Carole J. Bolster

The beginning of the revenue cycle is getting a fresh start as healthcare financial managers apply technology and process improvement to patient access.

At a Glance 

  • Technology and training are driving patient access improvement today. 
  • Although revenue cycle leaders face many of the same challenges they have dealt with in the past, technology is enabling them to work far more efficiently. 
  • Staff education boosts performance, and new training techniques use technology. 

Healthcare financial managers are in the business of caring. They must manage the business side of healthcare to help their organizations fulfill their caring mission. One vivid intersection of business and caring is the patient's initial encounter with a hospital at scheduling or registration. At this point, the hospital sets the tone for the patient's experience, the patient forms impressions of the hospital, and the revenue cycle gets under way.

The start of the revenue cycle-so critical to patient satisfaction, patient care, and appropriate payment-is getting a fresh start at some healthcare organizations. Scheduling, registration, cash collection, workflow, and staff education all are benefiting from savvy healthcare financial managers who are employing technology and process change to improve this crucial aspect of the business of caring.

Centralized Scheduling

One way that hospitals get the revenue cycle off to a good start is to make registration part of scheduling. For example, The Memorial Hospital in North Conway, N.H., has found that registering patients when they schedule services allows its patient access staff to work more efficiently and benefits both the healthcare organization and the patients.

"A lot of people say registration is the beginning of the revenue cycle, but in truth, it isn't. Scheduling is the beginning of the revenue cycle," says Jeffrey W. Shutak, CHFP, the hospital's director of patient financial services.

The hospital recently implemented a centralized scheduling/registration section as a subsection of its department of registration. Initiating patient registration at the time of scheduling saves time and is more user-friendly for patients, because they spend less time waiting in the lobby and don't have to repeat the same information to several different people, a chief complaint of patients. A byproduct of the process change is that the hospital is undertaking a $17 million remodeling project that will shrink the registration/lobby area and expand the hospital's square footage in ancillary service areas, such as laboratory and radiology.

Centralized scheduling is also part of revenue cycle improvement at The Carolinas HealthCare System, Charlotte, N.C. Carolinas has implemented an electronic centralized scheduling process that eliminates much of the manual work done previously.

"Working with our information systems department, we were able to develop a clinical and preservice scheduling module, which allowed us to take five different manual paper systems and condense them into one electronic scheduling system," says Christopher Johnson, FHFMA, Carolinas vice president of patient financial services.

The Carolinas scheduling system isn't completely centralized. A surgery suite that already had a scheduling module, for example, continues to use it. The organization's preservices division still has to use three different scheduling modules to register patients, but the automated tool allows the preservices staff to view the scheduling information and then pre-register patients.

"For us, that was a big win," says Johnson. "It was an easy module to build."

Wireless Registration

Another technology innovation at The Carolinas HealthCare System is a wireless patient registration process that allows registrars to enter patient information, scan insurance cards, verify the information, and collect co-payments and deductibles at the bedside.

"We have been registering patients at the bedside for a few years, but the process was performed manually," says Johnson. "We recently implemented the wireless registration process, and it's a huge improvement. We expect to be able to register the same number of patients with fewer FTEs, so there's going to be an FTE cost savings in the patient access area. Also, we should see higher patient satisfaction scores, because bedside registration is performed in one step rather than several trips back and forth by the registrars. A key driver for us is that our patient satisfaction scores continue to go up."

One thing the wireless patient registration process doesn't do is allow patients to sign forms electronically. Registrars still have to print forms such as consent for treatment and authorization for payment and have patients sign a paper copy. Then the copy is scanned into a document imaging system and added to the patient's electronic record. That's about to change, however. The health system plans to have keypads available soon that will allow patients to sign electronically for treatment or payment authorizations. When a patient electronically signs a consent form, it will automatically pass to the document imaging system, eliminating the scanning process and all the paper currently used in that process.

Carolinas also plans to implement an electronic patient check-in process. Patients will use an electronic tablet instead of paper copies of registration information to check for accuracy. When patients verify that the information is correct, the technology will notify the clinical staff that the person has an appointment and has checked in and that the information has been validated by the patient.

"Our goal is to have kiosks for patients so they can check themselves in electronically," says Johnson. "If you check in and say you've previewed the information and it is correct, you hit enter and you won't have to talk to a registration person. That's going to be very neat."

Automated Insurance Verification

Verifications are an essential part of patient access. If patient demographic and insurance information is not complete and correct, claims may be denied and payment will be delayed. HCA, based in Nashville, Tenn., is implementing automated eligibility tools to assist its insurance verification process.

"We had tried implementing automated eligibility five or six years ago without much success, because the payer community was not producing enough data in an automated format to keep us from having to make phone calls to get the rest of the information we needed," says Lisa Summers, chief operating officer of HCA's Financial Services Division. "As many major payers have evolved, they are doing a much better job of getting us better data, so we are now using automated eligibility in some of our facilities. When we enter a patient's insurance information at registration, the technology sends a query to the payer's database or web site and automatically returns the information to the registrar. This allows registrars to know what additional information they need to discuss with the patient. Some of the issues we are able to address through this process are identifying incorrect insurance information, identifying that the service being provided is not covered, and determining what out-of-pocket expenses are expected so that we can collect a deposit prior to services being rendered."

She adds, "Some payers are much more sophisticated than others, so you can't use this technology with every payer. But it does assist us with some of our major payers.

"Benefits of automated eligibility include having the right information at the start, being able to collect more money up front, and knowing that the organization is going to bill the right party the right way, therefore getting paid faster. It also reduces your cost associated with outbound calls to the insurance companies, which in many instances results in nonproductive time holding for an insurance representative," according to Summers.

Improved Cash Collection

Technology also is helping healthcare organizations with up-front cash collection-a particularly problem-prone aspect of the revenue cycle. HCA is using a web-based up-front payment estimator to help registrars know what deposit to ask patients for. The tool also provides data related to the service the patient is going to have performed, such as a lab test or same-day surgery, and stores historical charges for those types of services for others in their category, such as age. The registrar can see who the patient's payer is and what HCA's payment arrangements are with that payer and estimate the patient's portion of the charges. The tool performs the calculations, reducing the chance of human error that can occur with manual calculations. HCA has just begun the implementation of this tool, but the organization expects to implement it in the majority of its facilities over the next year.

Streamlined Workflow

Technology also is being used to manage overall workflow and productivity in the revenue cycle. One such technology is a rules distribution tool that allows users to set specific workflow rules and priorities, according to Sandra J. Wolfskill, FHFMA, president, Wolfskill & Associates, Inc., Chardon, Ohio. The tool considers the skill sets of staff members who are available to do work and determines where the work should go on a priority basis. Instead of working with paper folders or lists, managers use the tool to assign work as it needs to be done.

The tool allows staff to work on a desktop and then feed data back to the host, regardless of what the host processing system is.

"The workflow technology operates in real time," Wolfskill says, "so it recognizes the need to deal with changes when they happen, not the next time a list is created, as legacy systems do. Whether I'm a financial counselor, an insurance verifier, a pre-registration staff person, it doesn't matter. The technology is there to move work. It exists. It's real. It works."

Wolfskill adds, "There is a finite point at which you can't put human resources into the equation any more, because you don't have the capacity to absorb those costs. Healthcare financial managers need to look outside of core finance areas for their inspiration and innovation, and make sure that within their current processes, they're doing work at the earliest opportunity and eliminating rework. Technology can allow you to do that very easily."

Another example of a workflow tool is a registration patient tracker used by HCA to assess processes, fine-tune scheduling of employees or registration processes, and analyze productivity and performance of individual registrars. HCA began implementing the technology last year and completed implementation in all of its facilities by the end of August.

"We wanted to know whether we had wait time issues in any of our registration areas," Summers says. "Long wait times can cause patients to be late for their appointments or cause customer dissatisfaction."

The major benefit of using the tool is productivity improvement. The tracker monitors patients from the time they walk in the door until they leave the registration area, recording how long each step takes. The tracker also monitors how much time each registrar takes to register patients. Registrars who take longer than average can be coached for improvement.

The registrar can document why a patient's registration may have taken longer than average and why the outliers are being caused. For example, if a patient forgot to bring a procedure order, the registrar would have to contact the physician's office to have one faxed.

"These trackers were developed and integrated within our Meditech Admissions Module. The core functionality is available within the system, and it is a matter of using parameters and reports that we design and implement. It is a fairly easy process to implement, but the trackers provide a lot of benefit," Summers says.


Technology is also being used to make education for front-line staff more accessible and effective.

Some hospitals are using e-learning for staff education. Some use HFMA's e-learning modules, which cover a wide range of topics, including admissions procedures and avoiding claims denials. Other hospitals are developing their own e-learning programs.

"A cool thing we're seeing is intranet-based staff education," says Wolfskill. "It's very hard, especially in patient access, to get all staff in a classroom setting. Some hospitals are taking advantage of their intranet and developing web-based self-learning modules, similar to HFMA's product. As revenue cycle professionals realize, that is a valid avenue for education, and by tying the completion of those modules to performance evaluations, you have a very powerful tool to make sure that your staff stays current and participates in educational opportunities. That's important, because we operate in an extremely complex business, and having that standardized education available to staff is invaluable in terms of getting a quality performance every time."

E-learning is an excellent avenue not only for training the patient access staff, but also for communicating new payer requirements to staff, especially when staff is decentralized throughout the hospital or health system.

Start at the Beginning

Clearer claims up front and less rework on the back end-that's the name of the game. Hospitals are finding many technology-related process improvements that can increase the quality of registrations, which in turn can lower days in accounts receivable and increase the clean claim rate and collections. Using these techniques means hospitals discover earlier whether there is a problem and have time to correct it before the bill goes out.

"So often, finance people tend to focus on billing and collections," says Wolfskill, "but if we don't get the patient access and scheduling parts right, we're not going to get the rest of it right without a tremendous amount of rework, and that costs us money. So the key to making the revenue cycle successful starts at the very beginning."

Johnson agrees: "Patient access is what starts the entire process, so we need to look at how we can give people the tools to allow them to do the job we want them to do. We're putting these people at the front door. We're expecting them to be goodwill ambassadors to make sure the patients have a very pleasant experience. At the same time, we're challenging them to get all the information and get it right the first time. If that is our argument, we need to give them the best tools that are available."

Carole J. Bolster is a senior editor in HFMA's Westchester, Ill., office.

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