Registration-related billing errors dropped by more than 30%, as a result of an organization-wide focus on reducing accounts receivable (A/R) days at Stanford Children’s Health, reports revenue cycle operations director Shawn Tienken.
“We’ve also seen over a 25% improvement in claims resolution efficiency,” he says.
Tienken is chair of the organization’s Revenue Cycle Workflow Committee, which is improving revenue cycle workflows to reduce A/R. The committee includes managers from patient access, authorizations, health information management, patient financial services, and information systems.
“Our entire revenue cycle team is focused on billing and collecting appropriate payment as quickly and accurately as possible,” says Tienken.
Much collection-related work traditionally performed by hospital business office staff has shifted to patient access, notes Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle operations at Emory Hospitals in Atlanta. “All aspects of the revenue cycle are priorities of access, reducing A/R days conspicuously so,” says Kraus. “This has helped bring access front and center among hospital departments.” He says patient access can take the following steps to maintain low A/R days:
- Confirm demograph-ics and data for billing earlier in the process.
- Obtain correct diagnoses and procedures to calculate accurate estimates of insurance and patient liability.
- Collect patient balances upfront.
- Give staff the ability to determine exactly what insurance will pay.
“If access does its job well, it will be contributing maximum support to maintaining low days in A/R,” Kraus emphasizes.
Stanford Children’s switched to a new electronic health record (EHR) in 2014.
“We used that as an opportunity to implement a new ‘distributed A/R’ philosophy,” says Tienken.
Previously, the organization relied on back-end business office staff to clean up errors caused by front-end activities. The new distributed A/R approach moves accountability for registration and billing accuracy to the registrars who initially captured the data.
“If you were a front-desk person who didn’t record all of the required insurance information for a patient, then we wanted to push that incomplete record back to you to fix,” says Tienken.
Patient access staff monitor a dash-board that shows which areas are making errors or causing denials, and how much money is at risk. “Our new EHR has claims and billing modules integrated directly into registration and clinical systems,” says Tienken. “We are able to tie these processes together more easily and create alerts when things go awry.”
Patient access staff worked with the hospital’s information services team to create tools in the new EHR system to increase registration accuracy. “This makes it easier for registration staff to collect and document the right information, while they are interacting with the patient,” says Tienken.
The system alerts registrars if something looks wrong, such as an invalid subscriber ID format, an unverified insurance coverage, or a missing digit in the zip code of the billing address. Previously, says Tienken, errors such as these resulted in denials, claim rejections, or other payment delays.
“Most alerts can be fixed immediately,” says Tienken. If not, this delay usually is because the employee is rushing to get the patient into service. In some cases, the employees don’t have the information they need at their fingertips. For example, the employee might be taking registration information on a transfer patient via phone, and the person on the other end doesn’t have the valid insurance information to resolve the alert.
“In cases where the issue isn’t fixed immediately, visit records with unresolved errors or missing information are routed to a work queue for the clinic manager or department manager to review and resolve,” says Tienken. These work queues hold the claim back from billing until the problem is fixed. “There is a lot of visibility and pressure placed on patient access leaders to minimize such instances,” he says.
Revenue cycle leaders generate weekly dashboards on work queue activity for executive leadership. “They will follow up with department managers if error volumes and dollars start to spike,” says Tienken. “This further enhances our culture of accountability.”
INSURANCE IS FOCUS
Patient access and financial services trainers at Danbury-based Western Connecticut Health Network make correct selection of insurance information a primary focus.
“If the correct information is selected, it reduces A/R days,” says Valerie Macelis, MBA, CHAA, patient access/financial services trainer. “If we get the information to the insurance company correctly, we get paid a lot quicker.”
Macelis has found inservice classes to be most effective in reducing A/R days. “Staff are required to listen to the subject matter and ask questions if they don’t understand,” she explains. “Sending an email doesn’t guarantee that employees will read it.”
Unfortunately, patient access managers sometimes don’t have the correct information themselves about a new insurance plan. When the Health Insurance Marketplace exchange plans came out in 2014, it took patient access trainers several months to figure out how to train employees.
“We did not have any cards to look at, or any information on how to distinguish an exchange plan from a regular insurance plan,” says Macelis. When trainers called an exchange hotline for assistance, they sometimes were given misinformation. “We had to figure things out on our own through the Internet, word of mouth, and the pamphlets the insurance companies sent us,” says Macelis.
Trainers instructed registrars to identify exchange plans by looking for the word “exchange” or bronze, silver, gold, or platinum colors. In general, they encourage staff to examine insurance cards more closely, because exchange plan cards look almost exactly like regular insurance cards.
“Staff was really quick to just assume it is an off-exchange plan,” says Macelis. “They had to change their mindset.” If the correct plan is identified, payment will be received more promptly, she says, “and A/R days will be reduced.”
- Pete Kraus, CHAM, CPAR, FHAM, Emory Hospitals, Atlanta. Email: [email protected].
- Valerie Macelis, MBA, CHAA, Patient Access/Financial Services Trainer, Western Connecticut Health Network, Danbury, CT. Email: [email protected].
- Shawn Tienken, Director, Revenue Cycle Operations, Stanford Children’s Hospital, Palo Alto, CA. Email: [email protected].