SCI first to recognize importance of Access Management’s far-ranging impact.

Smart Advice: Cover Your Access. Improve Your Bottom Line.

Hans P. Morefield, SVP, Strategic Partnerships, SCI Solution

Not-for-profit does not, of course, mean free. While everyone recognizes providers need to be paid for the healthcare they provide, getting paid is becoming difficult. Those making the payments, whether health insurers, government or individuals, don't always do so easily or quickly. With the average payment for many services also declining without commensurate operational savings, providers are closer to the financial edge, leading them to make accelerating and maximizing revenue a top priority.

While claims are paid after the healthcare service, it is now widely recognized that the revenue cycle starts long before the patient's arrival on-site. Ideally it starts at the point of scheduling. What is less well understood (and for which consultants charge millions) is how key revenue cycle steps can be moved to the front-end to accelerate and maximize revenue with less effort. This article will examine four specific pre-encounter steps that providers can use to accelerate the revenue cycle for the greatest results.

Step #1—Be Payer-Specific Smart

The first key to an effective revenue cycle is to recognize there is no one solution—providers interact with many types of payers, and each has separate rules and obstacles to rapid, full payment collection. Providers need a revenue cycle process that recognizes and addresses payer-specific requirements and challenges.

Key challenges associated with the major types of payers

Payer	Unique Rule/Challenge
Medicare/CMS	Medical Necessity Rules For certain tests and procedures, CMS will only pay if the patient’s diagnosis demonstrates the service’s medical necessity. If the diagnosis does not meet the clinical standard (which can vary by intermediary), not only will CMS deny the claim, but the patient can only be required to pay if the provider obtained their consent on an ABN form before the service was provided.
Medicaid	Eligibility Medicaid patients often have their eligibility status change as their financial and family circumstances change, so a previous indication of Medicaid eligibility is no guarantee of current coverage. Restrictions: HMO/Site Rules & Limited Number of Visits/Services Over the past five years, there has been an increasing move of Medicaid members into some form of Medicaid managed care. Managed plans frequently limit where the patient can receive care and how many visits/services can occur before prior authorization is required. Since Medicaid patients are unlikely to pay claims themselves, it is imperative for the provider to ensure Medicaid will reimburse for the patient’s care by complying with the managed care rules.
Health Insurers (e.g., BC/BS, Aetna, United Healthcare)	Prior Authorization/Pre-Certification Private health insurance companies require providers to obtain prior authorization from the insurer for many surgeries, procedures and diagnostic tests. This authorization is typically requested by the ordering physician, but it is the service performing provider whose payment depends on this being completed. If not, the performing provider’s claim will be denied. The challenge is that the list of services requiring prior authorization vary by payer and even within a payer’s plan. If the requirement is not known, then the likelihood that the authorization will be collected diminishes.
The Patient	Ability to Pay For self-pay patients (and there are millions), a key issue for providers is whether the patients have the financial ability to pay for their care or what payment plan the patients’ financial situation can support. Patient’s Responsibility Even for insured patients, it is increasingly common that they will share the cost, either through co-pays, deductibles or co-insurance. The challenge here is knowing how much the patient is responsible for and getting the patient to make payment prior to the service, as the likelihood of timely payments made after services have been rendered is greatly diminished.

Step #2—Start Smart

Start the revenue cycle with the first interaction in the care delivery process: scheduling. Traditionally, scheduling has been considered a clinical process. Recently, however, it has been acknowledged to be a vital first step in the revenue cycle, offering the opportunity to reduce many of the claim denials that swamp business offices. Ideally, the following revenue cycle steps should be done during the scheduling process:

Medical Necessity Checking—to address Medicare’s rules the best time to check whether the diagnosis is covered according to the local coverage determination (LCD/LMRP) rules is during the scheduling call. Since the diagnostic tests with medical necessity rules are typically scheduled by the referring MD’s office staff, the hospital can receive and review the diagnosis and address any issues long before the patient arrives for the test. As a result, hospitals have reported near elimination of medical necessity denials.
Collect Authorization Number—for patients with commercial health insurance, scheduling is the ideal time to request an authorization number from the referring MD’s office. If the authorization has not been obtained, then at least the MD’s office has been apprised of the authorization requirement. The result is less work and uncertainty during pre-registration and fewer denials for lack of prior authorization.
Enforce Managed Care Rules—for patients whose coverage includes plan rules such as preferred provider networks, these rules need to be known and enforced at scheduling. This keeps the patient informed of non-coverage and aware of the associated financial consequences before the appointment.
Inform Patients of Co-pay/Co-insurance—for hospitals, the earlier patients can be reminded of their responsibility, the more likely they will be prepared and willing to pay upon arrival. To capitalize on business benefits of the scheduling process, these revenue cycles should be automated. SCI Solutions’ Schedule Maximizer seamlessly and intelligently automates this functionality so that schedulers can complete these steps quickly and easily.

Step #3—Work Smart During Pre-Registration

After scheduling, there are more revenue cycle tasks that should be completed prior to the patient arrival. This effort, which can involve many distinct tasks and individuals, is commonly referred to as pre-registration and may include:

Tasks optimally done during pre-registration that may have carried-over from scheduling, which couldn’t or didn’t get completed:

Obtain payer authorization (if the MD office/patient didn’t have at the time of scheduling)
Address additional payer-specific/plan-specific rules

Revenue cycle tasks best suited to be done after scheduling and during pre-registration:

Collect/verify patient demographics
Verify the patient’s insurance eligibility
Determine the patient’s co-pay/co-insurance
Collect the co-pay if possible
Finalize the ability to pay or payment terms for self-pay patients

The greatest challenge providers most commonly face is organizing and consistently completing all these tasks, particularly since the Byzantine nature of healthcare reimbursement requires providers to have specialized staff to handle specific tasks like authorizations and financial counseling. Too often, pre-reg staff is provided only a print-out of an upcoming schedule which does not guide them with respect to priority, status, or which tasks to complete for which patients. If a staff member is absent, it is likely that no one else will know what work needs to be done.

The solution is to use an online worklist capability that links payer and patient specific revenue cycle rules to scheduled appointments to provide pre-reg staff with a prioritized list of tasks to complete. Worklists can also track due dates and automatically escalate tasks when due dates are approaching or missed.

Step #4—Get Smart; Collect Cash Upon Arrival

For all the complaints about insurance companies paying slowly, patients pay slower. While the amount patients owe is usually much less (sometimes just a $5-10 co-pay), the amount and importance of these payments is growing. Revenue cycle success demands that providers improve their patient-portion collection processes.

There are four keys to successful cash collection on patient arrival:

Know how much to collect, using the pre-registration process to ascertain the amount owed by the patient.
Remind the patient as frequently as possible, of their responsibility to pay on arrival. This can be part of the pre-registration call as well as appointment reminder communications.
Train, motivate and measure front desk staff to ask for payments from patients.
Use systems to record cash collections. Paper envelopes are out; cashiering solutions are in. In order to ensure all payments are correctly captured and recorded, it is imperative to use proper systems for generating receipts and creating financial records.

Healthcare providers must be reimbursed, and there are proven tools and processes available to help them accelerate and maximize reimbursement through Access Management redesign. If you want to learn more about the experiences and results achieved by SCI Solutions customers, or for a product demonstration, please contact us.

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client quote:

“With SCI we reduced our lab monthly denials from $23,000 to 0, and increased utilization from 400 average orders a month to 3,230, as well as improved patient, physician and staff satisfaction.”

Eisenhower Medical Center

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