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There are idiosyncrasies to every culture. The US healthcare system itself is a third-party system. Hospitals bill insurance companies and patients, and so on. The revenue cycle management has traditionally been a US business. For the last 15 years, we’ve really watched a substantial portion of it transform into being offshore, predominantly in India. However, the Philippines, Pakistan, and some other countries also have significant amounts of RCM populations now performing that.

Revenue cycle management in India

Getting back to the idiosyncrasies of each culture, you’re going to have to deal with India if you’re in revenue cycle management. That’s just the nature of the business. There’s so much of the revenue industry now in India. Knowing some of the idiosyncrasies can be really important to ensure that revenue cycle management goes well but that the analytics works well. You can get data, analyze data, understand things, improve things and so on. Ultimately, what we care about is, “How do we improve the results of revenue cycle management, otherwise known as increasing the revenue?”

Tips for staff management

A few things that I might point out are worth knowing, and some of these may be incredibly obvious. If they seem culturally insensitive, I hope it’s actually coming from the complete opposite of that. Knowing and understanding cultures can help us bridge gaps and make things work better rather than not work well.

One of the things that come up often is sort of IST or Indian Standard Time. Most Indians are not on time for things. If a meeting starts at 11 o’clock, that doesn’t necessarily mean 11 o’clock.

I used to work for a Japanese company, “Toshiba.” I ran the CT or CAT scanner business for the United States. I reported up through the US and over to the Japanese General Manager for the entire world for a CT. One of the idiosyncrasies of dealing with Japanese management was we would all be sitting in a conference room for like 10-15 minutes, or something like that for hours on end with Japan. If we’re in the US, we are doing a videoconference and stuff like that, or if we’re in Japan, we’ve got 10, 12, 15, 20 people all in a conference room for hours and hours. 

One thing that totally blew me away was that I would look over, and I would see somebody who was a really high-level executive. Their eyes were not only closed, but they were snoring. They were lights out. They slept throughout the meeting. This was a totally accepted norm I had a hard time believing!

Time management

Getting back to India, nothing being on time is pretty standard. If you’re in Germany and you walk into a train station, and the train is supposed to leave at not just 8 o’clock. Still, it’s like 8:02.  It’s extraordinary. They’re on it to the second. Not so much in Italy. The same thing for India. Not so much on time which is worth knowing. Of course, that means something because if there are expectations that something will be on time or it’s going to work or not work, you’re going to have to deal with these things.

The other thing is, India has a bit of a culture of complaining where it’s kind of the norm to say, “Hey, there are problems with a lot of things,” and then voice those problems. If you’re dealing with an offshore RCM team, that’s going to come up quite frequently. The other issue that messes people up a lot of times is they’re shaking their head in a way that looks like a “no,” but it’s actually really more like a “yes.” That really messes people up.

Back to analytics

I think the one that I wanted to bring out was the statement of “We understand it.” When dealing with analytics, and we’re dealing with software, and we’re dealing with building something, whether an application or a particular analytical output, there is a requirement specification. There’s usually some logic like conditional logic in those requirements. However, we’ve talked about this in some other podcasts. Getting people to write that down can be challenging, especially when dealing with Indian managers.

I’ve run into that situation where I say, “Okay, it needs to be more clear,” and the answer that I’ve gotten back is, “Well, we understand it.” I don’t think so. First of all, because it’s not working. It’s clearly not working. That’s part of the reason why we’re involved in this process. It’s to try to bring some rigor, particularly analytical and data rigor, to a process so that somebody can actually watch over and know that something is working successfully. This way, they can actually monitor it, and they can actually quantify the performance. Getting somebody in India to clarify something in writing so that everybody understands it really is quite tricky.

Various levels of understanding

What do you do? Then, they say, “Well, we understand it.” I say, “Well, no, I don’t think that you do. We still need to make it more clear.” They say, “Well, no, no. We understand it,” and you kind of get locked in this almost horns locking. They are telling me they understand it, but do you really? I’ll bet not because the language there is not universally understood. “Universally understood” has to mean not only within a particular culture but across cultures. And that’s the great thing about data. It crosses cultural boundaries. Numbers don’t lie, and numbers aren’t interpretable. They’re pretty much finite and exact.

If the operational process is not working, please don’t tell me you understand what the language says because five different people may interpret it differently. And then, the output doesn’t work well. And then, when their manager comes back and says, “Hey, how is it going?” and they say, “Everything’s going great,” nobody knows. You can’t do quality control or even automate system issues to find errors because you can’t even agree on what is supposed to be happening.

A few more tips on business and culture

This brings me back to one of the last things about Indian culture. Indian people can be really stubborn. For those of you that are listening from India, I apologize again. We can go on a long rant about US issues and the people of the United States if it seems culturally insensitive. But trying to push through and agree on something or get something to happen when somebody in India says basically, “Oh, yeah,” and they kind of ignore it. Also, maybe they won’t do it, or you’re going in circles. They’re saying, “Hey, we understand it,” or “It’s okay” or “It doesn’t have to change,” that’s really challenging.

Just to reiterate some of this, a US-born and raised Indian American, not Native American but Indian American, said all of these things recently. I’m essentially parroting things that I’ve encountered and have been told by somebody who is Indian and has to deal with Indians regularly. We can go on about some things about Americans being loud and obnoxious and other things. I’m again not trying to insult Americans or anything. Still, amongst cultures, the US is generally considered, going in other countries, to be kind of loud and obnoxious. These are cultural perceptions. It’s okay; I’m not knocking anybody. I think it’s important to know and talk through some of these things.

Back to being stubborn and how to get things done, results matter. We have to get things done. It’s not insensitive to say that Americans are loud or Indians are stubborn. These are things we have to deal with. We need to understand a culture if we’re going to be successful, and working across cultures is challenging. It’s prone to significant issues that impact revenue cycle management performance.

Final thought

Acknowledging some of these, getting to know some of these, dealing with these, I think, is really important if we want to be successful. We want to be able to get through some of those. So when somebody says, “Well, we understand it,” how do you push through that? How do you get it done? How do you actually get that manager to go and actually write it down? Or do you sit down with them and work through it and demonstrate to them, “Hey, this is how we actually write out requirements so that we can actually improve things.” That’s the magic sauce.