By Lola Butcher

The health system has boosted numerous revenue cycle metrics after centralizing registration and providing intensive education to patient access staff. At the same time, patient complaints and cancellations have declined.

When the four acute care hospitals in the Crozer-Keystone Health System operated their own patient access departments, consistency was hard to find.

  • Preregistration was handled on a catch-as-catch-can basis
  • Upfront collections rarely occurred
  • Incomplete insurance information resulted in unnecessary denials
  • Patients eligible for charity care were not identified until after discharge
  • Patients were sometimes scheduled for preadmission testing with only one day's notice

"The patient would show up, stop in our registration area, and go through a process so we could revalidate the demographic information," says Richard Madison, vice president of revenue cycle operations, Crozer-Keystone, Upland, Pa. "It was an underutilization of the staff that we had, it was an inconsistent approach to preregistering patients, and it was a disservice to the patient."

In 2009, Crozer-Keystone developed an off-site pre-encounter unit called the Patient Services Center that centralized registration activities for the health system's four hospitals. The pre-encounter unit-which comprises 24 employees who were patient access staff members at Crozer-Keystone's hospitals-handles preregistration, insurance eligibility and benefit verification, payer authorizations, and preservice collections for all scheduled diagnostic testing and surgery patients.

"There's nothing small about this," says Madison. "This was a cultural transformation that the organization never experienced before."

Achieving Results

Preregistration and financial clearance now occurs at least five days-and sometimes as far out as three weeks-before the patient arrives for a procedure. Payer authorization or preregistration snafus no longer cause last-minute cancellations, which has improved patient flow and patient satisfaction, according to Madison.

Other results include:

  • Staff members complete, on average, between 40 and 60 preregistrations per day-an increase of more than 30 percent since registration was centralized
  • Administrative denials decreased from $400,000 in July 2009 to less than $150,000 in May 2010
  • Upfront collections increased by about $5,000 per month

"The patient experience has improved by removing the mystery out of how our registration process works," he says. "We developed a brochure that is provided to our patients that details what they can expect after services are arranged. Patients are now informed about their financial responsibilities prior to obtaining service. This way, they are not taken by surprise when asked for their copayments or deductibles."

Going Back to Basics

Shortly after moving to the Patient Services Center, patient access staff embarked on an extensive training program that covered basic patient access skills and knowledge.

"We had a lot of naysayers with 30 years of experience who thought, 'I know how to do this,'" says Madison. "We brought them back to the rudimentary processes of the registration system and elementary-level insurance coverage."

A comparison of pre-test and post-test scores showed how valuable the training was: An audit conducted 90 days after "go live" found more than 50 percent of patient access staff had 100 percent error-free work, and no representative fell below 85 percent.

Madison also developed a set of principles to guide the patient access redesign process and a set of operating characteristics so staff knew what was expected.

"Whenever we tended to stray from those principles or characteristics, we would go back to those documents and say, 'It doesn't fit this characteristic or this principle. We need to get back on course,'" says Madison.

The patient access guiding principles include:

  • A value-added patient experience and quality outcomes are our first priority
  • Synergy of operations between scheduling, registration, financial clearance, case management, and other hospital ancillary departments is a must
  • Existing staffing models and technology requirements will not be a "barrier" to process redesign
  • We will do what we say we will do, when we say we will do it

The operating characteristics include:

  • Ninety-five percent of all scheduled services will be preregistered
  • All areas performing registration functions will be guided by the same operating characteristics
  • Procedures will be standardized and all staff trained accordingly
  • Lack of preregistration will not contribute to treatment delays
  • Insurance clearance processes will drive a decrease in payer denials
  • Patient payment expectations will be communicated to the patients and (except for emergency department services) will be collected prior to or at the time of service
  • All uninsured patients will be offered a self-pay discount package or will be screened for medical assistance and/or charity care
  • Quality monitoring will be performed on a monthly basis with feedback to the employees
  • Physician offices will be notified of any noncovered services to make decisions regarding continuing with services
  • Denials will be work-listed for identification and resolution
  • Preregistration and financial clearance of scheduled services will be completed five days before the patient's appointment
  • Staff will use automated credit-scoring and address-checking software to identify a patient's potential to pay and potential eligibility for charity care

Improving Patient and Staff Satisfaction

Since the Patient Services Center opened, Madison says the unit has received fewer complaints from patients about preregistration and scheduling services and has realized a reduction in cancelled services.

"That means patients are aware of when they should expect to come in," he says. "Whether they come to Springfield Hospital or Crozer-Chester Medical Center, patients should experience the same preregistration process and be informed of any issues related to their registration."

That also means pre-encounter staff are doing their jobs well. Madison says the organization's emphasis on goal-setting, high expectations, and performance measurement has increased staff productivity and satisfaction.

For example, Patient Services Center leaders posted each representative's performance indicators-data-quality scores, number of cases they worked on, and their point-of-service collections-publicly and invited top health system leaders to visit the unit to witness the employees' productivity.

"The staff loved it," says Madison. "They have a sense of accomplishment rather than just the never-ending spinning of the wheel that they were experiencing at the hospitals."

Sharing Lessons Learned

One tactic that proved successful for Crozer-Keystone: Implementing an intensive communication campaign so that health system employees, physician offices, and patients understand the new centralized system. In the months before and immediately after the transition, Crozer-Keystone placed an article in its systemwide journal that is distributed with employee paychecks. The article explained how the change would improve service to patients and help the health system operate more efficiently.

Members of Madison's staff met in person with administrative staff from the top 30 physician offices that feed into the health system. "We gave them the brochure that we developed for patients that says, 'Here's the Patient Services Center, and this is what you should expect and anticipate when scheduling the service,'" says Madison.

Madison shares three additional lessons learned from Crozer-Keystone's transition to centralized registration.

  • Conduct a mock "go live" to help patient access staff adjust to their new responsibilities.
  • Establish key performance indicators that are tracked weekly and monthly to monitor progress.
  • Meet weekly with staff to give feedback and set performance goals.

While the process of converting to a centralized registration system is challenging, Madison expects to see the model adopted with increasing frequency as more hospitals consolidate and health systems seek ways to increase the efficiency of their administrative operations. "As systems grow and more hospitals attach themselves to one another, I think it's going to become more common," he says.

Lola Butcher is a freelance writer and editor based in Missouri.

Interviewed for this article:

Richard Madison is vice president of revenue cycle operations, Crozer-Keystone Health System, Upland, Pa., and a member of HFMA's Metropolitan Philadelphia Chapter (

Publication Date: Wednesday, January 11, 2012