaps in your data analysis. Improvement in the COA can be necessary to become more data driven, which is usually the difference between an effectively managed health center and one that is struggling financially (as long as there is the will to respond to the data but that is a different topic!).
Have you ever thought about the fact that for those of us who live in an urban area such as Boston (worst traffic in America, literally per studies) our use of technology often times does not help us? Cars are a wonderful invention, saving us time, and they’re just plain cool to drive usually, unless it’s a Corolla. No offense to anybody out there driving Corollas, and I drive them periodically as rental cars when I travel, but Toyota does not make that car in order to add to the cool factor. Anyway what do I mean when I say that the technology does not help us? In the morning, when I need to get to work, 10 miles away, I could probably get on my horse, which I do not have, and get to my destiny at least as quickly as it takes me driving a cool car. I would probably also be less angry. As I’m sitting on the highway going zero (0!) miles an hour, I imagine myself on my horse, galloping along at least a few miles an hour and arriving at my destination faster than in my car. Ugh.
And so I ask… In your business, is there any underutilized technology that you own but for which you are not making full use? Is there any technology available that could help your staff do their jobs more easily?
I have seen several instances in my career, where a company purchases accounting software, for example, along with several add-on modules, and two years later they are still paying for those modules, but never got past the barriers in implementing the features. Now it sits there collecting cyber dust.
Additionally, it is quite common for people to delay intentionally or unintentionally tapping into resources available to them. It’s easy for a company to just get used to the way things have always been, and let’s face it, a set of processes that include paper usually works, however inefficient it may be.
Examples include use of billing, purchasing, disbursement and payroll modules, HR platforms, and document management to name a few.
A CFO could be helping to assess those issues and opportunities. An assessment should include:
Then follow up, to understand what were the barriers and more importantly, what would it take to implement the use of technology? What would be the return on investment? Would it make people‘s lives easier? Would timing of said processes be different? Would we need as many staff as we currently have?
After an assessment is complete and if there are opportunities identified it will be important for somebody to take the lead and put a plan in place for execution.
A routine review of these matters will likely pay off in many ways. Don’t buy a horse to avoid traffic. You likely can find a pretty cool way to get to work!
Said no business owner, ever. Though it may be a popular method of ordering by adventurous customers at restaurants, no business owner wants to be surprised by financial matters that are within our control to avoid such surprises.
In the nature of the work we do at Baker CFO Advisory, LLC, we evaluate company processes, internal controls, and financial reporting. Sometimes it may take a while, but unfortunately, we find matters within pre-existing systems, processes and controls that may surprise our business owner clients, and then we put plans in place to help mitigate that risk of future problems. Often times it answers the questions the owner had about challenges that they couldn’t quite figure out.
Do any of the following challenges sound familiar to you:
I could go on. With the proper expertise, planning, systems, and implementation of technology, it is possible to avoid these surprises. There are enough challenges in running a business, that adding stability and expertise in the business office will eliminate at least one challenge.
The above list can be mitigated with proper best practices.
Revenues and Collections: You should be evaluating the recording of revenues and outstanding charges in accordance with cash collections, contracts and sales agreements to ensure your books reflect the economic realities of your sales and collections.
Cash flow: Additionally, regular cash flow projections should be set up to help anticipate cash flow challenges, helping to plan for seasonality of sales, debt payments, payroll, etc. If cash is particularly tight, daily cash management may be necessary, but it’s unlikely that anything less frequent than weekly cash projections will suffice, looking out 60-90 days.
Expense management and other accruals: You should be evaluating your system to assess whether all liabilities, including trade payables, customer credits, or other accrual risks are properly recorded. Depending on the nature of your business, it’s quite possible that significant estimates are necessary. We have worked with companies that had very significant IBNR (incurred but not reported) liability risks with such a material impact on the overall finances of the organizations, that it made the difference between overall profitability and near-bankruptcy mitigation. Imagine the surprise at these companies if they had poor systems in place to properly calculate those liabilities.
Staffing: Is workflow as efficient as possible? Is the company making proper use of technology to make work life as efficient as possible?
Budgeting: It is important to have a financial plan that is always looking forward, evaluating the basics, such as ongoing operations, but also such things as “same store” sales and profitability, service line finances, return on investment in growth ventures, research and development, etc.
Back to surprises… they’re great in gift giving and celebrations, but can be the downfall of a business when it comes to managing its finances. If you’ve recently been surprised due to accounting and reporting issues, we would welcome the opportunity to help.
Karl spends his time thinking about ways to help organizations with sound financial decisions.
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