Training, proper plan ID cut denials by $20 million

Most employees want to do a good job’

Looking at opportunities for improvement after becoming director of patient access at Children’s Health Care of Atlanta about two years ago, it was natural that Millie Brown would turn her attention to the quality of registration data.

And given the education-focused culture of her organization, adds Brown, a former manager in the billing department, it was natural that staff education would be an important part of her quality improvement initiative.

That initiative, which took place between January and December 2002, turned the spotlight on ensuring proper identification of patients’ insurance plans and has resulted in more than 75% of claims being paid the first time out, she says. "The industry standard is 52%, so we’re well above that." The positive financial impact on the health system has been approximately $20 million less in annual denials, Brown adds.

Training started with the assumption that "most employees want to do a good job, and the reason for the errors is they think they’re doing it correctly already," she notes. "Using that mindset, we created an insurance card test. We took a sample of the different cards submitted [to registrars], gave a plan code listing, and did a matched quiz."

The idea, Brown adds, was to give employees the opportunity to see that there was room for improvement. "We achieved some motivated learners."

The initiative was aimed not only at the 140 access employees who are Brown’s direct reports, but also the access staff at the health system’s many satellite clinics, for whom her department oversees training and quality control.

Easier said than donen

Identifying the correct plan — with insurance cards covered in different logos and the plan name not always the most prominent — is easier said than done, Brown notes. To show how confusing the process can be, she says, the departmental trainer administered the quiz not only to patient access staff, but also to patient accounting employees and system leaders (vice presidents).

"Often [those outside access] say, Just enter the name on the card,’ implying that the process really isn’t that hard, Brown explains. "When you think about patient accounting and billing, their job is usually set up so they’re working with one type of card. It’s not like in access."

The quiz gave the outside staff a better understanding of what it’s like to be on the front line and how difficult it is to identify the correct plan, she notes.

In keeping with Children’s philosophy of "making sure the message always is consistent," Brown says, one person does all patient access training.

To address the insurance card issue, she adds, Rose Cape, manager of quality and training, designed "tip sheets" around the appropriate way to handle the various third-party payers. Cape targeted the handful of payers that make up the majority of the organization’s business, Brown says, with the idea that would provide the "biggest bang for the buck."

"If three or four payers represent 70% of your business, is it the best use [of resources] to focus on 10 smaller plans?" she points out. "What if you got 70% of your business 100% correct?"

After receiving "some intense training" on the major payers, Brown says, staff were given the tip sheets, which also are available on the health system’s education web site. "If any access employee is having problems with one of the top plans, the supervisor can go to the site and print the tip sheet."

As the quality process continues, she notes, the collection of tip sheets will be expanded to include other payers.

The operative phrase for the tip sheets and for all aspects of training has been "Keep it simple," Cape emphasizes. "Use words that are applicable to [staff], that they’re familiar with, to get their buy-in. Give examples of when what they’ve done in the past hasn’t worked, and say, When you do this, you’ll get this result.’"

Regarding the insurance plan issue, Cape adds, she explains to employees that the hospital doesn’t get the correct payment when the wrong plan is chosen because it has different contracts with different payers. "Instead of looking [at an insurance card] in this way," she tells them, "look at it knowing the plans we have contracts with."

The format is the same for any type of constructive criticism of staff, Brown notes. "When you do [insert action], what happens is the wrong outcome. A better choice would be [insert correct action], and the positive result would be [the desired outcome]."

Repetition is another important part of the training equation, Cape adds.

Quality check follows training

Once employees were trained on the top payers and the tip sheets, Brown says, she did a quality check on the information. "Today, for example, we gave a huge training [effort] on Blue Cross Blue Shield," she adds. "Then we went back and checked and watched to see if [employees] are [processing those accounts] the right way. I took a sample of accounts — a very large sample — to see who was doing it correctly."

Those still making errors received additional training, Brown says. In some cases, she notes, tip sheets are adjusted after quality checks.

Any big changes in the process are covered at quarterly training sessions, Brown adds, and "in between those is when we’re checking quality. If we see a particular problem with a lot of people, [Cape] will send an alert bulletin, with a tip sheet attached, saying, Everyone be careful with this.’"

Supervisors are asked to make sure that all employees have read the bulletin and the accompanying information, she says. "Each supervisor is accountable for the quality scores of the staff and each manager is responsible for the quality scores of the team."

If the supervisor believes it’s necessary, the trainer will work one-on-one with an employee who continues to have problems, Brown says. "The tip sheets are so clear, so concise, that [one-on-one time] is not usually needed."

Brainstorming sessions improve quality

Access managers throughout the health system meet with Brown once a month to brainstorm ways to continually improve quality, she adds.

In addition to focusing on proper upfront identification of the top payers, Brown notes, she also works with the billing department to trend denials. That report often determines what the next training focus will be. "If a certain number [of denials] are related to Blue Cross Blue Shield, we need to do some education on [that payer] this month."

Each time the department goes through the cycle of trending denials, educating with tip sheets, and checking for quality, she says, "we get a little bit better."

Registration errors have been reduced by more than half, Brown says, specifically those errors that lead to denials. "For example, a [wrong] patient address does not cause a denial."

"We found that when we focused on [cutting denial-causing errors], it increased overall accuracy as well," she adds.

Employee recognition enhances quality

Annual recognition for employees who excel in claim accuracy has been another important part of the quality focus, Brown points out. Those who score 90% or above on claim accuracy — meaning at least 90% of the claims they process are not denied — receive a gold medal, she says. An accuracy rate of between 85% and 90% earns a silver medal, and a rate of 80% to 85% earns a bronze medal, Brown adds.

"Right after we [awarded medals]," she notes, "everyone — the entire team — jumped to 90%."

"It was a great year for access last year," Brown says. "We got written up in the hospital newsletter, and the staff was treated to a party and received [commendation] letters. A lot of times access people complain about not being recognized, but we can’t say that."

The recognition and sense of accomplishment not only has boosted staff morale, she adds, but has made the access department a more sought after place to work. "We have a lot more applicants, people wanting to be part of our team."

[Editor’s note: Millie Brown can be reached at (404) 929-7514 or by e-mail at]