Access managers share preregistration practice

In the June Hospital Access Management, Liz Kehrer, CHAM, manager of patient access at Centegra Health System in McHenry, IL, sought feedback from her peers at other health care facilities on their preregistration practices, with the goal of improving Centegra’s performance in that area.

Kehrer heard from Marne Bonomo, PhD, RN, director of patient access at Clarion Health in Indianapolis, who was seeking similar information on behalf of the University HealthSystem Consortium, to which her hospital belongs. Kehrer and Bonomo describe their own operations and pass along some responses they received from these access managers:

M. Holly Hiryak, director, hospital admissions, University of Arkansas for Medical Sciences Medical Center, Little Rock;

Mark A. Underberger, financial arrangements manager, admissions, Shands at the University of Florida, Gainesville;

Diane Shebelski, manager, patient registration, central scheduling, Wausau (WI) Hospital;

Marjorie Sisson, director of transition management, University Medical Center, Tucson, AZ.

We just succeeded in creating a career path in patient access. We’ve been experiencing turnover and recruitment difficulties due to the low unemployment in the county and competition with customer service positions that do not include weekend work. We have a new patient access trainer who is responsible for quality assurance and training for the system. I’m also trying to get approval for a coordi- nator/supervisor at each hospital. It has been so difficult trying to balance two campuses’ operations, plan for the future, recruit, counsel, etc.

Centegra’s staffing levels

We have admission counselor 1, which is the entry-level position. The next step is admission counselor 2, which includes the more sophisticated registrations and easy financial information (payment plan options).

Then we have admission counselor 3, which covers preregistration. These are the most sophisticated registrars, whose role includes calculating patient share, financial counseling, payment arrangements/collections, and advance beneficiary notice screening.

The financial counselors and insurance verifiers report to me. The financial counselor is in the main hospital to provide bedside counseling for patients who were not preregistered. The insurance verifier is part of the preregistration team. We will be starting to collect copayments, deposits, deductibles, and co-insurance. I’m seeking advice from someone who may be further ahead in the process who can share what worked well and what didn’t and how we can make our transition smoother and not alienate or upset our customers in the process.

What I envision for the preregistration team is this:

1. The preregistrar will register scheduled patients, including obtaining insurance information.

2. The preregistrar hands off to the insurance verifier, who reviews and obtains benefits, calculates patient share, and forwards the information to the originating preregistrar. Accounts with verified benefits would not require a copy of the insurance card on the day of service.

3. The originating preregistrar calls the patient for financial counseling and payment collection (credit card via phone) or arrangement.

4. The account is documented for the patient’s arrival. The preregistration team will be off campus in another building.

Liz Kehrer

I have requested in the capital budget:

• a forms writer to allow remote form printing;

• an on-line insurance eligibility system to provide expanded benefits information, which will improve financial counseling;

• a radio frequency upgrade in the emergency department for connection to the main computer system;

• portable personal computers to allow emergency department bedside registration in the system.

The on-line insurance eligibility system executes a benefit search during the registration process to expedite the process without increasing full-time equivalents (FTEs).

We are centralizing preregistration for our three hospitals and moving all necessary expertise to the front of the registration process. We would like to preregister as much as possible and make registration a formality for obtaining signatures and copies of insurance cards, wherever possible.

Marne Bonomo

We want our registrars to have the ability to provide insurance benefit verification. Financial counselors will move up front except for a small complement of people who actually set up payment plans for self-pay patients and enroll eligible patients into government plans.

We are centralizing our training program, working on a patient access career ladder. We hope to stimulate organizational change in pay practices and reward and recognition to improve retention of the best and brightest.

We also have tightened our requirements for employee applicants. What are your requirements? We are in Indianapolis and are having a staffing crisis along with all of our competitors. Turnover is high and applicants are scarce. Our competitors have actually disbanded their training unit and placed all support staff in registration positions to fill vacancies.

Does anyone have centralized preadmission and/or upfront insurance verification? Where do your financial counselors report? What are their responsibilities?

If you have recently implemented changes or improvements in your registration/preregistration/insurance verification, what did you do, and why? Do you collect copayments upfront?

M. Holly Hiryak

We preregister about 400 to 500 patients a month. I have 1.8 FTEs totally dedicated to the process. We do not have any type of on-line insurance verification, but we do call for benefits or check the Omnipath prior to making the preregistration call. Patients are informed of any deductibles, copays, etc., and are expected to pay when they present for admission/surgery. Our facility never collected upfront prior to this, so we continue to educate patients to the process.

One preregistrar works 7:30 a.m. to 4 p.m., and the other one works 11 a.m. to 8:30 p.m. The early person contacts primarily the Medicare population, while the other one concentrates on all others. We discontinue calls at 8 p.m. because we get complaints if we call after that time.

We are beginning to see staffing/recruitment problems, and we have tightened our entry-level requirements — basics like keyboarding. We still have centralized training but are struggling with the content and qualifications of trainers. I have submitted the beginnings of a three-level job description to our human resources department in an attempt to begin developing a career ladder. I would like to someday develop an "access specialist" training curriculum, but I never seem to have the time.

I envision including, of course, the basics of registration and coding, extensive insurance and managed care training, financial counseling, and dealing with the public in general.

Through process redesign a few years ago, all of our frontline staff were cross-trained to perform all functions. I have no problem with this concept. I just don’t think we have adequately prepared staff. I would be interested in any of your findings.

Additionally, if you are interested in developing some kind of "access specialist" curriculum that could be marketed nationally, let me know. Other specialists, such as coders, do this with some degree of success.

Mark A. Underberger

Shands currently has separate registration at all hospitals. There may be some value in centralizing when we are all on the same computer system. At the University of Florida campus, all registration is centralized under the admissions department. There are three major areas: inpatient/ surgery, emergency department, and outpatient services.

All staff have a set of financial counselor responsibilities. We do not have just self-pay people. Insurance verification and precertification are done whenever possible, and copayments are collected or otherwise arranged for in all areas. We currently collect about $3 million a year from patients at point of service.

Diane Shebelski

Registration is centralized in our hospital, and we have three areas within the registration department — registration, preregistration, and insurance verification. We preregister 95% of all scheduled patients, who are scheduled through our central scheduling department. Patients present to their point of service the day of the test or procedure, and staff in those reception areas take the account from a pre-status to a billing status and have the patient sign the agreement for service.

The insurance verification area verifies all day surgeries, magnetic resonance imagings, heart catheterizations, angiograms, cardioversions, myelograms, sleep studies, and IPs. Registration does not collect a copayment. It does, however, take copies of cards when possible. We are developing an insurance card file for each area to reference, which is especially helpful when preregistering by phone.

We also have a strict performance audit report, which is distributed monthly to all staff. Indicators are as follows: Medicare secondary payer completion, scheduled patients vs. preregistered, registration accuracy, patient satisfaction survey, and insurance verification accuracy.

All staff are cross-trained in each area and are expected to rotate on a month-by-month basis. Patients welcome our process because they don’t need to stop in registration the day of their test or procedure.

Marjorie Sisson

We’re working on an on-line eligibility verification system. The requirement is 100% eligibility and verification. Our registration staff are centrally managed and located in various areas of our institution, such as admitting, the emergency department, outpatient, and physicians’ offices.

We have a central training program with one full-time trainer and a trainer/registrar in the emergency department and are working toward an admissions coordinator/trainer. We lost one trainer in a cost-reduction effort. We’re developing a ladder on which staff are classified as I, II, or III. You cannot become a II unless you’ve worked as a I for one year and demonstrate the skill competency and values at a specific level. Our minimum hiring requirements are three years billing or registration experience.

Our staff are completely responsible for all unbilled accounts receivable. Once we’re done, coding/charge entry takes place at the point of service, and the claim drops. In some cases, we’re coding the charges. We have become very aggressive in collecting copayments upfront. We also are developing systems for handling ambulatory payment classifications and a pre-service module for advance beneficiary notice. We are working on enhancing the Medicare secondary payer questionnaire to make it more user-friendly for patients and staff.

[If you would like to provide feedback on this issue, Kehrer can be reached at Centegra Health System, 4209 Medical Center Drive, McHenry, IL 60050. Telephone: (815) 759-4061. Bonomo can be reached at Hiryak can be reached at HiryakHollyM@exchange.

If you would like feedback from your peers on any access issue, please contact editor Lila Moore at (520) 299-8730 or]