Why It Matters
Most academic medical centers and multi-hospital systems run six to nine revenue cycle functions - patient access, financial clearance, HIM, coding, billing, denials, customer service, vendor management, and analytics - reporting through different leaders who often optimize for their own KPIs. When those functions are structurally disconnected, three costs compound:
- Denial rework becomes permanent overhead. Denials rooted in registration errors never make it back to the access team as a learning loop.
- Patient financial experience fragments. Estimates, billing, and customer service produce inconsistent information because the underlying data isn't shared.
- Leaders manage to their swim lane, not the outcome. AR days can improve in one function while enterprise cash performance stalls.
The operational reality: rev cycle serves what Seidman calls "hundreds of bosses" - service line VPs, CFO, compliance, patient experience, payer relations. Siloed structures make it impossible to serve any of them well.
Key Takeaways
- Rev cycle is a loop system, not a linear chain. Design the operating model around integration points, not handoffs.
- Group dependent functions under a single leader. When redesigning structure, ask which functions have the highest feedback loops (e.g., denials and access, coding and CDI, estimates and billing) and consolidate reporting.
- Visualize the future state. Seidman built buy-in at Johns Hopkins Medicine by creating visuals showing which functions grouped together and why - not by repeating the phrase "world-class."
- Establish a weekly direct-report cadence. Direct reports should meet as a group weekly to surface cross-functional issues in real time.
- Build peer relationships before conflict. One tested approach: give each leader 30 minutes per month to meet another leader across the organization, so relationships exist before operational collisions occur.
- Hold leaders accountable for crossing lanes. If you grow leaders to own their area but never cross into others, you've reinforced the silo.
- Trust and mutual dependence are performance drivers. "The more and more we can work together and trust each other and depend on each other, you just become such a more powerful organization."
Expert Perspective
Sharlene Seidman spent 28 years in the Yale enterprise before moving to Johns Hopkins Medicine, where she inherited a revenue cycle team that had been without a permanent leader for roughly 18 months. Her first structural move wasn't a technology initiative or a benchmark exercise - it was a redesign of how functions grouped together and reported.
"What it did mean were some changes in positions and how we were thinking about what revenue functions depend on each other and should be grouped together under a single leader," she said. "Once I started to show visualizations of it and talk about what each group was going to be responsible for and how we were going to break down those silos between groups, then people started getting excited about it."
The operating rhythm she uses to sustain the model:
- Weekly direct-report leadership meetings for the full group
- Ad hoc cross-functional sessions when a specific issue requires it
- Ongoing exposure of leaders to internal "customers" â service lines, finance, compliance â so relationships exist before problems
A common mistake we see: organizations treat silo-breaking as a communication problem and try to solve it with more meetings layered on top of an unchanged structure. The structure has to change first. Meeting cadence sustains the model; it doesn't create it.