Access Management Quarterly

Costly errors are common in same-day surgery arena

Preadmission coordinator a must, consultant says

Mistakes involving patient classification and preauthorization of procedures are among a lengthy list of common errors made in the same-day surgery arena, says Bob Whipple, RNC, CCM, CCS, MHA, a Boston-based senior management consultant with ACS Healthcare Solutions, who specializes in all areas of the revenue cycle.

Those errors, Whipple adds, can cost hospitals thousands of dollars in denied claims, as well as cause them to lose business to a growing number of freestanding surgical centers.

With regard to obtaining authorization for the surgery, he says, "sometimes the hospital gets it, and sometimes the physician's office gets it. If they pre-certed for an inpatient, and you did it for an outpatient, the bill is denied.

"People who schedule for physician offices don't know the first thing about coding," he points out. "They will send a sheet that says 'possible kidney transplant,' and that's not a diagnosis."

When those orders get to bed placement, Whipple says, "it's crucial that someone with clinical case management skills — preferably a registered nurse — is on hand to make sure everyone who's going into a bed is at the right level of care."

The designation should be "inpatient" or "outpatient," but not "observation," he says. His experience, adds Whipple, is that a lot of hospitals make the mistake of pre-certing a same-day surgery patient under the observation designation.

"It's a big compliance issue," he notes. "How do you know they will have to observe somebody after surgery? You don't have a crystal ball."

A patient cannot be put in observation status preoperatively, Whipple emphasizes. "Postoperatively, you could think about it, but I wouldn't recommend it. Same-day surgery comes with an implied 24-hour length of stay, so the designation either should stay 'same day,' and the person should be discharged and go home, or if necessary, the patient should be converted to inpatient status."

These mistakes happen with the observation designation because people don't understand what it really means, he says. "The physician thinks, 'I want to observe the patient,' [so that must be the right classification]."

With Medicare, there are many CPT (common procedural terminology) codes that are for inpatient-only procedures, Whipple adds. "If a procedure happens to be on the inpatient-only list and the patient receiving that procedure doesn't have inpatient status", he says, "[Medicare] will deny the claim and you can't even appeal it. It's a technical denial."

There are hospitals doing mastectomies, laminectomies, and thyroidectomies — all inpatient procedures under Medicare — on an outpatient basis, and when the bills for those surgeries are denied, there is no recourse, Whipple points out. "What Medicare is trying to say is, 'We want our patients to be [admitted to the hospital] for these kinds of procedures.'"

This kind of occurrence is "very common," he adds. "I find it everywhere I go."

Again, the take-home message is that there needs to be a clinically trained person — within the access department — who literally reviews every patient before he or she is placed in a bed for outpatient surgery, he emphasizes. "You can't expect office staff to do it. They will put patients in a bed with wrong orders or no orders."

One of the other costly errors that hospitals are prone to make in their same-day surgery operations has to do with cardiac interventions, such as cardiac catheterizations, Whipple says. The Medicare reimbursement rate for cardiac caths is about $5,000, he adds, but if the physician ends up putting in a stint as well, the procedure — known as angioplasty — goes in the inpatient category, and reimbursement is about $19,000.

Therefore, if the change in patient classification is not made and the surgery is billed as an outpatient procedure, Whipple notes, the hospital loses $14,000.

"When I'm doing revenue cycle assessments, these are areas where [hospitals] fall down all the time," he says. "I almost always find it with angioplasties."

Other mistakes that are frequently made in same-day surgery settings include the following, Whipple says:

  • Developing a process that is organized around the hospital staff and not the patient, specifically as it relates to same-day work-up and surgery.
  • Not gaining cooperation from ancillary departments to facilitate and support same-day services.
  • Not changing surgical scheduling processes to support same-day services.
  • Not ensuring preregistration for all same-day patients, including preauthorization/precertification and estimation of copays for collection at time of service.

Coordinator 'should report to access'

The clinically trained individual — sometimes called a preadmission coordinator — charged with making sure patients and procedures are properly designated should report to patient access leadership and should serve as the clinical liaison for the entire department, Whipple contends. "If you don't have that position filled, you are losing a lot of money."

In fact, all areas that perform functions that are part of the revenue cycle ultimately should report to the CFO, he says. "Sometimes hospitals have the bed board report to nursing, or have some sort of precert department or a transfer center that works on its own in another location. [Access leadership] needs to understand all points of entry and make sure to have control over all of those areas."

Whipple recommends that access management work with marketing to create a patient satisfaction survey for the same-day surgery area, and use the results to make improvements and to provide feedback to staff.

General satisfaction surveys, such as those conducted by Press Ganey, aren't specific enough to meet that need, says Whipple, who suggests asking questions geared toward the outpatient experience: "Was it easy to get an appointment? Was the phone answered promptly? Do you feel you were given answers in a timely manner?"

Leverage as much technology as possible to keep customers satisfied, he advises, including providing on-line registration and implementing kiosks to allow service area check-in with electronic signature and payment of copays and deductibles.

Whipple suggests these benchmarks for the same-day surgery operation:

  • Wait times for outpatient registration — less than 10 minutes.
  • Registration data accuracy — greater than 98%.
  • Abandon call rate in scheduling — less than 2%.
  • Scheduling calls per day — greater than 95.
  • Scheduling quality — greater than 98%.
  • Average time to place in a bed — less than 10 minutes.
  • Registrations/preregistrations per hour by representative — greater than six.
  • Quick check-ins per hour by representative — greater than 12.
  • Precertification at 100%.
  • Point of service collections — greater than (your hospital's numbers).
  • Patient satisfaction score — greater than 95% per reporting period.
  • 100% auditing of Medicare Secondary Payer questionnaire.
  • Operating room cancellations — zero cases.

Freestanding centers an issue

One of the challenges hospitals face in regard to their same-day surgery operation is the competition posed by freestanding surgical centers, which tend to cherry-pick the easiest and most lucrative cases, Whipple notes.

If you're a patient access manager and a freestanding surgical center has opened down the street from your hospital, he advises collecting data to determine if your operation is being affected.

"Look to see if your volume is down and at the referral patterns of your physicians," Whipple says. "Then you are prepared to go to senior management and say, 'We've got a problem. Dr. Smith is referring patients [to the freestanding center].'"

To address this issue, it takes a lot of support from senior management, Whipple adds. "You need a chief medical officer who understands the problem — why that is a bad thing. It's happening more and more places."

(Editor's note: Bob Whipple can be reached at