Revenue integrity team adds rounds, web training

Accuracy on steady climb since 2000

The University of Arkansas for Medical Sciences (UAMS) Medical Center in Little Rock has been on an upward trend in registration accuracy since 2000, thanks to continuous tweaking of its education program and improved auditing methods by the access department’s revenue integrity specialist (RIS) team.

Registration accuracy is at about 85% now, up from less than 10% in 2000, with a peak score for 2005 of 87%, says Holly Jones, CHAM, revenue integrity specialist. “Our goal is 90%.” The latest improvements, she says, include the institution of “RIS rounds,” with regular face-to-face audits of access personnel and on-line modules to more efficiently ground staff in the definitions and background part of access training.

With the RIS rounds, team members have adopted a standard practice of doing site visits — at least twice a month — with the employees whose outpatient registrations they are auditing, Jones adds. “That seems to open people up to ask more questions,” than if the communication is by telephone or e-mail. It takes each RIS team member no more than about a half-day to do the face-to-face audits, she says, with each of four staff members auditing between four and 10 employees.

A fifth RIS team member is not part of the rounds, but works at home, completing more than 900 inpatient and emergency department (ED) audits in a 20-hour week, Jones explains. “We just added 10 hours to her schedule, and now she is helping create a fourth day of training.”

Central admissions and the ED have their own precept and one-on-one training process, headed by an education coordinator, she notes, but the RIS department provides the audit feedback for those areas. Of the five RIS full-time equivalents, two people audit and train, while the other three do only audits, including the RIS rounds, she notes.

Although inpatient and ED registrations are audited every month, because of the volume and high-dollar accounts, audits of outpatient areas are done randomly, Jones says. “The clinics are numbered one through 38. We plug those numbers into a randomizer web site, and it spits out what we will be doing that month.”

RIS team members audit anywhere from 20% to 100% of an area’s registrations based on monthly volume, she explains. “We used to do 20% across the board, but we found that with the smaller clinics, there could be only 10 or 20 accounts in a month’s time. If there were two errors, that would cut the accuracy rate to 80%, so we wanted to make the process a little fairer for our smaller clinics.

“So now if the occupational therapy clinic is pulled up, for example, every registration gets audited,” she adds. “For a larger area, like our cancer center, we will stay at 20% or 25%.”

The RIS team member working from home, Jones notes, has been auditing 50% to 60% of the inpatient and ED accounts. Recently, she says, the decision was made to drop that percentage to roughly 15% on straight ED accounts. “The average monthly [ED] volume was huge, and a lot of those are self-pay accounts, so there wasn’t a lot of [registration] information to look at. Even at 15%, that’s 265 accounts.”

The audit process is manual, she says, and is “basically a quality review of that registration to make sure that all the information to make a billable claim is put in correctly. [The auditors] also check the insurance piece, comparing what’s in the registration system to what’s in the electronic patient folder.”

The electronic patient folder, Jones adds, is a program the hospital purchased three years ago that is “basically an electronic medical record.”

“There are certain views specific to business functions that all registration staff have access to,” she explains. “They can look at an insurance card on-line, so they don’t have to keep making copies if the person has been in before. They can ask, ‘May I see your insurance card?’ and then compare it to what’s in the system.”

The three on-line training modules have enabled the team to reduce two full days of training to two half days, thus cutting down on the time employees have to be away from their positions, she says. “Everyone seems to be short-staffed, so now they can let [staff] go for a half-day, knowing they’ll be back at work for the rest of the day.”

After the initial computer training, new registration employees do the first module on their own, and then have the first half-day class, Jones says. In that class, they learn the why behind the way they’ve been taught to enter the data, get a look at different forms — such as consent forms and living will documents — and are given other general knowledge of their role as access employees.

The second half-day class, she adds, is an overview of all the different types of third-party payers the employee will encounter. “Then [the new employees] have a 60- to 90-day window, where they’re working in their departments,” Jones continues. “We hope they’re working with a preceptor, but that’s up to the department managers,” she says. After that, the employees come back for a third day of training, Jones notes, which is an in-depth look at the third-party payers they were introduced to earlier, including Medicare, Medicaid, other government insurers, and a full range of commercial payers.

The RIS team is in the process of creating a fourth day of training, Jones says, with more emphasis on precertification, preauthorization, insurance verification, and other financial aspects of the job. As the rate of registration accuracy has climbed, Jones notes, so has the number of education hours provided to access employees.

The efforts of the RIS team also have been tied to increases in hospital revenue and collections. (See charts.) “We work closely with our hospital and physician billing departments,” she says. “We have a document called ‘Error Criteria,’ which are guidelines on registration that we use to audit and that registration staff use as a toolkit as to what constitutes billable errors, those that will stop payment of a claim, and nonbillable errors.”

The billing departments approve those guidelines, Jones says. In addition to the training for new employees, she adds, the RIS team provides monthly inservices, about an hour in length, on such topics as “Denial Reports and How Registration Impacts Them” and “How to Handle Foreign Self-Pay Patients.”

To further improve registration accuracy, the team is looking at ways to take access to accounts away from new staff who haven’t been through the RIS training within a set time. In the extremely decentralized UAMS environment, Jones explains, some employees who perform registrations do not report to access management, and are on the job after their initial computer training.

“Even as recently as a couple of weeks ago, we were dealing with a lot of accounts where there were major errors with simple fixes,” she says. “We saw that they were from people who hadn’t been through our training.

“It’s a flaw in our system right now that [new registration employees] are able to get technical security access without having to go through [RIS training]. We are trying to track new employees now so we can catch those people.”

Part of the challenge is that all of the outpatient clinics have their own managers who report to outpatient administration, “so we’re dealing with several managers,” Jones adds. “The outpatient administrator has been very helpful with that.”

[Editor’s note: Holly Jones can be reached at (501) 526-7794 or at joneshollyr@uams.edu.]