3-team outpatient process generates quick payoff

Registration flow is unimpeded

When the University of Pennsylvania Medical Center-Presbyterian in Philadelphia transformed its outpatient registration staff into three teams, each with a specific task, the benefits were apparent immediately, says Raina Harrell, business administrator for patient access.

What existed before, she explains, was a typical outpatient registration area that handled scheduled and nonscheduled registrations, called for referrals and pre-certification if needed, and sent people to the appropriate areas to have their services. "What was happening, is that [staff] didn’t always know when a pre-cert was required, and we were getting a small percentage — less than half — of accounts preregistered," she notes. "So we had patients coming in for high-dollar MRIs [magnetic resonance imaging] and CAT [computerized axial tomography] scans, and they were not preregistered for services," Harrell adds.

Registrars who are busy dealing with the flow of patients sometimes allowed the authorization calls to slip through the cracks. If they did interrupt the registration process to make a pre-cert call or obtain a referral, waiting times often increased, she adds.

Attacking the problem

Although the hospital did not track outpatient denials, Harrell says, "we knew our outpatient accounts receivable [AR] days were very high, so we wanted to reduce [that number]."

With an eye on reducing outpatient AR days by boosting the number of preregistered accounts and making sure they are 100% secured, Presbyterian divided the 12 outpatient registrars into three groups, as follows.

1. Preregistration team: These four employees are focused solely on calling patients and getting them preregistered for services, with the objective of working five business days out.

2. Registration team: These five employees only take walk-in patients, those who come in for an unscheduled laboratory and radiology procedure.

3. Verification team: These three employees take care of pre-certification and verification issues for preregistered patients and check the insurance for every walk-in patient to see if a pre-cert, copay, or referral is required.

"We now have verification in the middle [of the process]," Harrell says, "and we’ve also put a verifier with the registrars. If anyone walks in and their insurance requires a referral they don’t have or additional documentation, the verifier can make the phone calls so the registrar does not have to slow down the process."

The reason the registration team has more employees is that in some of the ancillary areas covered by outpatient registration, the registrars perform both registration and preregistration functions, she explains.

Success was immediate

When the hospital went live with the new process in mid-February 2005, it was a success from Day One, Harrell says. "It went marvelously. We had extra management on hand in case [team members] didn’t know what the next step should be — they were so used to doing it all — but [the team members] didn’t need the assistance," she explains.

Patients experienced waits of only between 7.5 and 12 minutes during most of that first day, she explains, and when the process slowed down a bit at lunchtime, the longest anyone had to wait was 20 minutes. In the past, waits during busy times could average between 23 and 28 minutes, Harrell adds. The outpatient employees, most of whom have been on the job five, 10, or 15 years, are happy with the new system, partly because "there had never before been this much of an overhaul without staff reduction," she notes.

Employees also were delighted to have played a part in the design process, Harrell continues. "Management did the model, but we let [the employees] work out the details of the flow of information," she explains. "They were involved in the weekly meetings that we’ve implemented to talk about the process [and] any glitches we might run into."

Weekly meetings regarding the process are ongoing, Harrell says. "On Tuesdays, I meet with the outpatient manager and supervisor and the departmental manager for quality and training to talk about the previous week — the statistics and the areas for improvement."

Outpatient staff divide into two groups and attend Wednesday meetings where managers go over the past week’s results with them and talk about training initiatives, she adds. "We keep these meetings to a half-hour, so they move quickly."

Working through the process

Harrell, with the help of Portland, OR-based revenue management consulting firm Stockamp & Associates, is in the process of designing a statistical report that will provide data on how many patients come in, the percentage of scheduled vs. unscheduled patients, how many accounts were pre-verified, and so on, she adds. In fact, she explains, Stockamp facilitated the entire process of moving to the three-team model — doing flowcharts, organizing meetings, and helping hospital staff work through the different steps. (See Cash Central Flowchart.)

Cash Central Flowchart

"We were using [the company] in inpatient insurance verification and the business office with revenue-cycle improvement functions," Harrell says. "They have a tool — a work driver — that takes a download from our billing system and prioritizes and distributes the work to our inpatient verification team.

"Normally, Stockamp doesn’t go into the outpatient area, but we asked them to assist us there," she adds. "We did the design, and they helped us implement it. Using their knowledge, we did a homegrown version of [the work driver], with reports from our computer system."

The statistical report, meanwhile, will assist in holding team members accountable for how they perform, Harrell notes. "There are expectations — for example, a certain number of preregistrations that have to happen per hour," she says. Drawing an example from the inpatient side, an inpatient team member might be expected to enter 50 reservations from a physician’s office in a day. If the person does 40, the number will be "4," which is added to a number indicating whether the person met the expected accuracy level of 95%, adds Harrell.

While the departmental trainer still is determining what that number will be for the outpatient team, the system will work much as it does in the inpatient area, where each team member gets a number indicating the quality of their work and another representing quantity, she says. "We’ll put those together to get each person’s [score] for the week."

Harrell says she is pleased with the outpatient redesign and anticipates further improvement. "This is just the beginning of the project. We are looking forward to even more positive results."

[Editor’s note: Raina Harrell can be reached at (215) 662-9295 or by e-mail at raina.harrell@uphs.upenn.edu.]