EXECUTIVE SUMMARY

Accounts receivable days were cut by 15% in one year by moving back-end functions to the front end at Abington-Jefferson Health. Departments have included the following tasks as part of the patient access role:

  • Ensure authorizations are updated in required timeframes.
  • Contact payers if authorizations change from what was originally obtained.
  • Determine the root cause of claims denials.

When patient access took on the back-end functions at Abington-Jefferson Health (PA), accounts receivable (A/R) days were cut by 15% in one year.

“A/R days are now consistently in the mid-30s,” reports Kim Roberts, MBA, RHIA, CRCS-I, vice president of the revenue cycle.

New patient access processes prevent claims denials and get claims processed more quickly. As a result, A/R days were cut from 40.5 in fiscal year (FY) 2016 to 34.2 in FY 2017.

“We also have been working to improve the aging of our receivables via special projects to decrease our A/R over 90 days,” says Roberts.

Many back-end functions have moved to the front end. “We get it right the first time. This eliminates costly rework and delays in payment,” says Roberts.

Fine-tuning Authorizations

“We have spent a lot of time on authorizations, and continue to do so,” says Roberts. Often, the Healthcare Common Procedure Coding System (HCPCS) code on the claim ends up being different from the one that was obtained originally by the registrar. This certainly means a denied claim.

“Our imaging department has put out a comprehensive guide to help the physicians in prescribing and ordering the correct tests,” says Roberts. This is the first line of defense against incorrect authorizations. To catch the ones that do slip through the cracks, the department developed a “matching report.” “This shows the authorization and associated HCPCS that was approved, and the corresponding order that was completed and the HCPCS associated with that order,” says Roberts. If the two HCPCS codes differ, the claim will be denied. By flagging the problem early, patient access can call the payer to have the authorization updated. 

“Not too long ago, if we billed and got a denial, the business office follow-up person would make the call and get the authorization updated,” says Roberts. Most payers now require the authorization to be updated within 48 hours of the service.

“We have moved this function to patient access,” says Roberts. “This avoids denials and speeds up the process of payment.”

Front End Manages Denials

Organizations usually leave it up to the billing office to deal with denied claims. This is a missed opportunity to identify mistakes made by patient access that contributed to the denials, however.

“Little information is shared with the front end to address consistent errors,” says Benjamin Colton, a principal at ECG Management Consultants, a Seattle, WA-based healthcare consulting firm with expertise in revenue cycle optimization.

Patient access needs to fix their own mistakes to ensure only “clean” claims are submitted. “To that end, we encourage organizations to consider routing these issues to the front end,” says Colton.

At Orlando (FL) Health, the patient access department is currently in a redesign phase. Denial management is a major focus. While the back end traditionally handled denied claims, this has changed.

“We are bringing the expertise from the back end to the front end,” says Bridget B. Walters. Walters is former corporate director of patient accounting, and recently became corporate director of patient access. “I had created the denials management team a few years ago,” she says. “Collaboration with all the departments made it successful.”

The denials task force team is now the domain of patient access. “Work groups tackle the root cause of the denial,” says Walters. “They report back to the leaders of the task force team on how they are preventing future denials.”

There is no question that moving denials management to patient access is increasing the clean claims rate. “We are seeing increased point-of-service collections, decreased A/R days, and reduced cost to collect,” says Walters.

The denial management manager was transitioned from patient financial services into the central access office. This department is responsible for insurance verification, authorizations, and quality assurance.

“We are focused on preventing the denials, with processes in place prior to billing,” says Walters. The entire patient access team was educated on denials prevention, A/R, charity, and bad debt.

“We set up alerts to capture critical data elements that need resolution to prevent the denial,” says Walters.

Patient access created a scorecard to track point-of-service collections, patient experience, and quality. “This is shared with the team and leadership,” says Walters. The scorecard shows the total amount that could have been collected at the point of service and the percentage that actually was collected. Other key metrics include accuracy percentages, the clean claims rate, and A/R days by facility.

“We have seen overall denial rates decrease and point-of-service collections increase,” says Walters. “Quality scores have increased overall.”

Earlier in Process

Various revenue cycle tasks have been moved earlier in the process, even to the pre-encounter stages, at Abington-Jefferson Health. The department made these changes:

1. Patients are asked to pay out-of-pocket costs at the point of scheduling.

First, patient access obtains a copy of the patient’s script from the physician’s office. This way, Roberts explains, “there is no question as to the service to be provided.” Once this is verified, registrars make a single “schedgistration” call. This includes:

  • scheduling a patient’s service;
  • verifying the patient’s insurance coverage;
  • determining requirements for any referrals and/or precertifications;
  • validating medical necessity;
  • attempting to collect the patient’s out-of-pocket responsibility.

If a patient is unable to pay at the point of scheduling, the registrar collects the balance due at the point of service. “We have consistently collected over 1% of net revenue at point of service,” says Roberts. “This decreases A/R days, along with collection expenses.”

2. Patient access moved various payer edits to the registration system.

Registrars validate and update data while the patient is still present. “A cleaner claim can be produced and payer denials can be avoided,” says Roberts.

3. Registrars visit emergency department patients at the bedside, after triage and stabilization.

“They complete their registration, obtain required signatures via e-pads, and inform the patient of their copay to be collected upon discharge,” says Roberts.

4. Financial counselors meet with patients in hospital rooms, on the nursing unit, in the clinics, and by appointment.

The counselors help patients obtain insurance coverage or set up payment plans.

“We have partnered with an agency to make long-term, interest-free payment plans available,” says Roberts. “These can extend upward of 36 months, and are very accommodating to our patients’ financial needs.”

SOURCES

  • Benjamin Colton, ECG Management Consultants, Seattle, WA. Phone: (206) 689-2200. Fax: (206) 689-2209. Email: bcolton@ecgmc.com.
  • Kim Roberts, MBA, RHIA, CRCS-I, Vice-President, Revenue Cycle, Abington (PA)-Jefferson Health. Email: Kim.Roberts@jefferson.edu.
  • Bridget B. Walters, Corporate Director, Patient Access, Orlando (FL) Health. Phone: (321) 843-4530. Fax: (321) 843-6579. Email: Bridget.Walters@orlandohealth.com.