When Banner - University Medical Center Tucson implemented a triage and registration process for emergency department (ED) patients with symptoms consistent with COVID-19, revenue cycle leaders were right in the middle of it.
“Our revenue cycle team was tasked with tracking these patients as they presented, and identifying how we would ensure appropriate billing for each visit,” says Patient Access Director Ian Jensen, MHA. The new process removes COVID-19 patients from the general ED. Patients are screened, assessed, registered, treated, and discharged in an outdoor area. The entire process takes between 20 to 30 minutes. First, patients drive into a multistall screening area, where vital signs are taken and an acuity level is assigned. High-acuity patients are brought to a section of the ED that is physically separate from the general ED. There, registrars use eligibility checking tools, signature pads, and collection devices. “With our mobile workstations, it’s as if the rep was sitting at a registration desk,” Jensen says.
Lower-acuity patients drive up to a registration tent. “They are greeted by a rep who collects all of the required information to complete registration,” Jensen explains. Consents and signatures are handled verbally to reduce risks for both patients and staff. “Once all access functions are completed, labels are printed,” Jensen says.
The patient drives to the final tent for testing (nasal or throat culture). Lastly, nurses give discharge instructions. Throughout all of this, “our revenue cycle team maintains accuracy of insurance and demographics for clean claims,” Jensen says. These changes were made:
• A new payer code was created in the registration system to be added to the patient’s medical record number. “This allows us to quickly track volumes of patients coming in and their associated acuity,” Jensen reports.
• Registrars use eligibility tools on mobile work stations to validate patients’ insurance. “This is done in real time while the patient is in front of the registration rep,” Jensen explains. The same tool flags errors so registrars can fix them right away during the registration process.
• The department moved its equipment (label printers, scanners, collection machines, and computers) to the outside screening area. “This allows a faster turnaround time,” Jensen says. Registration takes two to four minutes on average, and five minutes during peak volumes.
Overall, the triage and registration process is not only safer for everyone involved, but also efficient. “We provide quick, yet thorough, registrations,” Jensen adds.
Normally, ED registrars see from 200 to 230 patients a day. “The new process allows us to accommodate over 450 patients,” Jensen says.
Four or five additional registrars are needed to accommodate the higher volumes. “Staffing challenges will always be the No. 1 logistical problem we face in incidents like this,” Jensen notes.
Registrars are brought in from other areas: outpatient check-in, inpatient registration, and outpatient infusion. “All will be monitored for accuracy and quality metrics, the same as with other ER registrars,” Jensen says.
Outpatient surgery volume decreased by 60% at the facility. “We repurposed our staffing resources that are normally dedicated to registering these outpatient modalities to focusing on the screening process,” Jensen reports.
Those registrars already were cross-trained to work in all areas, including the ED. “Staff are able to fix registration errors in real time while they register patients,” Jensen says.
Any incorrect insurance information, policy numbers, or subscribers will cause denied claims. “We are monitoring these registrations and correcting all errors prior to the day’s end,” Jensen says.
This is handled the same way as before the pandemic. A quality tool allows viewing of all the accounts any specific rep worked on for any given time. “From there, we can monitor all alerts that would prevent a clean claim,” Jensen says.
The hospital’s quality assurance team shifted its focus to COVID-19-related accounts. “During this time, we are all hands on deck,” Jensen says.
The goal is to maintain registration quality in the high 90th percentile. “We want to make sure that the facility’s A/R days remain consistently low, and that our unbilled days are maintained lower than four,” Jensen offers.
For inpatients, collections are handled by phone instead of face-to-face interactions. When patients are checked in, registrars verify insurance eligibility. “We use tools that offer coverage discovery to ensure all appropriate payers are identified. From there, we are able to collect over the phone, much like a pre-reg account,” Jensen says.
This same process is used in the ED’s respiratory waiting room. Registrars use phone numbers provided at check-in. “We then complete the registration and collection over the phone,” Jensen adds.
School teachers nationwide had to learn on the fly how to teach remotely. Revenue cycle educators at Banner Health did the same. “We were challenged to modify training in order to communicate changes affecting acute and ambulatory settings,” says Amber Hermosillo, revenue cycle educator and quality director. Two types of training were needed urgently:
• For existing patient access staff. Trainers used Adobe Connect to report on the new processes used for COVID-19. The switch did not come easily. “Our patient access team is used to face-to-face, facilitator-led trainings,” Hermosillo says.
• For staff outside of patient access who now are registering patients. A mix of corporate staff from revenue cycle service lines, central billing offices, analytical teams, and various other positions are helping. An educator covers the basics of registration via Skype. “There are times we have minor technical issues,” Hermosillo notes. “Overall, the staff, trainers, and leaders embrace the virtual platforms, with reasonable engagement.”