Pay disparity, staffing still hot access topics

Consultant: Rethink 'promotion cycle'

After 12 years on the provider side of the revenue cycle, and another 12 in outsourcing or consulting, James F. Heinking, CHFP, FHFMA, finds that the health care professionals he meets and works with "keep talking about the same issues we had 24 years ago."

Chief among those are the large disparity in pay between patient access staff and their counterparts in other health care roles and the related difficulty in hiring and retaining employees with the skills to do an increasingly complex and challenging job, adds Heinking, executive vice president of Healthcare Financial Resources Inc., an accounts receivable outsourcing firm in Schaumberg, IL.

Whatever the setting, he notes, "we all struggle with employee issues: Who do we hire and what kind of training and assistance do we provide?" His personal recommendation, Heinking says, is that billing and collections and other back-end departments should serve as the training ground for workers who would then be promoted to the position of registrar.

At the very least, he advises, give front-end and back-end employees the same status and compensation.

"Work toward integrating the front end and back end into a centralized unit," Heinking says. "Be creative, rotate management, and re-evaluate the promotion cycle. Either equalize or turn the pyramid upside down."

Additionally, he suggests, for someone (such as a well-trained registrar) who can "operationalize the diagnosis," use critical thinking skills and an acquaintance with medical necessity criteria to manage the patient's care, determine the corresponding financial liabilities and financial benefits that apply and comply with state and federal requirements, the pay should be about $30 an hour.

"[Employees] should be excited about being a registrar," Heinking says. The payoff to the organization for this upgrade, he maintains, would be a dramatic reduction in bad debt and increase in cash collections.

At the same time, organizations should "teach, teach, teach, train, train, train their patient access employees," he notes. "You will never lose money on providing new information to people who don't know what questions to ask."

The health care industry, unfortunately, is "in the Stone Age" where staff education is concerned, Heinking says. While there are independent schools providing structured training in medical terminology, coding, and claim preparation, he adds, they are too costly — typically $4,000 to $7,000 for a 160-hour course of study — and are not doing enough to fill the need that exists.

"How many times have we hired the best of the worst because there was an open position and we needed a warm body?" Heinking says.

Still, there are health care facilities that are making great strides in their operation by the effective use of technology, he notes. "If you can't improve the people, take the decision-making out of the process by getting wired."

Weigh all investment in technology, Heinking suggests, by determining whether it is vital to the operation: Will it decrease bad debt and increase cash collections?

'The good, the bad, and the ugly'

During a presentation in March to the Illinois Patient Access Management Association, Heinking — dressed as Clint Eastwood in the classic film — talked about separating "the good, the bad, and the ugly" in health care.

Most of the "ugly" issues, he points out, have to do with rules imposed by the government that providers have to follow. "EMTALA creates all kinds of desperate decisions and measures in the emergency department," Heinking says, while the Medicare "72-hour rule" — requiring the bundling of outpatient services with the inpatient claim if admission occurs within three days — is an ongoing threat to reimbursement.

Despite all that has been written and discussed about practices regarding the Medicare Secondary Payer (MSP) requirement, providers continue to struggle with its implementation, he notes. "I'm the primary caregiver for an elderly relative who receives services from a certain hospital," Heinking adds, "and not once have we had the MSP questions asked of us."

In one instance, a client approached his firm about taking on Medicare accounts more than 90 days old, he notes. "I asked why [the need existed] because Medicare pays within 14 days."

It turned out, Heinking says, that Medicare had the claims pending because they contained an accident code — a possible secondary payer situation — "and the hospital doesn't have that information collected."

"It should have been collected right away," he says. "MSP information must be collected."

His company's business model, Heinking notes, is if Medicare pays in 14 days, you shouldn't have an accounts receivable problem. "If you do, it's operational."

Heinking puts in the "bad" category such issues as staffing and employee training, as well as registration audits and other processes that are still done manually.

"It goes back to breaking down barriers," he says of automated technology solutions. "When you can reliably share information it helps improve staff's and patients' experience of care."

He advises providers to incrementally automate their operation and take action to "unify the members of the revenue cycle team, identify common goals, and work toward simplification of processes and elimination of rework."

The "good" centers around the people involved in health care, who are "some of the most dedicated professionals" in any field, Heinking adds. "Whether you're clinical or clerical, when you're dedicated, it's more than just a job. You've answered a calling."

He also includes on that side of the ledger the opportunities for networking and support provided by the industry's professional organizations.

[Editor's note: James Heinking can be reached at]