Error rates drop sharply with new monitoring plan

Insurance, employer tables redesigned

Plagued with inconsistency and errors in identifying patients’ insurance carriers during registration, and concerned that its new managed care contracting software have accurate data to build on, Southern Regional Medical Center in Riverdale, GA, redesigned its insurance and employer tables and developed its own computer program to monitor accuracy.

Within 30 days of implementing the improvements, the hospital’s error rate for linking insurance to employer dropped from between 25% and 30% to between 1.5% and 2%, says Linda Belgio, CHAM, director of patient registration. More accurate insurance data help the hospital make sure it is reimbursed correctly, especially when complex managed care contracts are involved.

"What we wanted to do was improve the integrity of the information we’re getting, reduce the error rate, and make sure the tool we had purchased, HBOC’s contract management system, worked," Belgio explains. "To make the contracting system work, we had to make sure we picked the correct insurance out of the table."

Through manual accounting methods, she says, the hospital recently had come across $1 million in underpayments covering a period of seven or eight months, the kind of error it hopes the new software will prevent, she says. "It’s like a watchdog to make sure that if you’re owed a per diem of $1,500, you really get paid that amount, and if you have an outlier clause that says you get paid 70% of charges if the patient stays so many days, that’s figured correctly."

The main problem in the registration process was that there was no consistency in the way registrars tied insurance to employers when registering patients. Some registrars, for example, entered "Delta," some entered "Delta Airlines," and some added "Inc." For that reason, it was impossible to pull one list for reporting purposes that would include all the patients employed by Delta Air Lines.

Although the proper procedure was to enter "D" and have the system pull up every employer starting with that letter, some registrars bypassed that step and "free-formed" by entering the entire name. If an employee free-formed, Belgio points out, she had to fill in several lines of information, resulting in more keystrokes than if she used the table, which fills the blanks automatically.

Belgio, the patient registration supervisors, two representatives from patient accounting, and one representative each from management engineering and the managed care department began meeting to come up with ways to accomplish two goals — maximize reimbursement and obtain accurate patient information.

The first step was to rebuild the employer table using only the top 100 employers (according to the frequency with which their employees use the hospital’s services) and numbering them beginning with "600" to prevent confusion with previous lists. To find employers not listed in that table, registrars would key in "999," the code for "not in the table." The 999 designation is used as a monitoring tool, Belgio explains. If an employer occurs in that category a certain number of times, the company is added to the "top 100" list.

Then the insurance table was rebuilt using only the payers which corresponded to the top 100 employers. For example, the Cigna file would include only those Cigna insurance carriers used by the companies in the top 100 employer list.

"Before, if you looked under "Cigna," there would be 500 listings," she notes. "We narrowed it down to only 15." If a Cigna insurance plan was not listed among that 15, registrars would find it by selecting a generic Cigna option. For example, the insurance carrier would be loaded in the table as "Cigna HMO, Delta Air Lines." So if Delta Air Lines wasn’t in the table, the insurance wouldn’t be employer-specific in the table, and the registrar would select the generic plan — the Cigna HMO not tied to a specific employer.

A training program is key to the quality improvement process. All patient registration employees attended two half-day classes held on Saturday mornings, a slow time for the hospital. Using samples of confusing types of insurance cards, instructors went over the proper procedures to follow. "If there isn’t a primary care physician [listed] on the card, consider it a PPO," Belgio explains. "If it does have [a primary care physician], consider it an HMO."

In addition to the insurance drills, classes cover customer service and UB92 codes. After the sessions, employees take "open-book" competency exams using manuals prepared by Belgio, her supervisory staff, and the rest of the committee. "All the information covered in the classes is in the manual," she says. "If [registrars] can’t spell a company’s name and can’t find it in the table, they look in the manual and see what the code number should be. It’s listed alphabetically. For all UB92 codes, there is a matrix that tells which insurances require [codes] for both inpatient and outpatient."

All the codes are listed for CHAMPUS, which requires a combination of four different codes, depending on whether patients are active duty or retired, to which branch of the military they belong, and their rank, Belgio notes.

After successful completion of the class, registrars received pins proclaiming "We Did It!" "They really felt good — the reaction was very positive," she says.

The ongoing success of the quality improvement innovations, Belgio points out, is based on a computer program developed by Carla Phillips, a systems analyst in Southern Regional’s information services department, using Microsoft Access. Information gathered by registrars is downloaded from the hospital’s HBOC Star system into Microsoft Access every night. It takes Belgio about three minutes each morning to download a report to analyze the data, she explains.

"I know exactly who didn’t do what they were supposed to do," Belgio says. "I know if they free-formed, if they left an [incorrect] employer in, or if they put in an insurance that’s been eliminated. Most of the time, I distribute the reports to the supervisors so they can show their employees what they did wrong and how to correct it."

Employees are given two or three chances to correct recurring errors. If they continue to make the same mistake, progressive disciplinary measures are taken, she adds, noting that some people have lost their jobs as a result of errors.

To make sure training is consistent, Belgio recently converted one of her most competent registrars into the departmental trainer. This employee now is responsible for training new hires as well as retraining existing staff and doing spot checks to make sure codes are used correctly.