Visions of a Perfect Access Process
A Business Office Manager’s Perspective
The Dream CAN be Reality!
Commentary by Dale Wilson, Business Office Manager of a 500-bed, not-for-profit hospital
There was a commercial a number of years ago that had the tagline: "It's what's up front that counts." I guess it was a great line because, all these years later, I still remember it. On the other hand, I cannot recall what product was being advertised.
I only mention this because, in the revenue cycle, this tagline is quite appropriate. I so often hear Business Office staff bemoaning the errors made by Access personnel. While few people intentionally make errors, there are so many hoops, crannies and nooks to get a patient properly registered that doing it right the first time (a noble goal) becomes a crooked path. Understand that the errors are of omission, in most respects, rather than commission.
As I’ve seen at other hospitals, our hospital also has had a program allowing back-end and front-end staffs to work together to actually see what the other does. While this has helped staff better understand what their counterparts deal with, we still need to provide front-end staff with better tools.
I have always believed that process is everything. No computer system can overcome a bad process. On the other hand, a good process can often prevail over a deficient computer system. The best alternative, of course, is where a superior process improves with a high-quality computer system.
In most instances, today’s Access flow involves not only software from the main hospital information system, but additional software or manual processes. This makes the experience generally herky jerky for both staff and patient.
Unfortunately, the Access process has received inadequate attention from hospital information system vendors. For many years, the focus was on billing and it then moved to clinical aspects ignoring the access process almost entirely. For hospitals using one vendor for patient accounting and another for clinical functionality, it really mattered little which one provided the Access piece, since neither provided a full solution. Additionally, scheduling, the start of the revenue cycle, has generally been treated as a disjointed piece.
To do it right, you need to address the full revenue cycle with processes and software that provides a smooth flow starting with scheduling. In the ideal setting, the only patient that is a surprise is the one coming through the emergency room as all others would be pre-registered. The biggest advantage of pre-registering is lead time because errors can be identified before the patient presents. Even better, identifying errors while you are working with the patient allows many to be resolved before they become billing issues.
It is unfortunate that we cannot channel our dreams into reality. If we could, I would want a process that had instant cooperation from all parties, so I will mention it first. Regardless of how good your staff is, there are a number of other players in the process, mostly outside the hospital’s control. To have that ideal process, you need a plan to get all the players on board.
The physician’s office originates the patient’s need for hospital services. While this is obvious, having and maintaining a fine-tuned relationship presents a major challenge for the hospital. I won’t address this or all the other external pieces, but want to acknowledge the full scope of what we deal with.
Another obvious statement: technology can solve problems. All too often hospitals install new software and try to re-create existing processes. The software was purchased because it was seen as an improvement to what the hospital had in place. It behooves management to discover how that software can improve their processes.
I have requested that my current hospital information system vendor, as they enhance our Access product, look for ways to walk the user through the process. Why force memory or notes posted around the CRT to be the way people know what to do for each patient? Once you enter the patient’s name and payer information, the software should have the rules that ensure all the right questions are asked.
The penalties of not doing it right the first time are many. The biggest one is not only being denied reimbursement by the payer, but not being able to bill the guarantor due to a hospital error.
Now imagine technology that actually solves problems in the hospital setting. I have to say “imagine” because we seem to lag behind other industries. In Rome, Italy, I put my debit card in an ATM machine and received lira. The technology that made that happen is far from the opportunities we see available to us in healthcare.
Our Access Manager says it takes six months to train staff to a point where she feels they can do the job properly. Much of that training goes directly to the myriad of rules that have to be followed to get the patient into the system correctly.
A system exists today where a Registrar can be led carefully through the process without worrying about the specific steps needed to take, based on the patient demographics such as sex and age along with insurance, insurance position and so forth.
The bottom line is simple – no manual process alone can create the ideal experience. The reason is also simple – even if staff could remember all the necessary steps for a specific situation (i.e., this insurance needs pre-authorization for this test), the system supporting the process has to have places to retain the data. How many hospitals have resorted to bolt-on or add-on products to improve the Access experience?
“It is unfortunate that we cannot channel our dreams into reality. If we could, I would want a process that had instant cooperation from all parties …”
What if you could put in place a process and system that does the job right? What would the net results be?
- REDUCED DENIALS
If you identify needed data up front, you reduce the situations that cause denials. My current environment prevents it, but if I could analyze what is happening with denials, I could show that many of them could have been avoided by better access processes. - BETTER CUSTOMER SATISFACTION
Patient satisfaction surveys beware—the revenue cycle is generally the patient’s first and the last experience with the hospital. To assist in getting positive results from patient satisfaction surveys, every reasonable effort should be made to make these experiences as efficient as possible. A smooth process takes less time, reduces question duplicity and so forth. It makes the event less of an ordeal. Assuredly, physicians are also customers and their satisfaction can be the difference between patients being sent to your hospital or a competitor. Imagine the efficiency of an order electronically entered by the doctor, pertinent clinical concerns being brought to her/his attention, being advised of a needed insurance authorization with the ability to get it from the insurer’s web site and that order going automatically to the hospital where the patient is contacted to set an appointment. - INCREASED CASH FLOW
Cash flow can be improved in a number of ways. Accelerating payments deals, in part, with cleaner claims reducing additional handling. The access process can help cash flow by catching upfront situations that are now not caught until after we have billed the account. There is also an increase if amounts do not need to be adjusted off due to missed steps (i.e., unsigned Advanced Beneficiary Notification). If some payment is being requested prior to providing service, you want to be asking for the correct amount. An often over-looked aspect in the process is the self-pay patient who can be screened earlier in the revenue cycle to find alternate payment sources or appropriately address financial assistance by getting needed supporting documentation before the patient is even seen. - SHORTER STAFF TRAINING CYCLE
If the system walks the Registrar through the process correctly, you reduce the amount staff needs to learn and redirects their focus from learning the myriad of scenarios to merely learning how to use the system. - COMPLIANCE WITH PAYER REQUIREMENTS
While it looks to us like ways to slow or eliminate payments, payers feel they have legitimate reasons for their rules. No matter how little sense it may make to us, we providers need to comply with these rules to get payment. Having a process that deals with these rules as early as scheduling will increase the ability to comply. - IDENTIFY POTENTIAL BILLING PROBLEMS
In many cases, a billing problem can be identified before it ever gets to the biller. Why wait? The opportunity exists to determine that a needed pre-authorization has not been obtained. Another dilemma that could be identified early is an ordering physician either not in your database or for whom the hospital has no UPIN or, later, NPI.
A check of insurance effective dates versus proposed service dates allows coverage issues to be identified and resolved before providing service.
When Medicare is involved, tools could be available to assure that the insurance priority is set correctly, based on responses on the MSP form.
Even small things could be checked to assure correctness such as the relationship between the patient and the insured.
AN IDEAL SCENARIO:
Dr. Jones has determined that she wants three diagnostic tests run on Midge Smith and enters the information into her order entry system. That electronic order has dynamically been added to my scheduler’s online worklist.
As the scheduler goes through his worklist, he comes to Dr. Jones’ order for Midge Smith which involves three procedures. Included with the order was demographic information on Midge to allow the scheduler to positively identify her in the database. He calls the patient to schedule the three procedures and reaches her on the first try.
The scheduler locates a day when all three procedures can be done both within scheduling availability and clinical considerations. The date and time work with Midge’s schedule. The system advises the scheduler that a pre-authorization is needed for one of the tests. Clicking on an icon to check the insurer’s web site, he determines that that authorization has already been obtained and adds that data to the record.
Based on information from the hospital’s information system and the 271 data returned from the payer, the scheduler is advised of Midge’s anticipated financial responsibility and asks how she will be handling that. She requests that the amount be put on her credit card and the scheduler takes that information to post the payment. The scheduler then obtains sufficient information from Midge to create a pre-registration record that is passed to the hospital’s Access software.
Midge shows up for her appointments, and the system displays a picture of her from her previously scanned driver’s license to assure she is the right person. Midge is sent directly to the first test location, where staff has the electronic order available.
The nice thing about this scenario (outside of its unlikely smoothness) is that all of it is technically possible.
As vendors better realize the importance of Access Management, including scheduling, has in the revenue cycle, it will get more attention. Until that happens, we will continue to have high expectations of overworked staff and we will have to live with those consequences.
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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