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It is more important than ever for patient access/registration departments to monitor outcomes, as this can "make or break" the success of the department. However, data can be missing, misleading, or just plain bad. Any of these scenarios means trouble for patient access.
What kind of trouble? You may have problems with timely billing, denied insurance claims, duplicate medical record numbers, duplicate encounters that require clinical staff to move charges and documentation, patient safety, increased bad debt, and poor patient satisfaction.
In 2009, NorthBay Healthcare System in Fairfield, CA, implemented a training and quality assurance (QA) program."After looking at three or four automated QA programs, we chose a manual process," says Terese R. Davis, MBA, director of patient access and communications. "We found that all the programs were rules-based, which is the same as our registration system. So, we identified many error types and built rules into our registration system to prevent the errors. This is also an ongoing process, and the cost savings was huge." Here are the steps they took:
Each access employee received two days of intensive training.
The training covered registration, including selecting the correct patient, the financial identifier number and encounter, capturing patient information, entering encounter information, completing forms, entering notes and documentation, updating accounts, scanning, and downtime procedures. The training also covered the financial aspect of the patient's visit, including compliance with the Emergency Medical Treatment and Labor Act, insurance verification, and financial counseling.
Other key topics are point-of-service collections, good communication, providing high-quality customer service, and ensuring patient confidentiality.
Program goals were identified.
These goals are identifying and correcting errors prior to the final bill being sent out, providing timely feedback to staff, identifying productivity concerns, making staff accountable, identifying training needs, managing the department from a proactive and not a reactive point of view, developing data to present the positive work in the department, giving auditors a thorough understanding of the registration process, increasing the accuracy of audits that are performed, and increasing the registration accuracy rate.
"We have seen a decrease in errors and denied claims since we started the QA program in November 2009," reports Davis. "In addition, our point-of-service collections have increased by 46% over last year."
Key data elements that needed to be audited were identified.
Previously, patient financial services notified the department of any denied claims. A plan was made to audit 100% of patient access registrations, then to decrease the percentage and do random audits.
QA leaders were asked to assist in the new auditing process. "We developed a process for completing the audits and provided training on how to audit to ensure that everyone was auditing the same way," says Davis.
The audit process generates printed reports, which identify accounts to be audited, and reviews accounts in the system for errors. "Errors are corrected in the system," says Davis. "All auditors attended training sessions on how to audit. In addition, the auditors meet quarterly to discuss processes, issues, and concerns."
All errors, defined as missing or inaccurate information in a critical field, are updated by the QA leader. These are then entered into an access database. From the database, weekly error reports are run, which are given back to the staff as feedback.
Then, on a quarterly basis, supervisors meet with staff one-on-one to review database reports for individual quality and productivity. Also, the employee accuracy rate is identified, so a group discussion can take place on what the errors are, why the errors are occurring, and what the resolution should be.
"Educational needs are identified," says Davis. For example, it was noted that admit time didn't match the arrival time, Medicaid as Secondary Payor forms were not being completed, and notes and documentation weren't being entered. These were all addressed by giving one-on-one training, providing department inservices, and developing more user-friendly work guides.
NorthBay's patient access department monitors these key performance indicators:
pre-registration/registration, including demographics, physicians, visit information, and consents;
insurance verification, including coordination of benefits, eligibility, and guarantor information;
insurance plan selection, including billing address, subscriber ID, and other subscriber information;
authorization, including authorization numbers, admission notification, and requirements for certification;
point-of-service collection, including copays, deductibles, and attempts to collect.
Clinical errors are also important to measure, as these impact access' ability to ensure "clean" claims. "In our organization, the clinical staff do the bed transfers, which includes accommodation codes," says Davis. "If the accommodation code is incorrect, then the room charge is wrong. We are working with the clinical staff to provide training on how to correctly transfer patients in the system."
Getting long-term employees to adjust to the change was one challenge, as was getting staff to be proactive in staying on top of information provided. Having decentralized registration areas with different reporting structures was another challenge.
After the top registration errors were identified, rule-based registration software was used to help prevent these from recurring. "This ensures errors are identified and corrected prior to accounts being final-billed," says Davis.
QA leaders were trained to assist with auditing accounts and giving timely feedback to staff. "They also develop trending reports for metrics," says Davis. "These are presented to senior management during their monthly meetings."
[For more information, contact;
Terese R. Davis, MBA, Director of Patient Access & Communications, NorthBay Healthcare System, Fairfield, CA. Phone: (707) 646-5301. Fax: (707) 399-2689. E-mail: firstname.lastname@example.org.]