Innovative system decreases denials and increases upfront collections
Carolinas HealthCare System in Charlotte, NC, regularly preregisters between 96% and 98% of its scheduled patients — while reducing denials and accounts receivable (AR) days — thanks to an innovative and ambitious pre-services department that serves four acute-care facilities.
In addition to handling preregistration, insurance verification, and nonclinical authorization for inpatients and a large outpatient population, the pre-services unit — located in an off-site office building — also does upfront cash collections, reports Lisa Grodevant, CAM, assistant vice president of patient registration. After verifying insurance for the patient who has just been preregistered, pre-services staff call the person back, explains Grodevant, who oversees registration for Carolinas Medical Center, the health system’s 795-bed flagship facility. "They say, We verified your information, and your copay is this amount. How would you like to pay?’"
Patients may give their credit card number or use an on-line check system, she says. For five of the first six months of 2004, monthly upfront collections by the pre-services staff have exceeded $120,000, Grodevant adds.
Annual upfront collections — including cash collected at all the system’s points of service — totaled just under $6 million in 2003, up from some $70,000 annually when the collections effort began 4½ years ago, notes Katie Davis, CAM, who also is vice president of patient registration, and has responsibility for the pre-services area and the system’s other three acute-care facilities. While the pre-services staff have a goal of having preregistered at least 94% of the patients scheduled for a procedure the next day, she says, "we have been exceeding that. We’re usually at 96%, 97%, or 98%."
Managers monitor the percentage of scheduled patients preregistered for days one through five (before the service), and then for those preregistered on days six through 10, Davis adds. (See charts for five days out and next day.) "The schedules are very dynamic," she explains. "Any schedule is subject to add-ons. Registration staff at the [four hospitals] depend on the pre-services department to get the work done for them. We don’t have staff at the facilities to handle preregistration."
Staff pull schedules frequently to make sure add-ons are caught in a timely fashion, Grodevant points out. "We check the schedule today for [add-on] patients coming in later this afternoon, and for the next day. That has helped our percentages go up in the past month."
While the goal is to have at least 50% of registrations done in week two before the procedure, she adds, "We’re usually running above that — at between 70% and 80%. A lot of streamlining with reports and processes has helped."
Dramatic improvements in the system’s revenue cycle in the past four years, particularly the increase in upfront cash and an 86% decrease in net denials, are largely due to the efficiencies of the pre-services department, Grodevant notes. (See revenue cycle chart.) "When we started our pre-services department four years ago, as with any new process, we ramped up staff," Davis says. "At one point, we had close to 70 people in pre-services. We also were doing a lot of things manually — making a lot of calls to insurance companies, then turning around and making another call for clinical authorization."
Over time, the unit — which now has 56 employees, including two managers — has gained efficiencies, benefiting from, among other things, an on- line eligibility system that connects with seven different insurance companies, she reports. "For those that are not on that system, we get a lot of information from web sites."
In another timesaving move, the pre-services department worked with Carolinas HealthCare’s managed care department, which negotiates payer contracts, to have a list of services that require authorization put on the health system’s intranet, Davis adds. Because of the resulting increase in accuracy and efficiency on the front end, there is less work on the back end, she points out. "Patient accounting has been able to reduce or reassign staff," Davis says. "They’ve brought some of the things they had outsourced, such as working returned mail, back in-house."
It’s hard to do a before-and-after comparison on the number of accounts preregistered, Grodevant notes. Before the establishment of the pre-services department, she adds, there was some preregistration activity and some authorization of high-dollar surgeries, but it was spread out and was done by different groups of people at each facility.
"We took the preregistration [function] from each facility, centralized it, and pulled it into one freestanding building that is totally separate from our other facilities," she says. Centralizing the process, Grodevant notes, has made possible a very refined level of specialization. An employee who has extensive experience in getting radiology procedures authorized, for example, can do that for all the hospitals, she adds, rather than having one person at each facility who must have that expertise.
While moving staff from four different facilities to one big building in an office park posed an initial hurdle, Davis says, "the staff who are out here really like the office environment where their only contact with patients is by phone. When we hire, we try to find somebody who fits the job. Some people really enjoy the pace [of the hospital setting]."
In September 2003, she adds, three of the pre-services employees agreed to move even farther from the typical work setting by becoming part of a telecommuting project that continues to expand. One of the technological innovations that has been particularly effective for the pre-services department, Davis says, is an on-line "admission log," or work list, that is used to communicate with other areas of the health system. "We work hand-in-hand with clinical care management [CCM], which is what we call our case managers," she points out. "When we make that first nonclinical authorization call, and the insurance company [representative] says, I can give you a reference number, but we need this clinical information.’"
To get those answers, Davis explains, pre-services staff communicate directly with CCM staff by putting the patient’s information on the on-line admission log, which can be viewed on the computer screen. "We say, Here’s the clinical [issue], and here’s the number you can call,’ and they work that in real time."
"If they send us something back, we get on it quickly," she adds. A color-coded system helps indicate the priority that should be given to each item. "We can put in stat’ if we need it right away."
Because the on-line admission log can be customized, pre-services staff also use it to communicate with the health system’s financial counselors, Davis notes. If, for example, outdated insurance information was given at the time of a patient’s admission, she says, the financial counselor may discover the account actually will be self-pay after going to the patient’s room to do an interview. "When the financial counselor gets that information, she puts it onto the admission log and shoots it over to us," Davis adds. Conversely, if the financial counselor provides information that the pre-services staff determines to be inaccurate or outdated, they communicate that back to the financial counselor via the same log.
"We send a message saying, This insurance is not effective. Can you talk with the patient?’ It’s a real good communication tool." While this back-and-forth communication could be done in the past by email, the beauty of the online admission log is that it is not dependent on one person checking his or her messages, Grodevant points out. "Everybody has access to the same list, so the next person available can take that message. It’s just getting it done that much faster."
The department’s managers have access to all the different logs — whether for care management, financial counseling, or insurance follow-up — so they can monitor them to make sure issues are being resolved in a timely manner, Davis adds.
The on-line admission log originally was developed by the information systems staff for use at the system’s individual hospitals so that nursing units could communicate with the admissions department without picking up the phone, she says. "Then somebody out here said, Why can’t we use that as a tool for pre-services as well?’"
At the smaller hospitals, Davis notes, if there is a patient in observation who needs to be admitted, a nurse enters that information on the log, which eliminates the need for a phone call. A registrar then pulls the account and changes the patient’s status from observation to inpatient. "It’s also a good tracking mechanism," she says. "Carolinas Medical Center is a big facility. Patients will come in and say, I had to wait three hours.’ We can look and see where the breakdown was. We can see what time the registrar went in and took that task, and what time she completed it."
Similarly, Grodevant notes, the hospital admitting departments can use the log to track productivity — how many tasks a person did on a given day — in the inpatient area.
Another important function performed by the pre-services department is the rescheduling of procedures for which authorization cannot be obtained, Davis says. "If we haven’t gotten an authorization 72 hours before the service, we send that patient’s name, account number, and information [to the appropriate department]," she explains. "For example, if the patient is scheduled for surgery, we send [the information] to the operating room scheduling area. They call the physician’s office and say, We don’t have an authorization at this time."
The physician’s staff may say they’re in the process of getting the authorization, or have just gotten it and will send it over, or that they’re having trouble getting it, Davis adds. What happens next is always the physician’s decision, she emphasizes. "We may ask, Do you want to reschedule until we have the opportunity to get the authorization?’ If it’s urgent, we do it — no questions asked — but if we can wait till next week, we do."