Access Management Quarterly

Putting nurses in access results in financial gains

'It's easy to show ROI'

Adding six nurses to the central scheduling department has dramatically reduced both denied claims and accounts receivable (AR) days at Delnor Community Hospital in Geneva, IL, says Karin Podolski, RN, MSN, MPH, CHAM, director of patient access.

Having nurses check physician orders for completion and take verbal changes for orders over the phone, as well as serve as a resource for other access employees, has led to improved relations with physicians and with other hospital departments, Podolski adds.

The program began in 2004, she explains, as a result of multiple complaints from clinical areas based on scheduling quality.

"We would book an exam, and the patient would arrive and it would be the wrong exam, or there would be a problem with the order and we couldn't reach the physician, so we would have to reschedule," Podolski says.

Now when a patient walks in with an order, registrars check it, but nurses are there as a resource, she says. They can amend orders with unacceptable abbreviations — such as an up arrow for increase or HTN for hypertension, Podolski adds.

"We have a lot of illegible orders, and [nurses] can call the physician's office and take the verbal change for the order," she says. "We use them to check Medicare orders for medical necessity. The nurse reviews the patient history to clarify whether the person has a [particular condition], and then can take a verbal amending of the order over the phone."

In the past, patient accounts staff would attempt to contact physicians by fax for further diagnoses, which the physicians didn't like, she adds.

"Say a patient is sick, and calls the physician who is on call on Saturday morning," Podolski says. "If the physician is at home or in the car and wants to send the patient over for an exam, [he or she] can just call [the hospital] and send the patient over with a verbal order."

Nurses trained in coding

Delnor's access nurses were hired either from physician offices or other outpatient settings such as same-day surgery, she notes, and received about two months of training in outpatient coding.

The investment has more than paid off, Podolski says. "We reduced our medical necessity write-off from 10% to 0.6%." During the same period, AR days have gone from the high 70s to 40, she adds. "It's easy to show return on investment."

Previously, Podolski says, "there were stacks of orders without diagnoses or that [staff] couldn't read so they couldn't code." Now the majority of the coding is done on the front end, with some completed on the back end, she adds, but it's all under the purview of the access department.

The original goal was to reduce the medical necessity write-off from about $11 million to about $3 million, she says, but the figure is now down to about $600,000.

"The only thing we really write off now is from the emergency department," Podolski adds. "It's virtually zero in the other areas. We don't intervene with the ED physicians too much because that's a hard area to address."

If an elderly patient falls, for example, the protocol is typically to do a CAT scan of the head, she says. "We can't really prove they fell and hit their head often because they are unable to communicate clearly, but [doing the scan] is good medicine."

Her own nursing background makes her particularly sensitive to ensuring that the department's nurses are kept "in the nursing loop" within the hospital and the nursing community at large, Podolski says.

"Last year, I had them give education to the entire [700-member] hospital nursing staff as part of spring nursing education," she adds. "There were six sessions where they talked about medical necessity, patient orders, and diagnoses. We do get orders from the ED and from the patient floor, so it's valuable to speak to those nurses so they know what is required."

Podolski says she also makes sure that access nurses participate in the nursing week celebration each May and in the shared decision-making opportunities for nurses within the hospital, such as committees on professional practice.

With hospital nurses typically limited to a 7 a.m. to 3:30 p.m. schedule, or a shift that begins at 11:30 p.m., the more flexible hours offered by the access position make it an attractive option, she points out. "We have a variety of staggered hours. I let them set their own schedules as long as the department is covered, with a nurse available in both the scheduling and medical necessity areas."

The access department hours are 7:30 a.m. to 6:30 p.m. Monday through Friday and 9 a.m. to 1 p.m. Saturday, Podolski says.

When hiring nurses for the access department, Podolski says, she looks for individuals with leadership traits. "They're running the show in problem solving, and they're also a resource for the rest of the access staff who may not be [clinically] trained."

Before registration staff call a physician's office, she says, "I try to have them filter it through a nurse, so they're not calling all the time."

Having nurses in her department, Podolski says, "has built within the hospital a reputation that we do have resources and we do have credentialed staff within access. If issues arise with clinical areas, they are very responsive when a nurse calls them."

Delnor is a magnet nursing hospital, she notes, and having the nursing component in access has contributed to that process. "It provides opportunities for nursing to grow and expand its role, which is important for magnet credentialing."

As part of their job, the access nurses visit physician offices, Podolski says, to build relationships with physicians and their staffs and to provide them with medical necessity tools. The frequency of the visits varies, but they are typically made twice a month, she adds.

"We give them access to software to check medical necessity, and we give them copies of local coverage determinations and updates on regulatory changes, like changes in Medicare guidelines."

(Editor's note: Karin Podolski can be reached at