Boost reimbursement with reorganization, teamwork

Build, maintain relationships’

Creating the most efficient staffing arrangement possible — along with fostering effective working relationships with those outside the access department — was integral to the development of a financially successful patient access department, says Patti Daniel, MS, CCM, LPC, LMSW/AP.

Daniel, who recently ended a stint as director of admissions and registration at a large publicly funded Texas hospital, helped the organization obtain millions of dollars in reimbursement for services that otherwise would not have been covered.

The reimbursement initiative

When she became director five years ago, explains Daniel, who spent a total of 19 years with the organization, there were financial counselors doing registration and registrars doing registration "and they all reported to different managers."

Daniel divided the 300-person department into registrars and financial counselors to allow each group to focus more on doing that job well, she says, and also created a second associate director position, so that there was an associate director to manage each group.

As a direct result, she notes, there was a large increase in the conversion of previously unfunded patients to Medicaid and other programs during her five-year tenure, along with revenue increases amounting to more than $100 million above budget.

Another key to the success of her reimbursement initiative, Daniel says, was the fostering of relationships with clinical staff, the hospital’s third-party eligibility vendors, and the state Medicaid eligibility staff. "If you don’t build and maintain those relationships," she adds, "you lose a lot of money."

Although the attitude of many hospitals — toward both Medicaid workers and third-party eligibility vendors — is, "We’re paying you to do a job, just go do it," Daniel says, she has a different philosophy."

"I’ve always considered it a win-win situation to make sure the third-party vendors had everything they needed to be successful," she notes. "I did everything I could to make them profitable, because every time they got somebody certified, we got paid."

She met with the contracted vendors each month, Daniel says, and reviewed their productivity. There was an advantage to having the accounts divided among more than one company, not only because of the large volume of business the hospital generated, but because it encouraged competition, she adds.

"Another thing I did was to allow [the third-party vendors] to have interview slots with [the on-site] Medicaid staff," Daniel says. "Some hospitals require that third-party eligibility companies get patients certified, but don’t allow them to use [hospital-based] Medicaid workers."

Her thinking, she explains, was that it was the hospital’s patients that were being taken care of, so why not make it a smoother process for them. "It not only increased the number of people we got on Medicaid, but it made it easier for the patients because they knew where to go. Some undocumented patients won’t follow through in a Medicaid field office, but felt comfortable going to the [state] Medicaid workers in our hospital."

Additionally, Daniel was proactive in obtaining new third-party contracts, putting out new requests for proposals since the two companies that had been in place had dwindled to one, which had trouble handling the workload, by the time she became director.

"Once two new companies were chosen, we needed them to ramp up pretty quickly so we would not lose money," she notes. "I set some aggressive goals for the companies, providing them quick access to inpatients and monitoring their performance."

As a result, Daniel adds, the productivity of the companies contracted to do the eligibility work is 300% greater than it was five years ago.

Daniel’s close working relationship with the Medicaid staff also contributed to the access department’s financial successes, she notes. "When I started working with the patient access department, there were only two of the contracted 30 Medicaid workers on board, and no one was even talking to them, much less making referrals to them."

Her efforts to repair the rift, Daniel points out, included staying in regular communication with the Medicaid workers, renovating their office, and holding appreciation receptions in their honor.

"They now love working there and know how much the hospital appreciates them," she adds. "It was all about building and maintaining the right relationships."

A move that benefited both the Medicaid staff and the hospital, she adds, was the offer to provide a Medicaid training site on campus. "This was a way to build our own work force and to ensure we had the Medicaid graduates to keep a full complement of staff."

Also, Daniel says, the state Medicaid office gave approval to pay overtime to the workers, which enabled the office to extend its hours. "This allowed patients who could not make appointments during regular business hours to apply up until 8 at night and on weekends. Thousands of additional patients were certified as a result."

To further enhance the financial viability of the system for which Daniel worked, the consulting firm Cap Gemini Ernst & Young (CGEY) was brought to the table to assist in an initiative called "Transforming Care."

"The health care system was very progressive in trying to find alternative funding for its patients," notes John Woerly, MSA, RHIA, CHAM, Indianapolis-based senior manager with CGEY. But in a period of decreasing funding from governmental and other public bodies, he points out, the question becomes, "How can an institution go further to enhance financial viability?"

Teams were deployed in all areas of the organization to analyze current processes and propose future processes that would improve both clinical delivery and financial stability, Woerly adds. The revenue cycle team, he notes, focused on improvements in patient access, health information management, and patient financial services. These ranged from reduction in discharge-not-final-billed activities due to charts awaiting medical record coding, to cash acceleration, which focused on getting old bills paid.

Patient access, he says, focused on three initiatives, which he lists and describes as follows:

1. Getting scheduling information in a timely manner, with attention to key data elements needed for clinical and financial clearance, such as diagnosis, procedure, ICD-9/CPT codes, pre-certification/authorization numbers and primary care provider referrals.

2. Performing clinical and financial clearance, including LMRP (local medical review policy) review of outpatients and IS/SI review of inpatient admissions/outpatient observation cases.

Emphasis in the past, Woerly notes, was on performing pre-registration only on funded patients, which in this case were a very small percentage. The newly designed focus, which called for the creation of a call center environment, combined care management (utilization review) and pre-registration/verification/authorization functions.

The emphasis, he adds, would be to ensure clinical and financial clearance of all patients, and to "thrust this function out to the community." In the past, most of the intake process was unplanned, resulting in large numbers of patients literally waiting all day for services.

This was not only a customer satisfaction issue, but a capacity management issue, Woerly explains. "The future state plan calls for scheduling financial counseling appointments for unfunded patients, as well as deploying a deny/delay policy for non-emergent, elective cases."

3. Enhancing time of service collections through the education and communication of patient liabilities (copayments, deductibles, co-insurances, deposits and outstanding balances) at every point of contact — scheduling, financial clearance, registration, financial counseling and at the point of service.

An analysis was conducted to establish goals, reports were designed to provide feedback, and training was conducted for more than 650 people.

(Editor’s note: Patti Daniel can be reached at John Woerly can be reached at