Don't make a mistake when asking for technology dollars

Know your facts before you commit

If you are being inundated with sales pitches from technology vendors these days, it's not too surprising. A number of solutions are aimed at improving patient access processes, such as compliance with new admission/registration requirements.

You can either invest in technology to manage regulatory requirements, improve accuracy, increase collections, reduce precertification denials, improve throughput, and reduce wait times — or you will fall behind your competitors. Without electronic solutions, you run the risk of having to hire scarce resources able to correct problems that are leading to precertification denials, for example.

"We've got so many gizmos on the road map for patient access," says Katherine Murphy, CHAM, director of access services for Nebo Systems, a subsidiary of Passport Health Communications in Oakbrook Terrace, IL. Murphy is also a delegate to the National Association of Healthcare Access Management (NAHAM) and the president of the Illinois Access Association. "Everything you read about is for the front end.

"We are being called upon to create a new, better way of doing business," says Murphy. "Consumer-driven health care and consumer demographics are also driving the urgency for these changes."

Without electronic solutions, you won't be able to correct problems that are causing precertification denials, for example. "The only other way to do it is manually, and if you do that, you will be so far behind the trends," says Tim Carney, manager of outpatient financial arrangements at Shands at the University of Florida in Gainesville. "By the time you have gotten 1,000 charts together and find out where your denials are coming from, you've got six months more of bad data coming in."

If you don't know where your denials are coming from and you're trying to figure it out on paper, "you'd better be the only game in town," says Carney. "Otherwise, your competition is going to squash you."

But making the wrong move with technology could cause you other problems. You risk a financial disaster if you are too far removed from the problems you are trying to solve.

"When you are trying to sell administration on a $300,000 project and you're doing it on the backs of an FTE savings or an ROI promised by a vendor, it's time to get your hands dirty and be sure you really understand what you're trying to fix," says Carney. "If you don't, you really better trust the people that are giving you the data. Because if it goes bad, they're not going after those people, they're going after you!"

When lobbying for a new technology purchase, do these things first:

  • Make sure your numbers are correct.

"One of the things I recognized early in my career was that if you make any kind of claim, you better have something to back it up. Because somebody is going to challenge it," says Murphy.

When selling your CFO on a technology tool, Carney says "make it a money deal." "If you say, you give me $300,000 and I'll get you a million, why wouldn't he do that deal?"

But you've got to be sure of a few things before you make a promise like that. First, be certain that the implementation's total cost isn't more than you claim. To verify this, you'll need to bring in your IT department.

"Don't listen to the salesman — you need your IT in there," says Carney. "You may find out that he hasn't told you you've got to hook it up to a LAN, or a server, or whatever, which will cost you another $30,000 or so. Bring everybody in. If you do this in a silo, the silo is going to fall on you."

Your case should be "all about numbers" says Carney, without getting personal. "Know the data inside and out. And make sure that your hospital-based HIS system and your IT department can support this," he adds.

Shands has a 150-person IT department, but if your hospital will need high-priced consultants for the implementation, all your figures will go out the window.

"If all of a sudden they are are going to bring in consultants at $150 an hour, plus airfare and room and board, and they're going to be there for months, your $300,000 project went over a million dollars real quick," says Carney.

Your CFO won't comprehend the day-to-day operations of patient access, but he or she will know about the bottom line. "If you keep it to figures, they understand that better than anything," says Carney. "But if you come in there and say, 'If you give me $300,000, I can make you $700,000,' you just better be right. And if you are right, the next time you come you will be questioned less."

The next step, he says, is that you'll be getting calls from your CFO asking you to recommend patient access technology solutions to improve the hospital's bottom line.

Shands is currently examining the ROI that would result from recording phone calls between patient access staff and payers, something that insurance companies routinely do. Carney estimates the cost at about $50,000 to $75,000 and is trying to determine how much would be saved if patient access could prove that a call was made, or an amount specified by a payer, and also, the reduction in staff errors as a result of being recorded.

When the time is right, make your business case

A solid business case can move your request for technology to the "top of the pile," says Kathryn Stevens, PhD, MBA, CHAM, manager of the Epic ADT Project at UW Medicine in Seattle.

"Most of my career, I've been required to provide a business case to get funds for new programs or to purchase and implement technology solutions," says Stevens. "I know from experience that presenting a strong ROI can make a difference when competing for limited capital resources during budget time."

It is not easy work, especially the first time you do a business case, says Stevens, but it does get easier. More often than not, vendors will provide you with ROI and testimonials from other clients and calculator tools you can use to populate with your volumes and prices to get bottom-line results specific to your institution.

"It is important to pay attention to the details," says Stevens. "This is an investment of time that pays off by eliminating resistance and facilitating the conversation when called by the budget committee to defend your request."

Several years ago, Stevens implemented an automated error tracking tool, tracking 100% of the 20,000 registrations completed every month. "It was a real-time system, so errors could be redirected and corrected immediately by the user who made the error," says Stevens. "We reported accuracy rates each week to department supervisors, which facilitated targeted training and error remediation actions."

Initially, there were few nationwide users of this system, so the ROI for this system implementation was based on a "sophisticated guess," says Stevens. "We developed baseline data regarding mail returns and bad debt," she says. "When we compared the actual to the baseline, we reported a significant improvement over our estimate. Mail returns were reduced from 11% to 4%."

ID a bad investment

Data provided by an error tracking technology system helped Stevens avoid a waste of resources. "You want to focus process improvement initiatives on the right problem," says Stevens.

In early 2007, a senior leadership group commissioned a performance improvement project to increase the accuracy of registration. At the time, however, the accuracy rate was already between 98% and 99%, as demonstrated by the automated system reports. 

"They were unaware of this improvement, which was up from 85% reported from the manually created sample report," Stevens says. "Their perception of errors was fueled by anecdotal accounts, and their reaction was emotional. By providing them current data and demonstrating the high-level accuracy rate we had achieved, I was able to redirect their energy to focus on some real problems, rather than spend resources on so small a return for our efforts."

"But they are going to give me this money only if I can make that money back or more. So I'm seeing right now how much true dollars I can get back," he says.

During the last fiscal year, Shands lost more than $150,000 in pre-certification denials due to payers stating services exceeded authorization, the date of service did not match date of authorization, the CPT codes differed from what was authorized, and incorrect authorization for facility. "Our records show those errors did not occur, but then it was our word against their word," says Carney. "With the recording device, we'll be able to see if it's our error or theirs and get paid."

  • Talk to patient access professionals who have recently implemented the same system.

When Shands was looking for a bedboard system, they were approached by Navicare. Carney asked for a list of hospitals using it and of the four he was given, he contacted the patient access department that was most similar to Shands, and went to see it. Carney asked them:

  • What do you like about it?
  • What don't you like about it?
  • What would you improve if you were doing this all over again?

After getting these answers, Shands made the decision to purchase the system, which is now in use housewide at two facilities. "We got down to, 'Did you like your installer? What was his name?' If they like him, then we'll probably like him and we want that guy," he says.

Buying technology is like buying a car, says Carney — you can't buy into what the salesman says without looking at all the consumer reviews. "You've got to listen to people using it. They're going to tell you the good, bad, and the ugly," says Carney. "They might say, 'It's not as good as they're saying, but it's so much better than nothing.'"

  • Make sure that you really understand what you're trying to fix.

"If you let some vendor sell you on ROI or staff reduction, and you don't really know what your problem is, you're going to be in trouble," says Carney.

Get input from patient access staff and the departments they serve before you make a decision on a solution. "I have been the victim myself of having to implement something without any input, and I have seen the backwards processes that it produced," says Murphy.

Murphy recalls that someone once decided to have a cost estimate pop up in the middle of registration. "Well, all that did was upset the registrar," she says. "It got the person unfocused and instead of data gathering, they were collecting balances. It didn't allow a positive relationship to come to a closure, and created chaos in throughput."

On the other hand, taking the time to truly comprehend the processes that you want to improve pays off. "If good processes are put in place and then automated, the results are astounding," says Murphy. "Both staff and patients recognize and appreciate great processes. This builds loyalty, respect, and confidence all around."

When Carney dug into the data on precertification denials, he was surprised to find that only 31% were due to patient access staff. Another 31% involved radiology. After the doctor ordered one view of a magnetic resonance imaging scan or computerized tomography scan, patient access staff would obtain the precertification. But the radiologist would realize that to show the doctor what he wanted to see, two views were needed. "So guess what? It comes back as a precert denial, because we ordered one view, not two views," says Carney.

Take these 7 steps before you commit

When making your case for a technology investment, use these seven tips from Kathryn Stevens, PhD, MBA, CHAM, manager of the Epic ADT Project at UW Medicine in Seattle:

  • Be specific about your goal and how it benefits the organization.
  • Be conservative. Cut any vendors' estimates by three-quarters.
  • Don't overestimate ROI or overinflate benefits, as is the tendency of most vendors.
  • Do research with local or regional clients. Tell their stories about benefits and lessons learned.
  • Get solid baseline data on your current process.
  • Be able to defend your numbers.
  • Find out if there are other similar or conflicting initiatives by other departments in your organization.

Another reason for denials involved divorced parents giving the wrong insurance for their child to patient access staff. "The parent might come in and say the kid has Blue Cross, but the problem is that the dad is the primary — but we didn't know that because the mom just gave us her insurance card," says Carney. "She gets the bill and it's denied, and by contract if we bill it, then we fall under those rules."

Knowing these underlying reasons for precertification denials becomes very important if you are looking for a technology tool to reduce these. "If someone comes down and says, 'Tim, if I get your team this great precertification tool, can you reduce denials by 50%?' and I say, 'Sure I can,' and they buy me this, the problem is, I wasn't responsible for all the denials."

In a situation like this, the promised results won't happen and the patient access manager likely will be blamed.

"The problem is that you weren't even aware there was a broken process in your radiology department," Carney says. "Stay connected to your day-to-day operations. I'm not saying you've to go down there and register, but you've got to understand your problem before you make a commitment."

Be 'in the know' on patient access tools

"Unfortunately, not all access professionals take advantage of the opportunities to learn what's outside their world and the technological tools available," says Kathryn Stevens, PhD, MBA, CHAM, manager of the Epic ADT Project at UW Medicine in Seattle. Attending conferences, for example, may be cost-prohibitive, your boss may not value external learning, or you may get caught up in "fighting fires" instead of looking for more long-term solutions.

Here are some ways to find out the latest and greatest technology offerings:

  • Attend local, affordable workshops.

These may be offered by vendors or national professional associations. "In addition to journals, these workshops and webinars are prime sources of information about the technology tools and the efforts under way to support access improvement," says Stevens. "While this takes me away from the job, the investment in time and the amount paid by my employer has been value-added."

Stevens says she attends at least four professional association sessions a year, but as a national board member of the National Association of Healthcare Access Management (NAHAM), most of her sessions are free, especially when she volunteers to be a speaker.

"I used to attend a lot more national events, but time away is costly in terms of workload, and flight costs have increased substantially," says Stevens. "It has been cheaper and more effective to arrange for vendors to come to my organization and demonstrate new products."

  • Meet with vendors at conferences.

Carney says he attends the National Association of Healthcare Access Management conferences every year, and listens to what the vendors have to say, but then goes to the hospitals where the solution has been implemented for "the true story."

  • Participate in user groups for your hospital's HIS system.

"I'm on a Siemens system, so I like to go to a Siemens user group with other hospitals that are using my system. It doesn't help if they've got McKesson, because they are different," says Tim Carney, manager of outpatient financial arrangements at Shands at the University of Florida in Gainesville.

  • Contact your patient access counterparts at other hospitals.

Carney says he finds hospitals with patient access departments similar to his own to compare notes with. These include Vanderbilt University Medical Center, Ohio State, and University of Alabama at Birmingham. "These are people that are doing my job with the same kind of concerns. I look at myself against them, and ask, Are these people having the exact same problem that I'm having?'" he says.

Carney says he couldn't go talk to patient access at a local hospital since they're a competitor but that other hospitals will openly share their problems. "I'm not going to divulge my innermost secrets to the hospital that's two blocks over," he says. "But Baylor will tell me anything I want to know because I'm not 20 feet away from them trying to steal their business."

  • Compare yourself only with similar departments.

What patient access does on the front end varies widely, and so do technology needs.

"For some people, their job is to make sure there is an account out there, get the signature, armband the patient, and do proper ID and that's it," says Carney. "But where I'm at, I have to verify the insurance, obtain the precerts, collect the cash, and work the denials. I do everything but put the bill out the door."

If a denial comes back, the billing department has it on its denial database and it goes back to the front end to resolve. "They figure that if the back end is working your denials, then the front end doesn't know what it's doing wrong," says Carney. "Since we obtain precerts, we also do the follow up."

In contrast, patient access staff at a community hospital in the Shands health care system verify insurance and confirm the precertification, but don't actually obtain it. "You've got to watch when you are trying to compare an apple to an orange, even though we all call ourselves 'access,'" says Carney.

[For more information, contact:

  • Tim Carney, manager, outpatient financial arrangements, Shands at the University of Florida, 1600 SW Archer Road, Gainesville FL 32610. Phone: (352) 265-3673. E-mail: carnete@shands.ufl.edu.
  • Katherine Murphy, CHAM, director of access services, Nebo Systems, 1 South 376 Summit Ave., Court B, Oakbrook Terrace, IL 60181-3985. Phone: (630) 916-8818. Phone: (630) 916-8818 ext. 34. E-mail: katherine@Nebo.com.
  • Kathryn Stevens, PhD, MBA, CHAM, manager, Epic ADT Project, Northgate Executive Center II, Box 359101, 9725 3rd Avenue NE, Suite 509, Seattle, WA 98115. Phone: (206) 598-0797. E-mail: stevek12@u.washington.edu.]