Quality assurance audits may be too subjective

Staff must view them as impartial

Registration accuracy is always a foremost concern for patient access leaders, as problems in this area can lead to needless claims denials; ineffective quality assurance audits, however, won't get results, says Diane E. Mastalski, CHAA, CHAM, Virtua's corporate director of patient access.

In October 2008, Virtua Healthcare System in Marlton, NJ, decided to revamp its patient access internal audit/education program. A seven-member audit/education team was dispersed through Virtua's five hospitals.

The three largest campuses each had a team of two auditor/educators. The remaining auditor/educator's time was split between Virtua's two smallest campuses and serving as the team lead for the manager of those divisions.

The program had been successful, Mastalski says. The department's registration accuracy rating had increased from 92% when the program started in 2000 to 97% in 2008. But despite the success, the program was in need of some fine-tuning, she says.

"Our registrars felt that the auditing process was too subjective," says Mastalski. "There was a perception that the auditors would let their personal feelings determine who would receive an edit and who they would let slide."

This may not have been the truth, but it was difficult to change this perception, she says. In addition, what may have been considered an edit on one campus might not be at another location.

"We realized we needed a more uniform process to keep the audit as objective as possible," says Mastalski.

The decision was made to pull the auditors from campus-specific positions. They were moved to a central location where they would audit the three largest hospitals. The two smallest campuses would continue to be audited by their auditor/team lead.

"By removing the auditors from the campuses and rotating on a daily basis, not only which registrar but also which campus they audited, we felt that the audit process was as fair and impartial as it had ever been," says patient access supervisor Alice Wood.

Pooling the auditors also had another benefit. "We have five different auditors with five different skill sets and five different approaches to education," says Wood. This meant that the education process could be catered to the individual registrar's needs.

"If one auditor/educator is having difficulty creating that moment when the light bulb goes on for the registrar, we have four more auditor/educators ready to step up to take on the challenge," says Wood.

The new process did create some challenges, however. The three campuses totaled more than a hundred registrars, with experience levels ranging from new hires to staff members with more than 30 years of experience.

"We have registrars working twenty-four hours a day, seven days a week," says Nate Wolf, auditor/educator. "And our staff's experience and computer competency levels vary widely."

Being able to provide them all with education catered to their needs proved to be difficult. However, the team found that its flexibility, both with schedules and education methods, turned into one of its greatest strengths.

"Some staff needed face-to-face education, while some were fine receiving e-mails," says Wolf. "Some preferred to receive group education, while others wanted one-on-one meetings. Discovering each individual's needs was difficult at first."

The auditor and educators had to first overcome the registrars' misconception that they were "out to get them." "Many people felt that the only time they heard from us was when they had made a mistake," says Amanda Whitman, auditor/educator. "In order for the program to be successful, we needed the registrars buy-in. We needed them to understand we are a resource, to help them do their jobs to the best of their abilities."

The educators make sure to reach out not just when a mistake has been made, but also when someone does a good job. Congratulatory e-mails are sent out at the end of the month to registrars who achieved a 100% accuracy rating for the month, and also those who make a marked improvement.

"Something as simple as an e-mail saying 'Hey, that was a tricky insurance, great job!' or going to a campus for no other reason than to be available to answer some questions, goes a long way," says Whitman.

Virtua converted to electronic medical records in November 2009, doing away with paper charts. This allows the auditors instant access to any scanned documents and eliminated the need for paper charts to be transported from the campus to the auditor/educators, Mastalski says. It also allows the audit to be done within the important five-day bill drop period, she says.

"When the charts went electronic, it was a great help to us," says Gabrielle DiCristo, auditor/educator. "Now if the registrars have a question about an insurance card, all they need to do is give us the billing number and we can see what they're seeing. It's a great learning opportunity."

The registrar is told what the correct insurance is on the spot. "Hopefully, they will remember that for the next time it comes across their desk," says DiChristo. "It's especially helpful for registrars who work second or third shift." If these registrars have a question, they can send an e-mail with the billing number to anyone on the team. The following morning, the question is answered, and the chart is corrected if necessary.

The instant access to scanned documents had a positive impact on the department's administrative denials. "We went from a denial percentage of 11.53% in 2005 to 2.25% in 2010," says auditor/educator Dana DeLuca. "A big part of that is how quickly we can perform the audit and notice any trends that are giving the registrars issues."

Since the team corrects any deficiencies before they are billed out, incorrect billing is prevented, along with the denial that would potentially follow. "In addition, we're able to identify areas that need education immediately. We nip those problem spots in the bud," says DeLuca.

The creation of a uniform audit process for the health system, the ability to correct any potential insurance issues before the billing process is completed, and nearly instant feedback provided to the registration staff have helped Virtua to achieve its best-ever registration accuracy ratio in 2010, at 97.9% year to date, says Mastalski. But having actual registration experience may be the team's greatest asset.

"Each member of the team has been, at one point or another, a registrar," says auditor/educator Cynthia Loveless. "We all know how difficult it can be to enter the information in a timely manner, keep track of ever-changing insurances, and most importantly, provide each patient who sits across the registration desk from them with excellent customer service."

Loveless says that the team "absolutely takes that into consideration when performing the audit. We do our best to ensure that the registrars know we're working with them to accomplish their goals."

With technological advances continuing to shape the registration process, Virtua has found that the key to a successful quality assurance program is to be constantly adapting to meet the needs of the registrars.

"Patient access is the front line for creating an outstanding patient experience," says Mastalski. "Our registration staff know they can rely on the support of the audit/education team as they continue to strive for excellence."

[For more information, contact:

Diane E. Mastalski, CHAA, CHAM, Director of Patient Access, Virtua Healthcare System, Marlton, NJ. Phone: (856) 355-2155. E-mail: dmastalski@virtua.org.]