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We had a phenomenal turnaround in less than a year’
With the help of some user-friendly software and a comprehensive staff training initiative, Parrish Medical Center in Titusville, FL, has dramatically reduced its medical necessity write-offs while improving customer service.
"Our Medicare fiscal intermediary is a very stringent one," says Christine Rich, MHA, business director, "with a ton of local medical review policy [LMRP], for which we need to make sure we’re meeting the [medical necessity] criteria."
However, registrars, faced with a complicated, inconvenient process for determining if a procedure met medical necessity and then informing patients that it might not be covered by Medicare, often skipped the step altogether, adds Linda Lilleboe, RN, MSN, business office manager.
"They had [medical necessity] software up front," notes Rich, "but to use it, they had to leave the registration module and go to another module. If the [physician order] didn’t have an ICD-9 code or CPT code — if it was just a narrative — they had to go to a book and look up, for example, CBC,’ and then look up anemia,’ and hopefully choose the correct code. They also relied on the coding department for help, which caused a strain on their resources."
If, after all that, registrars found that a procedure was not covered by Medicare, they had to inform the patient, and later the ordering physician, that the scheduled test didn’t meet medical necessity, she says. Patients had to be asked to sign an advance beneficiary notice (ABN), indicating they knew the procedure might not be covered and that they’d be responsible for payment.
"They were not prepared for the answer the patient might give," Rich adds. "The patient might say, I still want the test; how much is it?’ and the registrar didn’t know, so there was a whole set of phone calls."
Meanwhile, registrars also were dealing with a room full of waiting patients, Lilleboe says, and getting constant reminders on the need to reduce wait times. "It was easier not to get it signed."
With ABNs not being consistently offered to — or signed by — patients whose procedures were not covered, Rich explains, the hospital found itself writing off the cost of an excessive number of outpatient procedures.
Part of the problem, Lilleboe points out, was that registrars didn’t fully understand the significance of what they were being asked to do. "They had no support," she says. "They didn’t understand the bigger picture, the amount of money the hospital had to write off. Even if they had a signed ABN, if the codes were not an exact match to what we billed, the account still had to be written off."
The mission, therefore, had to be "a whole new re-education of staff," Lilleboe says, making sure they "understood these things are not negotiable." The message to employees was, she adds, "We will give you the tools to do it, but it must be done." As a result of that effort, which took place between October 2002 and September 2003, the hospital reduced by about 75% the amount of outpatient Medicare procedures that had to be written off due to lack of medical necessity and lack of proper documentation, Lilleboe says. "We had a phenomenal turnaround in less than a year."
Registrars get reminder
Key to that turnaround, Rich and Lilleboe say, has been new medical necessity software that not only is far superior to what the hospital used previously, but also clearly better than several other products they either had experience with or checked out while deciding what to buy. Some of the others, Rich notes, were so complicated, registrars had to just print out the information and send it to the coding department for interpretation.
One of the biggest advantages of the new software is the ability to customize its dictionary to fit the hospital’s specific needs, Lilleboe says. For example, a patient might come in with an order for a carotid Doppler study, she adds. "If they didn’t know the CPT code or that this procedure was also known as an extracranial study,’ they would never find it. To expect the registrar to remember all that was not realistic."
"At the beginning [of implementing the software], we would contact the coding department, get the code, fill out the LMRP Customized Procedure form, and say, This is the common name of the study, and this is the CPT code,’" Lilleboe explains. "We would customize the software dictionary so registrars could just pull up what Parrish Medical Center had and go to it. Diagnosis clarification was also done using this form."
In the past, she says, registrars might be handling a physician’s order for a stress test, and there might be five or six codes attached to that procedure. "They would pull up the stress test and do one code, but miss several others."
To remedy that, Lilleboe adds, "we took the physician order sheet and customized the software to match the codes."
Another convenience of the new system, Rich says, is that registrars automatically are prompted at the end of a Medicare patient’s registration with the question, "Enter/Edit CPT and ICD-9 codes?"
"That question is attached to outpatient registrations with the financial class of Medicare, so it’s a no-brainer for the registration staff; it just pops up," Lilleboe adds. "If the patient had commercial insurance, [the question] doesn’t come up." With the old software, she notes, registrars got in the habit of bypassing the reminder because it appeared with every registration.
To facilitate the transition to the new software, Lilleboe says, the business office trainer scheduled one-on-one sessions with registrars. "She would go through the process, train them on the software, and then audit them to see how they were doing." A little more than a year later, she notes, the trainer continues to get weekly requests from staff to update the dictionary. "A strange test will turn up, and the trainer gets the information and inputs it into the software dictionary. We remain very current since updates are sent consistently to our IS department. They do the update, and the business office trainer spot-checks to make sure everything works."
Audits are done every month, and LMRP write-offs continue to be monitored, Rich says. "There’s been a real benefit. We still have issues, but we can go back and research if there are problems with a certain code and we can make changes."
Information is put into a spreadsheet so it can be sorted by registration type, and then by CPT code, Lilleboe notes. That’s how staff noticed that a high number of electrocardiograms (EKGs) were not meeting medical necessity criteria, she adds. "We traced it back and found there was a standing order by a physician that said, Do these tests regardless,’" Lilleboe says. "It was probably a standard practice to do an EKG for every man over 45."
Such occurrences are discussed at a monthly LMRP/denial meeting, attended by representatives from health information services, the emergency department, registration, and the business office, she says. One of the most positive things the audits have revealed, Lilleboe adds, is "we never found one outpatient procedure that a registrar didn’t run through the system. We couldn’t have said that a year ago."
Our goal is to move forward’
Good customer service was at the top of the agenda during the implementation of the new process, Lilleboe and Rich emphasize. "We want the registrars to be first and foremost patient advocates," Lilleboe adds. With that in mind, she says, "upfront" determination of medical necessity means at the point of registration, not — as is the case at some facilities — when the patient is in a dressing room getting ready for the procedure.
To make the process even more seamless for the patient, Rich notes, there is an effort under way to get physicians to fax over more orders in advance, so they can be checked for medical necessity at the time of scheduling. Despite the vast improvement of the current process, she says, it does take up time during registration and can be inconvenient for the patient. "Our belief is the sooner we do it prior to the time of service, the happier everyone will be. Our goal is to move forward."
Ensuring clear communication with patients has been paramount, Rich says. "It’s an uncomfortable situation. Patients feel like you’re saying to them, Your physician shouldn’t have ordered this test,’ but you’re really saying, This procedure did not meet medical necessity based on the diagnosis given.’"
To help them become more comfortable talking with patients about medical necessity — and to make sure the proper message is getting across — registrars were given cards containing "scripts" to use in various situations, depending on the patient’s reaction to the information, she adds. (See sample script.) "Any time we want staff to give a consistent message," Rich notes, "we script it and give them a laminated card."
Despite the best of intentions and procedures, patients sometimes will complain, she says. "However, we remain consistent and always encourage the patient to contact the ordering physician to discuss any issues. We also notify the physician’s office with an explanation if we are unable to complete the order."
[Editor’s note: Linda Lilleboe can be reached at (321) 268-6745 or by e-mail at firstname.lastname@example.org. Christine Rich can be reached at (321) 268-6870 or at email@example.com. The hospital’s web site is www.parrishmed.com.]