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With collections, all eyes are on patient access
There is more pressurebut also more opportunities
Patient access professionals report being under intense pressure to help the hospital's bottom line.
There is "absolutely more pressure on patient access," according to Jamie Biegler, director of patient access at Shands Healthcare in Gainesville, FL. "We are under a lot of scrutiny right now. Our precert denials and cash collections are the focus of a lot of meetings."
On the other hand, the bad economy means that patient access, in some cases, is finally getting the attention and resources it needs to reduce claims denials and increase collections.
"We are taking this time to put better processes in place, and upper management is willing to give us the resources we need to get it done," reports Biegler.
Cathy Foster, director of revenue cycle at St. Joseph Medical Center in Towson, MD, says she thinks the bad economy is "absolutely an opportunity for patient access. While hospitals are probably looking at reducing some of their resources, I think they have to look at the value that one patient account brings to the table."
Show the payoff
In order to obtain additional staffing resources in these tough times, you'll need to demonstrate to upper management that more FTEs will result in significant increases in collections. Foster says it's clear that if more attention to detail can be given to every account, "they will see the payoff very shortly."
Foster notes that the average registrar's salary is about $25,000. "You have many patient accounts that are way over $25,000. You can pay a salary with one patient account, if the account is registered correctly, with the benefits verified, and the patient's portion collected."
However, Foster says she thinks it's still a struggle for patient access managers to emphasize the importance of the registrar's role in reimbursement. "That is a still a challenge.
"I still hear us considered as 'overhead,'" she says. "It's true that we don't generate revenue by giving patient care, but we do by assuring that we are getting paid for whatever the patient is coming here for."
Foster notes that employees in clinical areas often will say that it's not their job to make sure the patient's insurance is good. "But on the other end of that, if they are scheduling patients themselves, what is the use of having volumes of patients if we are not going to get reimbursed?" says Foster.
Share these indicators
Katie M. Davis, director of patient financial services at Carolinas Medical Center in Charlotte, NC, agrees that the challenging economy provides an opportunity "to show the value of patient access to the organization."
She recommends compiling statistics on collections, denials, and patient satisfaction. "Do monthly reports showing the impact of up-front collections, as well as other key performance indicators that show value to the organization," says Davis.
Davis uses a matrix that shows cash collections, both month to date and year to date. The matrix also lists performance indicators specific to pre-registration the percentage of accounts pre-registered for the next day and for four days out, and the percentage of pre-registered accounts that are completed for the next day and for four days out.
"Our definition of 'completed' is the account is pre-registered, insurance has been verified, the non-clinical authorization has been obtained, and the up-front cash call has been made to the patient," says Davis.
Davis shares this matrix with her vice president at their weekly standing meetings, and in turn, he shares them with the senior vice president at monthly meetings. "I have used the information for both obtaining additional resources and to spotlight the work we do," she says.
According to Peter Kraus, CHAM, CPAR, a business analyst with patient financial services at Emory University Hospital in Atlanta, "Access should know how much it collects up front each month. If the department trends its collections, that can be helpful."
Upfront collection of elective self-pay accounts is an essential part of access' responsibility, notes Kraus. "However, while I have nothing against upfront collections of copays and deductibles, this is bound to be only a small fraction of a facility's total cash collections," he says. "I admit that sometimes it puzzles me that so much emphasis is placed on copays and deductibles."
Two arguments, however, argue in its favor, says Kraus: First, copays and deductibles are getting higher in today's environment of reduced benefits. Also, vendor verification software is available to provide a more accurate estimate of patient-owed amounts than was once the case.
"Even so, in terms of percentages of total collections, it isn't difficult to see why a budget-constricted CFO might be willing to sacrifice access FTEs in preference to the business office," says Kraus.
But there's more to the story than that, says Kraus: Access departments with robust, proactive pre-registration programs catch patients with potential financial problems before services are rendered and expenses incurred.
"I don't know whether access departments typically track these patients. But a savvy access manager or director should ensure that the powers that be are aware of the role pre-registration plays in identifying and following up with patients at financial risk," says Kraus.
Upfront collections are 'a must' for survival
Increasing upfront collections has always been a top priority for patient access departments, but in today's economy, it's "a must," says Cathy Foster, director of revenue cycle at St. Joseph Medical Center in Towson, MD. "We have to do that to survive."
At press time, Foster says that her department has not set its targets yet. "But we will be focused on getting at least $75,000 to $100,000 per month," she says. "This may not sound like much, but it will receive a lot of attention now because of the economy. Now all of the clinical areas want to know their worth to the facility. They are also open to the collection processes, especially now that we have centralized registration."
Foster notes that if you are not getting anything at the point of service, many hospitals wait until get they get paid from insurance before they bill the patient. "So that's increasing the number of days in A/R. At least if you are getting something at the front end, it's not as hard of a hit on the A/R."
At Shands Healthcare in Gainesville, FL, the patient access department has a $7 million a year goal to meet for cash collections. This includes the ED and outpatient and inpatient areas.
"This amount is adjusted annually after consideration of our financial climate and our ability to meet the previous year's goal," says Jamie Biegler, director of patient access. "Our administration has been very supportive in providing the necessary tools and staff to achieve the goal."
Here are some strategies that various patient access departments are trying to increase their upfront collections:
Patients are given the opportunity to use kiosk registration.
Foster says she has high hopes to increase her department's upfront collections with a kiosk registration program her department is implementing this spring. She says this is particularly important for her department, as the Maryland Health Services Cost Review Commission does not allow for discounting more than 2% for day-of-service payments or 1% within 30 days after discharge. "So given the fact we cannot discount to increase payment at the time of service, we will hope to increase collections significantly because now we do not even ask in most cases," she says. "I expect collections to increase up to 50% more than we receive now."
The kiosk will allow patients to swipe their credit card. At that point, they can determine if they can pay their entire copay, and also, it will bring up previous balances so patients can pay these as well.
Transfer patients are now financially cleared before arrival.
The economy has changed the "take all comers" practice for patient transfers at Shands, according to Biegler.
"We are a state-of-the-art teaching hospital and a lot of people want to come here," says Biegler. "Before, we would try to get the insurers to verify after the patient got here. The physicians kind of had an 'open door policy,' and we were able to get most of it authorized after the fact. But as the economy took a turn for the worse, things got real tight."
Where in the past transfers were usually a "done deal," insurers are increasingly denying authorization for these, says Biegler. "So that was a new challenge for us."
In light of this, a new process was implemented with patients financially cleared before, instead of after, they arrive. "We now get the transfer and the procedure authorized before the patient comes in the door. There has to be an identified payer source," says Biegler. "Physicians like it, because they don't have to get involved in the clinical aspect of it until they know the patient is going to come."
The only exceptions to the policy are neurological cases, pediatric cases (because it's usually possible to get a payer source such as Medicaid identified), and burn cases, since Shands is one of the few facilities in the region with a trauma unit. "Authorization is not usually a problem with these particular cases," says Biegler. "But for the other ones, the policy is followed strictly. The administrators know it, the doctors know it, and we saved ourselves tons of money in the process."
Occasionally, doctors will want to bypass the policy and have their patient transferred to Shands regardless of payer source, but this has to be approved by administration first. "We do a workup financially and let them know what they are looking at. If they choose to approve it from that point on, then so be it. But more and more these days, they are declining because of the impact to the bottom line," says Biegler.
One problem was that physicians were worried about maintaining good relationships with their referral sources. To avoid problems with these relationships, patient access "gets between" the doctor and the referral source to explain that although the doctor has clinically accepted the patient, patient access can't financially clear him or her.
Some insurers even allow the patient to see the physician several times but when the patient needs surgery, they won't pay unless the patient has the surgery at another facility. "We try to bargain with the insurance companies, but they haven't budged on a lot of these cases," says Biegler. "We see that becoming a lot tighter."
ED copays are collected aggressively.
Self-pay patients have increased dramatically at Shands' ED. "We find ourselves being, more and more, an urgent care center. There is not much you can do there, except to have an onsite vendor for Medicaid," says Biegler. "We do screening on the spot and try to get them some sort of assistance. And we are aggressive about collecting copays."
After the patient receives a medical screening examination as required under the Emergency Medical Treatment and Labor Act, insurance is verified and copays are collected at that time.
Almost all patients are pre-registered.
Foster says a patient recently called her because she was worried about getting hit with an unexpected bill at the hospital. "She told me that she recently had surgery at another hospital and was called into the financial counseling office there and had to pay $900 that day, without any preparation," says Foster. "We don't want to do that to the patient. That is why we want to have 100% of our scheduled patients preregister. We have the interview with them at that point."
At Carolinas Medical Center in Charlotte, NC, patient access works with a company that makes outgoing calls to surgery patients to inform them they are not pre-registered for their upcoming visit. The call gives them the choice of receiving instructions for pre-registering over the web, speaking to an access representative, or leaving a message for a time that is more convenient for staff to call back.
"This has allowed us to pre-register further in advance without adding staff," says Katie M. Davis, director of patient financial services.
Staff are being trained to set up payment plans.
Patient access staff at. St. Joseph are being trained to set up payment plans for patients who can't pay their entire copays at the time of registration.
"Our goal is to have every access staff member trained to set up a payment plan and collect whatever the patient can pay that day. Even if they say, 'Well, I can pay a quarter of it,' that is better than not paying any of it," says Foster. "It hasn't been in our culture to do that."
Many hospitals fear that their volumes will go down because in this economy people are putting off elective procedures. "Unless we make it easy for them to pay, our volumes will decrease," says Foster. "And we also realize that getting something is better than getting nothing."
At St. Joseph's registrars go by a corporate policy and procedure to determine the minimum amount they can accept from a patient. "If it's a large amount, we can give them a longer period of time to pay, vs. a $25 copay that we would probably want within two months," says Foster.
Foster says she has heard that another hospital is considering implementing a new policy: If a patient has a copay over a certain amount and can't pay it at the time of service, they will suggest that the patient put off the service until they can.
"That's a philosophy that the hospital as a whole would have to decide on," says Foster. "I personally feel that if the patient is insured, at least you are getting that payment for the procedure. But the decision we can make in patient access is that we can discuss payment arrangements with everybody, no matter what the amount is. We don't want to put off people getting elective procedures if they are insured and have a copay."
At Shands, patient access staff have noticed an increasing number of patients can pay only a portion of their copays or deductibles. "We are seeing more and more of that these days, where patients will say, 'I've got $150 but I can't pay it all,'" says Biegler.
For this reason, a new web-based system was implemented so patients can easily make payment arrangements, such as paying $50 a month. "Our staff can actually put in a set amount for the patient to pay each month on their check routing number or credit card, so it can come out automatically," says Elizabeth Faulk Brooks, assistant manager of outpatient financial arrangements at Shands.
Patient access has tightened up processes for intake.
Biegler sits on a committee on payer mix liability, commissioned by upper management with the goal of saving money on self-pay dollars. "Administrators are keenly aware of the increase in self-pay dollars," she says. "We are looking at this across the board at our facilities."
Biegler says that recently a decision was made for patient access to "tighten up" some of its processes for intake and identifying payer sources. "If we are giving a lot of self-pay dollars to folks out of state, we aren't able to take care of our own," she says. "Whereas before we would take a patient in, no questions asked, that's no longer an assumption. They now have to be cleared by upper management."
Patients are given more accurate estimates about what they'll owe.
"A lot of people do want to pay their bill upfront, and they want to know what they are going to owe," says Biegler. "If you get it upfront, you are in much better shape than if you wait until the end and the patient doesn't have it any more."
To give patients better estimates, Shands has developed a new estimate system, which will be implemented by mid-2009. In the past, patient access staff took the last five cases, looked at the high and low amounts, came up with a rough estimate for a procedure, and collected on that amount, which may not have been accurate. "We will be using a new system developed by IS that should be spot on," says Biegler. "It will give self-pay estimates as well as deductibles owed."
A new process is used to reduce claims denials for radiology.
At Shands, patient access is completely decentralized, with 58 FTEs in outpatient areas, all located where services are performed. "We create the account, get all the authorizations, do the precertifications, contact the patients, and collect at point of service," says Brooks.
This means having to work with every single ancillary department each with different processes. "Each ancillary has its own scheduling system that we have to pull from. So that is a barrier as well," says Brooks. "The processes are not similar and nothing is streamlined. Our schedules are multifaceted they are web-based, pulled from the physician group's system, or they're paper. Each of our employees has to have multiple sign-ons and be educated on each system."
Recently, patient access noticed "huge percert denials" involving radiology. When the X-ray is ordered, such as a computerized tomography (CT) scan, patient access staff would call in for notification, but in the meantime, the radiologist would sometimes change the order. "The order would come down for CT of the head, and then, the radiologist would protocol the order and say they also need a CT of the brain. So we had to add that on, which was causing numerous denials," says Brooks.
Patient access is currently working out a process where radiologists contact them before the service is performed. "That way, we can change the notification number, which obviously has to be right on the mark," says Brooks. "We are trying to work out a process where the ancillary service can tell us upfront what services are actually going to be performed."
In the meantime, the hospital's IS department created a report for this process, so that the payer is contacted to change the authorization, in order to reduce the denials. "We do reports for radiology so they can see what it's costing us. We are showing them the losses in their revenue," says Biegler.
This "really got the attention" of administration, says Bielger. "That's why they have given us an edict to work with other ancillary areas so we can get these losses down," she says.
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