Michael S. Friedberg
Patients' first impressions of hospitals are likely to improve dramatically as a result of recent breakthroughs in managing the revenue cycle's patient access processes.
At a Glance
- Patient access management requires skilled staff to fill the new role of patient representative.
- Unlike registrars in the past, patient representatives must perform a diverse and complex range of tasks, including reviewing referrals, obtaining authorizations, verifying eligibility, and requesting payment at time of service.
- Providing patient access staff with adequate training and ensuring they undergo sufficient quality assurance monitoring are critical steps to effective patient access management.
It is not far-fetched to call scheduling and registration processes the "face" of a hospitals' revenue cycle operations. A patient's first encounter with a hospital's revenue cycle typically occurs with these processes, and it is here where the patient forms his or her first impressions of the hospital. Yet for many years, the evolution of these patient access functions lagged behind that of other areas of the revenue cycle. Today, these circumstances have changed, as new developments in patient access are raising this area to new levels-and giving hospitals the opportunity to present a new face to patients.
U.S. hospitals have long used sophisticated methods and technology to manage other key revenue cycle processes. Over the past 20 years, keeping step with the increasingly complex requirements for managing coding and billing processes, hospitals have seen their business offices evolve into patient financial services, and medical records transform into health information management. Today, patient admitting and registration processes are undergoing a similar transformation as patient access management has become the latest area of focus in the development of the hospital revenue cycle-with the promise of reduced denials and increased point-of-service cash collections.
Patient Access Management Benefits
Patient access functions have long been the revenue cycle's Achilles heel-with poor data collection providing a classic example of "garbage in" producing "garbage out." The causes of poor data collection during the registration process are well documented:
- Lack of initial formal training
- Absence of routine, periodic retraining
- Lack of feedback on error rates, resulting in a lack of accountability for errors
- Pressure to register patients rapidly, often at the expense of data quality
- Lack of tools necessary to accomplish the tasks required
- Complex systems that provide too many choices
Patient access management aims to eliminate these deficiencies. The improvements from creating such a department can not only have a direct impact on cash flow and operating cost, with a readily measurable ROI, but also produce intangible benefits with a less easily quantifiable ROI, such as:
- A reduced need for rework in the business office
- Improved customer service
- A reduction in duplicate medical records
Patient Representative: A Challenging New Role
With patient access management, the shift from relatively simple admitting and registration functions to more sophisticated functions is forcing hospitals to reevaluate the responsibilities and qualifications of patient access staff. Where registrars used to get by with "cheat sheets" and Rolodex cards with summary information on local employers and their health plans, today's patient access professional must also review referrals, obtain authorizations, verify eligibility, and request payment at time of service.
In many instances, unfortunately, these complex new patient access tasks are still performed by high-school graduates paid at a rate comparable to that received by a Wal-Mart cashier. A new, more sophisticated professional is required to fulfill these duties: the patient representative.
The complexity of the task facing this individual is too often underappreciated by hospital leadership.
View Exhibit 1
Patient representatives have much broader responsibilities today than did the traditional patient registrar in the past.
For example, hospital information systems use insurance plan codes to identify the various products offered by each insurance carrier. The patient access staff is rarely consulted when plan codes are assigned, but patient representatives must choose the correct plan code based on the insurance card presented by the patient. Insurance carriers also offer myriad products to employers including indemnity insurance plans, health maintenance organizations, preferred provider organizations, point-of-service plans, and more recently, health savings accounts. These products come in different flavors and sizes with different billing and notification requirements, further complicating the patient representative's task.
The patient representative is expected to quickly decipher which plan the patient belongs to from the patient's ID card. Most information systems are set up with too many plan choices for each carrier. Meanwhile, the patient representative's choice affects the manner in which the claim is sent to the carrier, and an incorrect choice can delay claim submission and often result in rejected claims and delayed payments.
Managed care agreements have added another level of complexity. Patient representatives must know when to obtain preauthorization and referrals, and to verify the appropriateness of the place of service. Even the most sophisticated "managed care matrix" cannot address every scenario for every plan. Within a specific carrier, the rules can differ down to the level of a particular employer. Unfortunately, the technology that can electronically validate information for all payers to plan-level detail is not yet available.
The patient representative's actions also could have clinical implications that could adversely affect a patient's care and have a financial impact as well. Consider a patient brought to the emergency department complaining of chest pain for the second time in the past six months. If the patient representative does not accurately identify this patient and, as a result, creates a new medical record number, then existing EKG and other test results will not be accessed and the procedures will probably be repeated. Yet the risk of such errors is high because the patient representative is under intense pressure from ED directors to register patients as rapidly as possible to minimize the time the patients must wait for treatment to begin.
Other factors that can add to the complexities of the patient representative's job include decentralized registration and a perception of registration as non-revenue-producing overhead activity. As pressures to maintain the margin needed to continue the mission increase, "overhead" departments are asked to "do more with less." Yet the ED, in particular, must be staffed 24 hours a day, seven days a week regardless of patient volumes. Staffing reductions and shortages are a reality for patient representatives. Accordingly, the inability to provide adequate supervision of these patient access staff during "off hours" and weekends makes establishing staff accountability extremely difficult.
Hospitals have had to become highly creative in implementing best practices for patient access management to address these challenges. The following are some solutions that have been used effectively to meet these challenges and provide sound ROI for hospitals.
Solution: Quality Assurance and Training
Obviously, having an adequately trained team of patient representatives is critically important. Not surprisingly, therefore, best-performing hospitals make sure they have tools and processes for formal and consistent quality assurance and training of these staff. Patient access directors require the means to track and compare the productivity of all patient access staff-both with each other and against national standards. The QA process also should provide qualitative data as to causes of errors.
Registration Data Quality Checklist
Manual audits of a percentage of registrations should at a minimum look at the following fields in which errors are most likely to prevent a clean claim:
- Master patient index addition
- Copies of insurance and identification
- Account notes
- Patient demographics
- Guarantor information
- Department location
- Insurance selection
- Insurance verification
- Insurance precertification
- Electronic eligibility check
- Charity care screening (if applicable)
- MSP questionnaire
- Physician selection
- Room and board accommodation
It is important that training go hand in hand with a comprehensive QA program. Hospitals might be tempted to train new patient representatives by having them observe those who are experienced. Too often, however, the result of this approach is that the new employee perpetuates the existing employee's deficiencies.
In best-performing hospitals, patient access leaders have a formal employee screening program (including a typing test) and a formal training program for new hires. The trainees are tested at the end of their training, and those who do not pass the test are not allowed to register patients. The results of such QA monitoring are then routinely used to provide targeted retraining to patient representatives.
In addition, a number of electronic tools have emerged recently that effectively "scrub" registration data in batch mode or on a real-time basis. Such tools should be used to enable patient representatives to correct their own errors. These tools also provide management reports that highlight when focused additional training-or in some instances, progressive discipline-may be needed.
Absent an electronic method, best-performing hospitals implement, as a minimum standard, manual audits of a percentage of registrations looking at fields in which errors are most likely to prevent a clean claim.
Regardless of which method is used, investment in QA and training FTEs is required. Yet such an investment will almost certainly provide a significant ROI.
Solution: Departmental Structure
Patient access management structures vary among hospitals, but in best-performing hospitals, core patient access functions report within finance. Best-performing hospitals also typically divide their patient access staff into three areas-preservice, time of service, and postservice-to address the issues unique to the different processes at each of these points in the continuum of care.
Preservice. Hospitals are now realizing the importance of managing the patient's expectations prior to arrival. Physicians have led the way by creating in their patients an expectation that copayments, referrals, and authorizations all must be completed before services are rendered. Hospitals need to adopt similarly aggressive philosophies of patient financial responsibility before delivering nonemergency services; if the patient cannot meet the basic payment requirements, the services should be rescheduled.
Best-performing hospitals have learned that the revenue cycle begins with the phone call to schedule an appointment. Under a patient access management approach, the patient representative also performs some preregistration activities during the scheduling phone call. In such instances, it is likely that the patient has visited the facility previously, and his or her information already resides in the IT system. The patient representatives, therefore, can easily preregister the patient, check eligibility, and make any necessary financial arrangements before service is provided. At the end of the phone call, patients can be instructed to bring their identification and insurance cards and asked to make their copayment. Technology is a key to making these calls a smooth and productive experience for both patient and provider.
Time of service. With patient access management, in every clinical area but the ED, a robust preregistration program is combined with a redesigned registration process to facilitate patient flow and produce more accurate patient data. Best-performing hospitals have established "fast track" areas for preregistered patients. Some of these hospitals allow the patients to report directly to the clinical area, where ID and insurance card copies are scanned and signatures obtained. In a wave of the future, highly "wired" hospitals are deploying self-service kiosks for preregistered patients to check themselves in, allowing information to be verified and copayments to be collected without human interaction. Such devices, however, are not practical for all facilities, and their rate of adoption will depend heavily on the success of the preservice models that are in widespread use by hospitals that have established patient access management areas.
Postservice. Unfortunately, the nature of health care is such that many services provided cannot be scheduled in advance. ED volumes have increased dramatically as the growing numbers of uninsured use the ED as their primary care source. From 1993 to 2003, ED visits grew 26 percent from 90.3 to 113.9 million as hospitals closed 425 emergency departments (Hospital-Based Emergency Care: At the Breaking Point, Institute of Medicine, June 2006). On average, more than half of inpatient admissions derive from the ED.
Best-performing hospitals have a stringent process in place for insurance verification within 24 hours of admission seven days per week. In particular, these hospitals also scrutinize accounts registered as self-pay within 24 hours of admission seven days per week. They also periodically reevaluate patients with long hospital stays to make sure that eligibility is maintained.
ED patients who are treated and released pose a greater challenge, especially if they lack insurance. While ensuring compliance with the Emergency Medical Treatment and Active Labor Act, best-performing hospitals ensure that a high percentage of ED patients are financially screened prior to discharge.
Solution: A Revenue Cycle Approach
In the best-performing hospitals, patient access management is incorporated as an element in a comprehensive approach that ties together all of the areas of the revenue cycle.
View Exhibit 2
Patient access management should be an element in a comprehensive approach that ties together all of the areas of the revenue cycle.
Many hospitals might claim that they use such an approach. However, a true revenue cycle approach requires a formal structure for the dissemination of information. Minimally, there should be monthly revenue cycle task force meetings that include all key elements of the revenue cycle (patient access, PFS, HIM, managed care) as well as the chargemaster manager and a representative from information systems. These meetings should produce a log of issues related to the revenue cycle.
View Exhibit 3
Monthly revenue cycle task force meetings should produce a log of issues related to the revenue cycle, with a record of the target date for resolving each issue and the date when the issue is actually resolved.
Issues should not be allowed to remain on the list for a significant time, and those responsible should be held accountable for completing the root-cause analysis needed to solve the issues. To minimize "finger pointing," the revenue cycle leader should chair the meetings and direct the discussion toward resolving the issues without recriminations.
A comprehensive revenue cycle approach also ensures that patient access management plays an integral part in the hospital's management of issues such as denials, bad debt, and patient bed placement.
Denials. Best-performing hospitals aggressively track denials and zero payment accounts, and diligently seek ways to eliminate process deficiencies that lead to denials. They establish a simple system for categorizing denials by type and for reporting relevant data to the revenue cycle task force so that the root cause of the issue can be resolved. Denials attributed to patient access are commonly due to problems with eligibility. Such denials are preventable if the processes already discussed are implemented. It is important to drill down as far as possible by payer, area of service, shift, and/or staff member to identify trends so that they can be addressed.
Bad debt. Bad debt files should be reviewed regularly and high-dollar accounts should be scrutinized. Best-performing hospitals have a sign-off system in place so patient access and patient accounting managers and directors can work collaboratively on large dollar cases.
Bed placement. Patient access functions are traditionally responsible for bed placement. There is some debate as to whether this function should remain with patient access or be transferred to nursing, and indeed, best-performing hospitals are exploring opportunities to improve inpatient flow by using technology and process redesign to allow nursing and housekeeping departments to work together on bed placement, with the promise of reduced patient length of stay. Whether or not patient access determines bed placement, however, patient representatives will continue to play a critical role in the collection of financial information.
Solution: Centralized Registration
Those hospitals that have not created centralized scheduling departments are at a disadvantage in that decentralized schedulers are not as financially oriented as those in a centralized unit. There are several additional advantages to having centralized patient access:
- Central scheduling systems can provide patient representatives with prompts so that they do not require clinical knowledge of a procedure.
- Changes or issues related to carriers or departments can be better communicated through a central unit.
- Centralized scheduling provides better customer service for patients and physicians' offices.
Nonetheless, decentralized scheduling sometimes cannot be avoided. In many hospitals, outpatients are registered directly at the point of service (e.g., laboratory, radiology, and dialysis) by an individual who works in that clinical service line. There are many instances, for example, of phlebotomists and radiology technicians being cross-trained to perform registration tasks, but clinicians by their very nature must be more focused on patient care than on the financial results of the encounter.
When it is necessary for clinical staff to register patients, these staff members should receive the same training and retraining, and undergo the same QA monitoring to identify areas for improvement, that patient representatives in the central patient access area receive.
A Worthwhile Investment-for Hospitals and Patients
During the past several years, financial leaders at best-performing hospitals have come to appreciate the value of high-performing patient access functions, and to support investments in staff and technology for patient access management that can produce measurable ROI. Best practices implemented by high-performing hospitals include:
- Centralized scheduling departments that can preregister patients, manage their expectations, and facilitate time-of-service payments, all during the initial phone call to schedule services
- QA programs that measure data quality and provide timely feedback to patient representatives
- Training programs (including periodic retraining) that use QA feedback as a basis for providing consistent direction for patient access staff
Patient access management continues to present new challenges, and for many hospitals, much more remains to be accomplished. But the nation's most forward-looking hospitals are leading the way in adopting even more sophisticated and effective approaches to managing this key area of the revenue cycle.
Most important, these changes should be effected with the needs of the patient in mind. Patient access representatives should consider it their duty, and their delight, to greet each patient with kindness and a professional, competent demeanor-in short, to present a friendly and reassuring face for the hospital's revenue cycle.
Michael S. Friedberg, FACHE, CHAM, is a manager, revenue cycle consulting practice, BESLER Consulting, Princeton, N.J., and a member of HFMA's New Jersey Chapter (firstname.lastname@example.org).
Publication Date: Thursday, March 01, 2007