The Patient Access Tango: Planning Each Step of a Successful Registration Dance

EXECUTIVE SUMMARY A high-quality Patient Access department is vital to any Healthcare Organization -- ranging from Critical Access Hospitals to large Acute Care Hospitals. Although their needs may vary, Organizations who face numerous challenges within Patient Access can miss the important steps in the dance and struggle to stay with the music. Often Managers are over-tasked and under-resourced. Patient complaints, and ongoing compliance related duties, take priority. In the meantime, the Billing office is highlighting errors that prevent untimely or reduced reimbursement. Without the right Organizational structure, leaders can sashay into a trap that uses a “Band-Aid” approach to “fix” the hottest day-to-day issues that pop up within the department. The result of this can range from confused staff working inefficiently to costly compliance and lost revenue. Not to mention the ever-so-popular patient and physician dissatisfaction. When a centralized approach is not the strategy, Hospitals can become vulnerable to having a reactive Patient Access operation that isn’t driving performance. Patient Access impacts every single aspect of a patient’s care, the efficiency and accuracy of departments’ administration of patient care, and can put a serious dent in the Organization’s financial performance with just one mistake. Investing time to thoroughly evaluate the operation and its performance is unarguably worthwhile.

Contents EXECUTIVE SUMMARY ............................................................... 1

INTRODUCTION .......................................................................... 3

ESTABLISH ORGANIZATIONAL STRUCTURE ................................. 4

INVEST IN YOUR OPERATION ..................................................... 6

AUTOMATE WHEREVER POSSIBLE .............................................. 8

KEY PERFORMANCE INDICATORS ..............................................10

MONITOR QUALITY & COMPLIANCE..........................................12

CONCLUSION ............................................................................13

FOR MORE INFORMATION ........................................................14

INTRODUCTION In the movies, at the most opportune moment, the lead couple will effortlessly break into a beautifully choreographed dance. The supporting cast and extras easily interact, supporting each component of the dance as it moves from one ridiculously intricate maneuver to another. While the number looks spontaneous on the screen, it undoubtedly required many hours of practice and almost certainly many different takes to finally get the one that makes it to the screen. When patients arrive at a provider seeking care, they want the same sort of effortless coordination, and want to quickly move through the administrative steps to get to their care. But to make sure their experience is as smooth as a ballroom tango, Patient Access Directors need to plan ahead, lay an appropriate foundation, and train their staff accordingly, choreographing each patient experience in advance. To choreograph that patient experience, directors should learn a few basic moves that can make up a beautiful number:

• Establish Organizational Structure • Invest in Your Organization • Automate Wherever Possible • Key Performance Indicators • Monitor Quality and Compliance

ESTABLISH ORGANIZATIONAL STRUCTURE Centralizing Patient Access functions which follow the lead of strong management is paramount -- but achieving true centralization is difficult. Inevitably, there are numerous units within the hospital setting that will involve clinical aspects of a patient’s care. For this reason, many models succumb to ‘one off’ decisions to reorganize these functions. Patient Access leaders struggle to make a compelling case as to why this should be avoided, and the mistake to then limit managing resources within the departments begins. Taking time to think through the impact of these decisions and then quantifying the impact is key to gaining support. Let’s examine one of the most common scenarios:

Surgery scheduling: Commonly this function reports up through the Surgical Room Management team. Clinicians require a resource for connection with the OR physicians and staff to ease the process in controlling appointment blocks, physician preferences, and required resources for surgical cases.

Evaluating performance and cost for Patient Access areas that are out of scope will provide additional support for centralizing the functions. In the example of Surgery Scheduling:

1. Cancellation rate due to Financial Clearance failures 2. % of Eligibility and Authorization Denials

Staffing the team with a role that can deal with the clinicians needs in a “concierge” approach, while trained Patient Access staff can work with strategies such as scheduling elective cases that require lengthy authorization process strategically will decrease cancellations and denials.

In this example, the strategy does not end with centralization: well-run means your team is well lead. Skilled, experienced Directorship and Middle Management is critical. When evaluating the scope of Patient Access, evaluate the leadership model in tandem. A Best practice ORG structure includes working supervisors or team leads, as well as, Educator and Quality resources. This will assist with Span of Control and will allow Directors and Managers to drive performance. Employees are more engaged and loyal when given clear direction, feedback and education on how to perform their job.

Role Reports To Time spent on the “Front Line” Focuses Remaining Time

Patient Access Director

Revenue Cycle Director

10% for observation and connecting w/front line staff.

xEnsuring compliance xDriving performance xRepresenting the dept. xVarious initiatives

Manager Point of Serv. Pre-service. Emergency Financial counseling

Patient Access Director

25% observing, connecting with staff and actually performing tasks.

xDriving compliance xCustomer Satisfaction xDriving performance xTime/Attendance xAll HR related needs xVarious Mtgs. & initiatives

Supervisor or Team Lead

Manager 50% - 75% performing tasks alongside or in place of front line staff.

xStaff scheduling xDay to day questions xOther duties as assigned

Education/Quality Coordinator

Patient Access Director

25% observing and connecting with front line staff.

xEducating Front line staff xRegular QA monitoring xContinuing Education

INVEST IN YOUR OPERATION Taking time to train staff properly, investing in detailed standard operating procedures (SOPs) and factoring in ‘downtime’ for staff interaction have big returns. These activities, if done properly, will aid in increasing clean claim rates. Education and training to give staff the necessary, foundational skills (especially entry-level staff) will increase performance and decrease turnover. The reality is that this is where many departments take short cuts due to time and resources. It comes down to three key concepts. ACTION STEPS 1. Classroom Training

• An overview of how they fit into the big picture: cause and effect • Subject matter content • System training and practice time • Course Testing

Example

Category Should Contain Overview xRevenue Cycle ‘101’: Beginning →End

xStakeholder Departments & How we Impact Subject Matter xCustomer Service: Internal & External Customers

xInsurance ‘101’: How to read Health Insurance cards ‘102’: Insurance Products & Characteristics xMedical Terminology xPatient Access & Billing Terminology xCompliance: Advanced Directives, Medicare Secondary Questionnaires, Section 1557, etc.,

System xRegistration (A/D/T) System xInsurance Eligibility Systems xDocument Scanning System xJob Specific systems as needed: EMR, Bed board, Price Estimation, etc.,

Each Job Description should be evaluated to determine what classroom

training is required and administered accordingly for all employees upon

being hired and then again annually.

2. On the Job Training • Departmental Policies

• Departmental Standard Operating Procedures

Example

Category Should Contain

Policies All department specific policies that are in addition to the Organization’s Employee Handbook, such as:

xPolicy for Uninsured Patients

xProductivity Policy

xSystem Downtime Policy

xDuplicate Medical Record Policy Standard Operating

Procedures

Covers span of topics per function. They should be specific to the work to be

completed, exactly how and when it is to be done. It should be informational in

nature & include checklists:

xPre-Registration

xPoint of Service Registration

xInsurance Verification & Price Estimation

xPre-certification/Authorization

xFinancial Advocacy

Standard Operating Procedures should be maintained within each

individual department and reviewed quarterly by the Management team.

3. Probationary Performance Period • Two weeks with a preceptor watching 100% of their worktime

• Two additional weeks of 100% QA review

• Formal Core Competency sign off

The probationary period should be well documented and placed in each

employee’s file. This will satisfy Joint Commission requirements, Human Resource and will assist with maintaining truly qualified staff.

AUTOMATE WHEREVER POSSIBLE Current programs can provide functionality that has automation potential. ACTION STEPS Fully assessing Patient Access workflow will provide clarity to what might be a bad process that is causing inefficiency. Taking this step can also save time and budgetary funds; frequently, inefficiencies are the result of both a broken process and the need for additional ease-of-use technology. Observe and document workflows to identify where manual or broken processes have crept in. Map out each step in the process to evaluate what is taking extra time or all together not working. Involve all stakeholders.

LAB – BUCKET PROCESS

MD

Off

ice

Lab

Cen

tral

Sch

edul

ing

POS

Reg

Patient is seen in the MD Office

MA submits to UTMC lab hold with New order signed

Office MA submits to UTMC lab with action New order signed

Will the PT have lab work today?

RegistrarSees account in worklistReviews patient account in ATHENA

Registrar Uses ATHENA registration info to create an ODX in STAR

Registrar submits to UTMC lab ready

Patient arrives to lab w/labels.Lab accesses the HLAB system.Lab draws the PT.

YES

NO

Patients results are sent to Ordering MD

Patient arrives on a new day for lab services. Reports to POS

POS RegistrarCreates STAR Reg.Prints labels

Patient advances to lab for services

!MAs forget to submit

! Specimen only cases are not being placed in bucket

!MAs occasionally make errors & order requires correction & resubmission

!MAs are not routinely asking

!PTs are not always dependable

!Patient & lab delays: must stop and call for a registration when there is no registration in place

!No direct interface w/lab system.

!Results are misrouted or not sent at all

!Issues with ability of STAR contribute

!Margin of error w/multiple MDs

!Limited w/sending to ordering MD

!There is not future date possible.

!This assists only to avoid creating un-necessary registrations.

!Staff must refresh screen constantly

!There is no first in/first out logic in list

!Quality concerns create delays

!Pts sometimes report directly to lab creating delays for patient, lab & C.sched

If technology is currently working in all areas, but it falls short in efficiency, look for options that can be added to increase efficiency without expensive, untimely and cumbersome system implementations before making a decision to completely replace a system that staff is already using, comfortable with and otherwise operating well. In this case, both process and technology were adjusted and the outcome was a more efficient process.

LAB –PROPOSED PROCESS

MD

Offi

ceLa

bPO

S (la

b) R

eg

Patient is seen in the MD Office

Services complete. Patient departs.

Office MA submits order with action New order signed

Will the PT have lab work today?

Registrar Uses previously verified demographics to create registration

Phlebotomist draws the patient s lab.

YES

NO

Patients results are sent to Ordering MD

Patient presents to lab window for service.

Registrar checks for ABN and prints labels.

Patient is directed to the Lab

Does the patient have an order?

The lab Registrar retrieves order

Phlebotomist interfaces order manually.

Did the lab interface pass?

NO

NO

YES

YES

KEY PERFORMANCE INDICATORS The habit of using Key Performance Indicators (KPIs) are vital to any Patient Access operation; however, KPIs alone are not enough to drive performance. Consistent execution and discussion are critical to improving and hitting your targets. ACTION STEPS Establish baseline performance for all KPIs

1. Set both ‘achievable’ and ‘stretch’ goals. 2. Don’t overdo it. Stick to metrics that are going to lead to meaningful

performance.

Example

Establish individual productivity goals

1. All front line staff should be tracked. 2. Goals should tie to staff’s annual review. 3. When an individual is not reaching their potential, an action plan

must be developed with progressive follow-up.

Example

Hold regular meetings

1. Frequent yet brief huddles between front line staff and management 2. Monthly staff meetings with KPI reviews on the agenda 3. Weekly or bi-weekly ‘one on one’ meetings between Manager and

Director Roles 4. Monthly Management meetings with KPI review & discussion on the

agenda Require accountability from each team-member. If staff is not achieving their goals (whether that is front line staff or a management team), they should be bringing their barriers to success forward. When they do, the Patient Access leader needs to support their efforts. In a timely and consistent manner, remove the identified barriers. Holding the team accountable means everyone on the team. If the staff IS achieving its goals, understand what the contributing factors are. Celebrate success, and then get ready to reach for the stretch goal.

MONITOR QUALITY AND COMPLIANCE Poor quality and compliance issues spell TROUBLE – examples include untimely billing and write offs, patient safety events, HIPAA breaches and non-compliance with Governmental agencies. Common areas that need to be examined to prevent this type of attention:

1. Medicare Secondary Payer completion and regularity 2. Duplicate Medical Records 3. Incorrect/outdated Guarantor demographics

ACTION STEPS

Perform regular quality and compliance reviews and solicit feedback from Stakeholder departments such as patient Financial Services and Utilization Review departments.

o Ask these departments to submit written quality feedback when they encounter it.

o Create a ‘Front to Back’ meeting creating a platform for these groups to share quality feedback and updates

Establish a ‘Quality committee’ to achieve the following:

• Define ‘critical VS non-critical’ errors • Establish methodology and frequency of auditing accounts • Set a baseline performance for Patient Access functions and any

‘out of scope’ departments • Engage Stakeholders and trend performance, working towards an

organizational goal

CONCLUSION Just like any well-performed routine, running a successful Patient Access department takes hours and hours of instruction and practice. Knowing the steps of dance and the beat of the music is just the beginning. It may feel clumsy at first, but after learning the dance, it becomes a series of natural actions: you anticipate each mistake and make small adjustments to prevent a public disaster. You become confident that your dance routine is well developed, as all of the elements are on point - right down to your choice of fashion. Before you know it, you realize that you are leading and your partner is glad to follow. All of that hard work pays off, and you are doing a silver screen-worthy Tango!

FOR MORE INFORMATION

Please contact us with questions, comments, or for additional information. The Colburn Hill Group and author of this paper can be reached through our website:

www.colburnhill.com/contact.html

or

by e-mailing info@colburnhill.com

We look forward to hearing from you!