Every outpatient registration is checked
Not only do the verification and quality services personnel at North Carolina Baptist Hospital in Winston-Salem perform one of the most thorough registration quality checks around, they’ve been doing it for 12 years. When Keith Weatherman, CAM, assumed his position there as associate director of patient finance, he was pleasantly surprised to discover the data quality review process was "the best I’d ever heard of."
"It seems like there is still finger-pointing [at registration] going on at other places I hear about, but here the front end is pretty well covered," he adds. "We just don’t hear the fussing from the back end that happens at other hospitals."
Weatherman credits Darlene Caudle, manager of the verification and quality services department, and supervisor Teresa Colvert, who does all the departmental training and directly oversees the quality review staff. Both have been with the department since it was created. "At the time," explains Caudle, "I was working in the collections department, cleaning up errors that occurred at registration and all the way through. I suggested it would be good to have a department to review registrations and get those errors corrected before the account was billed."
At first the department included two groups of employees — the quality review group (for outpatient registrations) and the verification group, which verified insurance and benefits for inpatients, outpatient surgery and the 24-hour observation unit, adds Colvert. "It was Darlene, myself, and 17 employees."
Several years later, a preadmission function was added, along with 10 new employees and a second shift," she notes. "[Preadmission counselors] would call patients who were scheduled for admission, outpatient surgery, or a procedure in our day hospital. They would make calls until 9 p.m."
A few years later, Colvert says, a pre-certification group, made up of nurses formerly with the hospital’s utilization review department, joined the mix. "Now we have nurses who get pre-certs started with patients who are going to be admitted or have outpatient procedures, she adds. "So we’ve gone from 19 people to about 42 people."
Colvert has trained all new employees since department’s inception, she says, with some help from the quality review group. The reviewers show new employees how to use the Blue Cross Blue Shield network, known as Blue E, and the Medicaid common working file to verify eligibility. Sometimes, she says, the new hires sit with quality reviewers so they can better appreciate the importance of registration accuracy.
Two years ago, Colvert notes, she acquired a training assistant who helps out about once a month and otherwise works as a financial counselor. Conversations with access colleagues at other hospitals indicate that "a lot are talking about but not many are doing" the kind of extensive quality review that Caudle and Colvert oversee, Weatherman notes. "It’s a good tool to show where employees stand and where they might need more training."
Unlike at many facilities, where random quality checks are conducted, quality reviewers at Baptist Hospital check every outpatient registration. Inpatient registrations do not go through the same process, Caudle says, because financial counselors verify that information in advance.
Registration report is key
The basis of the quality review is the registration report, which is a single sheet of paper for every registration done the day before, Colvert adds. "The front side has the demographics and the physician information, and the back side has the insurance information."
On a daily basis, Caudle explains, the quality review process works as follows:
1. Sheets are gathered from all outpatient registration areas, including the emergency department, outpatient clinics, and private outpatient areas (tests and other diagnostic procedures).
2. One of the reviewers — typically the same person — divides the sheets among those on duty that day. Each reviewer’s name is put on a board, along with the sheets that person has been assigned. If a reviewer doesn’t finish that day’s sheets, because of illness or reports that take extra calls to insurance companies. "Everyone pitches in and helps, so that everyone stays together. The team atmosphere keeps the whole group moving along," Caudle adds.
3. Reviewers examine each work sheet, which is "a picture of the registration as it is in the computer," looking closely at 19 key data elements, including name, telephone number, next of kin, accident screen, and insurance information. "We look closely at family and referring physicians because we’re very interested in tracking that at our facility," Caudle notes;
4. Errors are highlighted in yellow or pink.
"Yellow [indicates] a critical area that would cause a problem with reimbursement," she says, "such as an ID number, policy holder, or insurance address." Errors highlighted in pink are considered less serious, Caudle adds, and are either sent directly to the individual registrar for correction, or in some cases, to the registration manager, who distributes them to the registrars in that area. Because of reimbursement concerns, reviewers correct the more critical errors to ensure a clean claim is sent to payers, she says. "The bill goes out in five days, regardless of what we do."
During the highlighting process, Colvert explains, quality reviewers call insurance companies as necessary, and use the electronic tools like Blue E and the common working file to check the data. "Before they send the highlighted sheets back [to the registrars], they access a weekly Excel spreadsheet, which has a separate file for each department we review," she notes. "Within each file, there are separate folders for each [registrar] in that department."
Each day, reviewers pull up the folders of all the registrars whose work they have checked and load the resulting figures, or scores, into the spreadsheet, Colvert says. "They compute a maximum potential for that [registrar] — the possible number of data elements they could have gotten correct in that work, and then subtract the errors to come up with the number achieved."
On a weekly basis, the computer calculates a demographic achievement rate, an insurance achievement rate, and an overall achievement rate for each registrar, she adds.
From the spreadsheets, Colvert says, she creates her part of the report, an achievement summary that is given to all registration managers. "It includes all the [registrars] in their department, and shows the number of registrations reviewed for that person that week, the total maximum potential for that week, the number achieved and the achievement rate. [Figures] also are totaled for the entire department."
Managers get a packet containing the departmental report and individual reports, which are distributed to the registrars, she adds. In most of the affected departments, Colvert says, the quality review results are used in employees’ annual evaluations. Registrars who maintain an accuracy rate of 99% over a six-week period receive a special benefit, Caudle notes. Their work is given a cursory look, but no longer is reviewed like that of their peers.
"Every quarter or so we pull [a sheet] to make sure they maintain [the quality level]," she says. "If they don’t maintain it, we take away the exemption; but most work hard to maintain." The managers in their departments also recognize these registrars for their achievement, Caudle adds.
"It’s quite amazing, but the big majority of [registrars] are quite conscientious about this," she says. "I’m often asked the question, Doesn’t [the process] cause morale problems or negative interaction?’ It has not had that effect. We try to show everything in a positive light and make certain they understand the importance of the role they play, and that if it’s not right, we don’t get paid."
Using phrases such as "maximum potential" and "achievement summary" in the review process was a very deliberate choice, Caudle points out. "We are very careful to keep it on a positive note, not a negative one, and we’ve gotten good feedback from the [registrars]."
To help ensure consistency, she says, "every 90 days or so, we take the same [registration] sheet and give it to each quality reviewer. Then we look at the sheets to make sure they’re verifying in the same way."
If registrars disagree with a mark made by the reviewer, they can take their complaint to a manager and, if the issue is not resolved there, send the sheet back, Caudle explains. "Usually, Teresa and I look at those sheets and, if it’s appropriate, we adjust the person’s score. Either way, we always give feedback."
"If we see that particular [registrars] are having problems keeping their scores up," she adds, "we ask the manager to send the person back for some additional training." Less often, Caudle says, she, Colvert, or the financial counselor/training assistant will work one on one with registrars in the individual departments.
Caudle has been working part time in the ED registration area, she notes, not only because staffing is short, but also to see firsthand how registrars are doing. "It allows them to use me if they have questions, and for me to see if they were properly trained."
[Editor’s note: Keith Weatherman may be reached at (336) 713-4748 or at firstname.lastname@example.org. Darlene Caudle may be reached at (336) 716-0720. Teresa Colvert may be reached at (336) 716-0721.]