Donald C. Riefner
Accuracy in pre-arrival revenue cycle functions improves patient satisfaction and produces best-practice financial outcomes.
At a Glance
- UPMC revenue cycle operations analyzed front-end processes to improve them, thereby also improving the patient experience.
- UPMC focused on scheduling, eligibility/insurance verification, and financial counseling to develop an integrated work flow ensuring data integrity and expediting account resolution.
- Automating the processes increased efficiency and reduced errors, while improving patient satisfaction.
Revenue cycle improvement begins and ends with viewing the revenue cycle from the patient's perspective. The patient experience affects how the health system is perceived in the community and is a reflection of how well it is running its business. At UPMC, we focus on areas within the revenue cycle that are important to our patients' circumstances. We believe that the numeric results are patient driven and that improvements to revenue cycle processes will enhance the patient experience and directly translate into improved financial performance.
When assessing the overall health of our operation, we walk backward. We analyze our outcomes, and determine how the results affect the patient experience.
View Exhibit 1
We strive to improve the patient experience through innovation, simplification, and process improvement and have found that using automation is one of the best ways to build a patient-friendly revenue cycle. In support of this finding, we have developed a package of interwoven technological processes that can:
- Access any data system
- Compare data sources
- Identify data differences between sources
- Compute tasks electronically
- Mimic a person's activity
- Create prioritized work lists
Using these processes, we have practically eliminated the potential for manual error, ensuring accuracy through each step of the revenue cycle process and ultimately leading to financial improvements and greater patient satisfaction.
The revenue cycle experience begins with pre-arrival services. At UPMC, we have put a significant emphasis on analyzing front-end processes to see how we can improve them, thereby improving the patient experience. Each process affects the patient experience in different ways, and it's important that we analyze each process individually to determine how we can improve it to better serve patients. Focusing on the patient-centered processes of scheduling, eligibility/insurance verification, and financial counseling, we developed an integrated work flow that ensures data integrity and expedites the resolution of accounts.
We focused first on reservations and scheduling.
Define process. UPMC is a complex, integrated, multifacility healthcare system. Many services are scheduled before a patient visits UPMC. The reservations/scheduling process relies heavily on successful communication with the patient. To complete a reservation, patient access representatives must obtain considerable patient information, such as demographic and insurance information, physician name, service to be provided, and diagnosis code. The necessary data elements are collected by the physician office and communicated to the facilities so they are aware of and prepared for the patient visit. Annually, UPMC physicians conduct more than 4.5 million outpatient visits and more than 187,000 inpatients are admitted to one of the 4,200 licensed beds in UPMC's 20 hospitals. To effectively serve such a large patient population, accuracy in scheduling is essential.
Old process. As we analyzed the reservation process for elective and same-day services, we determined that the best way to improve it was to eliminate opportunity for manual error. Using a paper-driven, manual process seemed antiquated and inefficient. Private practice physicians submitted fax reservations to the central business office (CBO) for manual booking and registration. The paper forms were sorted, distributed, and manually entered into the patient accounting system to create the booking and preregistrations. Registrations were printed at the sites after insurance verification and authorization. Each reservation was handled 12 times, totaling more than 1 million manual processes, with an equal number of potential for error in data transcription, translation, and/or transmission of the form. Faxes could be lost in transmission, duplicate bookings could be entered, the wrong patient could be scheduled for services, and benefit information could be verified incorrectly. The opportunities for error were endless. As UPMC does not have a standard scheduling system, we also recognized the need to interface all scheduling systems to the accounting systems.
Revised process. We created a web-based tool, called eReservation, for affiliated physicians to enter required elements electronically to send to the pre-arrival center and operating room schedulers. eReservation is used for elective admissions and surgical outpatient or inpatient stays. eScheduling is similar to eReservation in that it electronically transfers scheduling information from various scheduling systems, such as radiology, to the host patient accounting system. eReservation effectively reduced a multistep manual process to a one-step electronic process, virtually eliminating the potential for manual error.
Benefit to the patient. It is important that physicians and patients be prepared for scheduled services. The hospital needs to have the appropriate medical staff present, the required supplies available, and the room reserved and ready before the patient's arrival. Patients should be informed of any precautions that need to be taken prior to their services. Patients expect to be seen promptly, the proper service to be provided, and the process to occur smoothly. Any glitches in this process will lead to an unpleasant patient experience.
- We ensure that patient information is accurate.
- We confirm that the reservation was sent to and received by the CBO.
- We clearly define any special equipment and/or supplies required to provide services.
- We can electronically store and retrieve historical data.
- We confirm that the patient reservation does not conflict with another reservation at a UPMC facility.
By eliminating handwritten faxes, we ensure that each reservation is legible, accurate, and complete and that we do not receive duplicate faxes. The electronic reservation process eliminates paper sorting and storage, increasing staff productivity and throughput and reducing costs. The insurance, service, and diagnosis information is at our fingertips, and we are able to expedite the insurance verification process and confirm coverage for services.
View Exhibit 2
Once the eReservation/eScheduling process occurs and the reservation has been automatically printed at the corresponding location within our 20 hospitals, we begin the insurance verification process. This was the second process we analyzed.
Generic process. Insurance verification is an essential component of the pre-arrival process. In essence, we verify that the patient is a member of that plan and is covered for the scheduled service date. We also determine whether the patient is "in network," whether the scheduled service will be covered, whether a referral or authorization is required, and whether the patient will incur an out-of-pocket expense.
Old process. There are many ways to collect insurance information and verify benefits, and most of them require manual effort. Verifiers call insurance companies, often waiting on hold for a representative to answer the phone. Then the verifier will validate the benefits and request authorization for services. If the patient is not covered by that insurance, the verifier either marks the patient as self-pay or contacts the patient and starts the process over, wasting time and decreasing productivity. If the patient is covered and services require authorization, the verifier must request and record the authorization number. The verifier can also use one of the many online systems to verify benefits and request authorization. This manual process presents the potential for error in data translation.
Revised process. In the current business climate, we use electronic transmissions of information for almost everything, including benefit eligibility information. We capitalized on the electronic availability of data to streamline the insurance verification process so that we can automatically query online payer systems to verify eligibility, benefits, and authorizations for services. Our web-based eligibility verification and authorization work tool is called ePayer. The ePayer process is performed before service to minimize the financial risk for the facility and patients. Patient demographic/benefit information in the payer system is compared with the information in our patient accounting system, and authorizations are validated through an electronic process. Patient responsibility is automatically identified and posted into the host patient accounting system for collection upon presentation for services.
Comparisons with no exceptions are automatically verified and designated as "no-touch." No-touch eligibility and verification indicates the absence of manual intervention to accomplish the task. Cases that require manual intervention are prioritized and routed to insurance verification staff via a web-based exception-only work list. The work list has a standard format, regardless of patient accounting system, and is prioritized by date of service and financial risk, so that staff members work accounts with more pressing issues first. Universal and payer-specific logic identifies cases where not all requirements are met and identifies the exact issue that requires manual intervention.
View Exhibit 3
Cases that require no manual verification are automatically updated, thus performing the preregistration and insurance verification functions. Regardless of whether the account qualifies for the exception work list or the no-touch process, the benefit information, notification of patient balance due, and other relevant comments are entered into the memo screens of the patient accounting system. Once the insurance is verified and the authorization is obtained, the account is closed on the work list. If required authorization has not been received by the physician two days before service, we notify the patient and the physician that the authorization has not been received and that the patient's care may not be covered, thereby protecting patients from financial exposure. We work aggressively through e-mail notification to the physician offices to obtain authorizations before this two-day mark.
Benefit to the patient. Accuracy and timeliness are important in insurance verification. Accurately verifying coverage for the patient's scheduled services and requesting the appropriate authorizations eliminates delays in providing patient care. We need to be sure that we have all of the appropriate information to verify the benefits and ensure that the scheduled services are covered by the patient's health plan.
Ensuring that the appropriate insurance is billed and authorization requirements are met reduces payment delays, prevents increases in insurance accounts receivable (A/R), and prevents controllable losses and denials. Patients must be informed of any noncovered services and/or out-of-pocket expenses before they present for services. It is important for the healthcare provider to collect appropriate copayments, coinsurance, and any other outstanding patient balance at the point of service. When registrars receive the copayment, coinsurance, and deductible information before patients arrive for service, they are able to inform each patient of his or her financial obligation and appropriately collect the amount for which the patient is responsible, thereby quickly resolving self-pay balances.
The ePayer tool also provides the registrars with information regarding the patient's prior outstanding balances. The information is transmitted electronically, posted in the patient accounting system, and printed on the armband and the patient face sheet so that the pre-arrival staff can collect these amounts and facilitate the resolution of the patient's outstanding financial obligation. If we identify a patient as uninsured or underinsured, we reach out to the patient and provide financial counseling services to ensure that the patient is able to have his or her healthcare needs met. Providing patient care is the focus of every healthcare organization, and anything we can do to ensure prompt and effective delivery of services, and ensure payment for services, is extremely important.
We are able to accomplish all of these steps with no transaction costs. Our work has substantially reduced potential for error, streamlined the work flow, and increased productivity, all without incurring any additional expense. Sounds like a no-brainer.
Finally, we focused on improving UPMC's financial counseling process.
Generic process. Patient financial counseling takes on many forms. It does not simply involve working with uninsured patients to try to obtain temporary or need-based coverage. It also can involve working with underinsured patients struggling to pay out-of-pocket expenses, or simply working with patients to consolidate medical bills for multiple visits/family members and setting up manageable payment plans. We must obtain an accurate picture of patient liability, and then communicate that information to patients. Unfortunately, errors in insurance verification can lead to errors in identification of patient balances and cause patients to be financially unprepared for services. Before service, pre-arrival representatives need to reach out to patients who may have large out-of-pocket expenses and counsel them regarding these matters.
Old process. Identifying patients in need of financial counseling used to be a reactive, rather than proactive, process. Patients would be seen and then billed after the visit for any out-of-pocket expenses incurred. In certain scenarios, patients would call in requesting more information regarding services identified as noncovered by their insurance company. Using a reactive model, patients were not identified as underinsured and provided with financial counseling before their visits. Billing statements were sent to patients on a monthly basis, and if the balance was not resolved and/or payment arrangements were not made, the balance was referred to an external bad-debt agency for collection. Patients in need of medical assistance or UPMC financial assistance were not identified until after UPMC contacted them to remit the balance or they contacted us advising of their financial situation.
Revised process. We have expanded our financial counseling processes to ensure that all patients are getting the assistance they need. When we identify noncovered services, we advise the patients so that they may be prepared to fulfill their financial obligation. Payment plans are offered to all patients, and patients are given the opportunity to make monthly payments based on what they can comfortably afford.
Through a minifinancial assessment, the centralized medical assistance eligibility and financial assistance staff quickly determine whether to pursue medical assistance processing or whether the patient meets the guidelines for approval for the UPMC financial assistance program. UPMC is successful in obtaining medical assistance for 70 percent of patients who complete the application process. For the remainder, the financial assistance guidelines are applied and patients may then receive such assistance. The UPMC financial assistance program covers patients who earn up to 400 percent of the federal poverty level. Exceptions to the guidelines also may be made for cases considered to be catastrophic (i.e., paying the balance in full would be jeopardize the patient's financial survival). We want to provide financial assistance to patients who lack the ability to pay. In fact, our financial assistance percentage as a component of uncompensated care is more than 50 percent. This means we give more than 50 percent of financial assistance for all patient balances.
Benefit to the patient. UPMC openly communicates the availability of financial assistance by many means. We provide brochures at registration sites, post our financial assistance policy and contact information on our website, and include information regarding financial assistance on patient bills. We consider it important that our patients be aware of our financial assistance program and not be deterred from getting the health care they need due to an inability to pay. Through this expanded process, we can appropriately accommodate patients who are uninsured or underinsured. By ensuring that even the most financially challenged patients are able to receive high-quality health care, we are supporting our mission and our community.
Collecting patient balances promptly assists with our financial goals relating to resolution of outstanding A/R. Notifying patients of their out-of-pocket liability also reduces incoming calls to customer services as patients are given the appropriate information they need before services.
View Exhibit 4
Improving Patient Satisfaction and Financial Outcomes
Through technology, innovation, and simplification, we have improved our processes and ensured ultimate efficacy and accuracy in pre-arrival functions. Pre-arrival is generally the first contact we have with patients, and we want to ensure that patients are confident, comfortable, and prepared before they present for services. When patients are satisfied, we all win. Patient-friendly revenue cycle processes support the health system mission of providing high-quality patient care and, as shown, translate to greater financial outcomes for the health system.
April Langford is vice president, revenue cycle, UPMC, Pittsburgh, and a member of HFMA's Western Pennsylvania Chapter (firstname.lastname@example.org).
Lyda Dye is director, revenue cycle, UPMC, Pittsburgh (email@example.com).
Jessica Moresco is system coordinator, revenue cycle, UPMC Pittsburgh (firstname.lastname@example.org).
Donald C. Riefner is vice president, finance, UPMC, Pittsburgh, and a member of HFMA's Western Pennsylvania Chapter (email@example.com).
Headquartered in Pittsburgh, UPMC is a not-for-profit health system with $8 billion in operating revenue. UPMC encompasses 20 hospitals with 4,200 licensed beds and more than 400 clinical locations. The system also has a health plan with 1.4 million members and has almost 5,000 affiliated physicians, including 2,700 employed by UPMC. With 50,000 employees, UPMC is western Pennsylvania's largest employer.
UPMC annually sees more than 187,000 inpatient admissions, 4.5 million outpatient visits, 480,000 emergency visits, 165,000 surgeries, and 800,000 home care visits.
Publication Date: Wednesday, September 01, 2010