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As part of its ongoing reinvention of access services, ScrippsHealth in San Diego has created RAVe Center, which consolidates registration, authorization, and verification functions and removes them from the distractions of the front line.
The small "e" in the acronym indicates the work will be done via e-commerce, explains Norma Pearce O’Toole, manager of the center, and plans are to extend the RAVe Center’s role even into the emergency department (ED).
The RAVe Center staff, she says, will be responsible for preregistering all patients, identifying any authorization or precertification needs, verifying eligibility, and determining how much the patient will owe out of pocket for the service being provided. (See flowchart.)
Source: ScrippsHealth, San Diego.
"The problem, we have found, has been that registration personnel, due to the demands of the facility, are pulled away from their primary role of registering patients to do other duties," Pearce-O’Toole says, such as providing customer service or supporting clinical staff. Under the new arrangement, the RAVe Center staff will be located in Scripps’ patient financial services building, away from the daily pressures of the admitting/registration office, she explains.
Its staff will make payment arrangements — or at least give an estimate of the cost, depending on the patient’s benefit plan — before he or she even arrives at the hospital, Pearce-O’Toole says. "The focus is [for the patient] to pay at that point," she says, whether by credit card, an electronic check from the patient’s bank account, or through a payment plan with the hospital.
The RAVe Center pilot program was in the radiology department of one of Scripps’ facilities, and that focus will continue as the center gets up and running this month, she notes. "Green Hospital radiology department performs about 300 services per day, and with that volume, we don’t have the staff to perform this [preregistration] function in its entirety," Pearce-O’Toole says. "That’s why we chose it [for the RAVe Center debut], to have the greatest impact."
The largest impact, she adds, is expected to be on the rate of claim denial. Because prior to the center’s creation, there was no one in that radiology department to verify insurance eligibility, make sure the proper authorization was in place, or determine benefits and patient out-of-pocket costs, the gains in those areas will be significant, Pearce-O’Toole suggests.
Although it’s starting out small, the RAVe Center ultimately will support all the departments in Scripps’ five hospitals, including the ED, and will operate 24 hours a day, seven days a week, she says. The full rollout of the program is expected to take about a year.
"We have determined that the more electronic enablers we have, the more successful the process will become," Pearce-O’Toole notes. "We want to build an electronic database to hold all the benefit plan information so that we may access these easily to determine the patient’s out-of-pocket responsibility. Everybody has a benefit plan code. Some have a $200 deductible, some have a $500 deductible, some have 20% coinsurance. We will obtain all that information from the carriers and load it into the database."
With that information at its disposal, the RAVe staff can run queries on each service, and inform patients of their copay or uncovered cost, she adds. "We currently don’t have that level of detail available electronically for all of our health plans, so we have to make some phone calls."
The e-commerce feature of the RAVe Center will facilitate extending the process to the ED, Pearce-O’Toole says, but patients’ rights under Emergency Medical Treatment and Labor Act regulations will continue to be protected. "We hope that when the patients are triaged, they will give the nurse their name, date of birth, and Social Security number," she explains. "That information, in electronic format, will be sent to the RAVe department. It will do an inquiry as to what insurance they may or may not have and, if there is a match, will determine what copayment that patient will owe." Before that patient leaves, Pearce-O’Toole says, the RAVe staff will have informed the ED that the patient, for example, owes $50.
Scripps has a team working to ensure that the confidentiality of patients’ medical information, as provided for in the Health Insurance Portability and Accountability Act of 1996 privacy standard, also is safeguarded, she says. They will be feeding information back to the RAVe team regarding the standard, which becomes effective in a little under two years.
Enhanced customer service is another RAVe Center goal, Pearce-O’Toole notes. "Historically, when the patient comes in, [he or she] is not even aware of what the out-of-pocket costs will be," she points out, and hearing that information at the point of service may be disconcerting. "The RAVe Center will address those expectations before the patient is even seen."
Additionally, she says, the RAVe Center staff will answer any questions regarding the logistics of the visit, providing such information as directions to the facility, where the patient should park, and how much it costs. The calls made to patients also serve as reminders of the appointment, Pearce-O’Toole adds. "We currently have a large no-show rate."
The largest obstacle to putting the RAVe Center in operation has been obtaining the consensus of physicians and department administrators on the necessity of getting authorization before services are rendered, Pearce-O’Toole says. She cites a typical scenario:
Currently, the physicians send over a patient, a walk-in, to have an MRI (magnetic resonance imaging) with no authorization, she says. "[The physician] has requested the authorization from the insurance or the [management services organization], but hasn’t received it. The physician still wants the patient to have the MRI, so as a courtesy we perform it, but if we don’t get the authorization, we don’t get paid."
To make the new system work effectively, Pearce-O’Toole notes, "we have to gain the administrators’ and physicians’ [cooperation] to say we are not going to perform services without authorization." It’s a customer service issue as well, she says, in that staff at times may inform patients that the service they are about to have may not be covered and ask them if they are willing to take responsibility for the cost. Those patients, Pearce-O’Toole adds, may be asked to sign a noncoverage waiver.
[For more information, contact Norma Pearce-O’Toole at (858) 657-4091 or by e-mail at pearce-o’firstname.lastname@example.org.]