Next Generation Patient Access

Transcription

1 Next Generation Patient Access 1

2 Next Generation Patient Access The role of Patient Access in defending the healthcare provider s organization Financially and enhancing patient satisfaction HIMSS Revenue Cycle Improvement Task Force Task Force Participant List Lincoln Fish Senior Vice President Avadyne Health Tyson McDowell President, Technology-Enabled Services Avadyne Health Mark Cameron, MBA, FHFMA Managing Principal Revenue Vantage Lee Remen Regional Director Healthware Systems Dhiraj Sharma, MBA, PMP Senior Manager Healthcare Business Wipro Technologies June St. John, CTP SVP, CTP - Healthcare Product Manager Wells Fargo Bank, N.A. HIMSS Revenue Cycle Improvement Task Force February 17, Healthcare Information and Management Systems Society (HIMSS) 2

3 Next Generation Patient Access Abstract Patient Access is generally the patient s first experience of any healthcare organization, and it often sets the tone for the entire revenue cycle. The purpose of this paper is to highlight the role of Patient Access in defending the healthcare provider s organization financially and enhancing patient satisfaction. It is getting more important, more impactful, and more complicated but all healthcare providers need to embrace the fury and go all-in to support Next Generation Patient Access. While this document is intended to look at Next Generation Patient Access, it will do so mainly by examining the state of the industry in terms of technological capability. It will touch on issues of patient satisfaction, but only in a cursory manner. The authors and editors of this paper want to underscore the fact that the human component of patient access, especially as it pertains to patient treatment, is perhaps the most important factor in the success of any patient access initiative but since that requires a different type of discussion, the focus here will be on the technology which can support those people delivering the services. The scope and expertise of patient access professionals has expanded tremendously in recent years, and they have met the challenge brilliantly, but they need the types of tools discussed here in order to do their best work. The patient s portion of the healthcare bill is rising and the complexity of getting a patient financially cleared is increasing due to regulation and market pressure. According to Market Watch in the Wall Street Journal, the out of pocket expense for insured patients increased 34% from 2004 to 2006 alone, and the numbers have only exploded since that time 1, with the medical preferred provider organizations (PPO) deductible at $1,000 in At the same time, the percentage of plans requiring deductibles also has increased significantly Healthcare Registration Newsletter reported that 81 percent of PPO plans required deductibles at the end of And the amount of dollars which are exposed to risk by any inefficiency in patient access is staggering. Financial losses experienced because of patient access challenges are sometimes attributed to the business office, as they ultimately go uncollected in the follow-up procedures, but increased focus on and support of patient access procedures can prevent many of these losses. To optimize patient access, providers need sound processes and controls, integrated information technologies, customer service and patient focus, and proper financial clearance and financial counseling procedures, to make sure that every opportunity for optimizing reimbursement has been explored up front. Providers also need to understand the potential financial exposure for those situations with limited or no reimbursement. 1 Gerencher,Kristen.MarketWatch. Costs Eat Big Holes in Employers Health-Insurance Net. June 2, Accessed at articles.marketwatch.com/ / finance/ _1_jon-gabel-job-basedhealth-average-out-of-pocket-costs 3

4 Table of Contents Key Patient Access Concerns to Combat:... 5 Patient Access It is Complex Today, and Getting More Complex... 5 Getting Started: What is the current Financial Clearance Rate?... 6 demographic Check... 6 eligibility... 7 Challenges Surrounding Patient Access... 9 continually changing demands create bursty environment... 9 healthcare Information exchanges (HIX) will add new complexities... 9 Patient portion collection is tough... 9 collecting pre-access data with a single phone call is difficult Payers may not always provide the right information up front Weak scheduling systems are either not electronic or don t integrate well Patient portals are difficult to integrate with current systems difficult to get pre-authorizations and generate estimates Patient Access Action Plan Next Generation Patient Access... 1o Attack the patient portion issue and bolster denial avoidance An eligibility system and process that is multi-tiered to obtain needed detail A process for conducting a patient friendly discussion around financial obligation feedback from denials to understand which charges are not getting paid as detailed...12 feedback from collection rate for which policies worked, and which didn t Attack the Patient Consumerism issue implement faster processes (one call) let the patient help with rapid check-in (kiosks and portals Be prepared when calling the patient on collections create a feedback loop on Patient Satisfaction around Revenue Cycle Make sure patient access staff know when to offer Financial Counseling. 14 Patient Access Technologies Chart The Time is Now to Focus on Patient Access Appendix: Patient Access Process Maps Scheduling Process Flow Pre-Registration via Phone Process Pre-Registration On-site Process Emergency Room Registration Process Inpatient Admission Process Outpatient Registration Process Financial Counseling/Discharge Process

5 Key Patient Access Concerns to Combat: In the revenue cycle, much energy over the last decade has focused on optimizing process and technology in the business office. This seems natural, as the majority of reimbursement comes in through billing and follow-up processes. Increasingly, however, revenue cycle professionals everywhere have recognized the need to pay equal or even greater attention to the patient access process. Without proper process, controls, and technology, it is possible for incomplete patient access procedures to continue to produce substantial financial loss for providers, and in today s world of many distractions, patient access isn t getting the attention and support it needs to maximize the organization s financial and patient satisfaction outcomes. Patient portions of healthcare costs are increasing quickly deductibles are growing, and co-pays are getting larger to keep plan and employer costs down yet, processes have not significantly changed to collect more up front. Estimates vary widely, but it is generally acknowledged that many billions of dollars are under collected. Patient touch points are often more numerous in the administrative process than in service delivery and more patient complaints are found in this portion of the process even many billing-related complaints that are generated around business office functions can be traced to mistakes made during the access process. The patient is now a true consumer, and patient access is the face of the organization. Patient access is a critical path issue for the revenue cycle. When taking into account the increase in patient consumerism, if access professionals are not given the tools and resources they need, a recipe for disaster is lurking for the enterprise or practice. Fortunately, technology can help, as discussed in this report -- now is the time for systems and process to do a better job in supporting the expertise of patient access professionals. From a technology and process standpoint, now is the time for a Patient Access Revolution. Patient Access It is Complex Today, and Getting More Complex The best place to start when measuring Patient Access is by identifying all of the items required for a patient to become financially cleared. Verification of each of the tasks on this list will go a long way for aiding this analysis and perhaps even identifying low hanging fruit that could be implemented to improve processes immediately. Of importance, the process of becoming financially cleared varies considerably by patient and this of course adds to the complexity. Access professionals are well aware of these needs and often handle them today based on their body of knowledge, but the definition of what is needed for each patient, and 5

6 the technological support to make sure that those boxes are checked has been somewhat lacking. In other words, we are asking too much of our access team in an increasingly complex reimbursement world. The list of potential Financial Clearance items are: Insurance Eligibility Verified Insurance Benefits Verified Pre-certification/Pre-authorization Verified Patient Portion Estimate Generated Advanced Beneficiary Notices (ABN) Signed Patient Portion Collection, including Financial Counseling and Payment Plans Delay of Service and many more Not only is this a variable list per account, but the list over time will get longer, and the tasks themselves much harder to complete. This process is driven by more complex insurance rules, more risk around patient portion, and therefore, more pressure to apply service and payment policies to patients ahead of service, and other complications, such as the potential for additional specificity required by the ICD-10 conversion making it more challenging to accurately define the Chief Complaint for a patient, and estimation of charges. Clearly, best practice policies and processes coupled with the appropriate use of information technology are needed to stay ahead of this increasing revenue risk. Moreover, the enterprise must consider not only financial risk but reputation and patient relationship risk. As the patient becomes more central to the healthcare process, bad experiences with payment, unexpected liabilities, late rescheduling of surgeries, and more will undermine patient satisfaction. In recognition of these factors, the following section seeks to provide pointers on proven best practice measures around Patient Access. Getting Started: What is the current Financial Clearance Rate? One way to measure success in patient access is the real Financial Clearance Rate. This is not a measure of the ability to accurately bill for patient owing balances and insurance portions. It is actually a quality measure that shows what percentage of all required actions was completed on each account before service was provided. Generally, the tasks and steps will include: Demographic Check This review of a patient s basic demographic data, such as SSN, address, DOB, gender, etc., is perhaps the most straightforward of all the checks but nevertheless an important process, as incorrect or duplicate data here will certainly lead to denials. Additionally, if complete data is obtained it should be 6

7 carefully checked to confirm the data is current and accurate. Eligibility The eligibility process appears to be quite simple: Does the patient have coverage or not? Yet much is often lost in the details. For example, a patient may be eligible today but what about at the time of the scheduled service? If the information is obtained electronically, and all that the payer makes available is a straight yes or no, is that sufficient? If insufficient, what additional information needs to be collected to provide payment assurance? How current and accurate is the electronic response? Finally, how much has been learned about the other details from this payer: co-pay, deductible, etc.? This seemingly straightforward process is often much more complex than it appears on the surface. To address this, process and technology can be used together as follows: Pre-Authorization Typically, the most common of all patient access-related denials is the lack of precertification or preauthorization. There are three major reasons for this: Failure to attempt a pre-authorization: While more organizations are defaulting to a position of getting a preauthorization if there is any confusion about one being necessary, the failure to recognize the need for a pre-authorization remains a major reason that claims are denied. This relates to the earlier point on accountability, as such failures are not often brought to the attention of the registrar or access worker who failed to accomplish this task. It could be that a policy change on the part of the payer was not known to the access staff. But unless the information comes forward from the business office that a new rule is needed to require a pre-authorization for this issue in the future, the access professional will continue to work as usual. Adopting pre-authorization policies and procedures will help improve the entire process of claims and payment processing to improve. Lack of clarity of what the pre-authorization is for: Without a clear idea of what service should be pre-authorized, it is often quite difficult to contact the payer and ask for a specific pre-authorization. This is often due to the difficulty of getting detailed information from the medical professionals (e.g., referring doctor, admitting doctor, etc.) responsible. Educating the medical professional about the importance of this processing step is vital for improving revenue cycle. Asking and being told don t worry about it : All too often, a call will be made to a payer with enough detail to request a specific authorization and the response is, You don t need a pre-authorization for that. Then later on, a denial is received for lack of pre-authorization on that very service. While the payer is obviously a complicit player in this process failure, providers should be prepared for this response each time a pre-authorization is sought. Some ideas to approach this process will be discussed a bit later. 7

8 Data Quality While data quality assurance ( QA ) is a critical part of the patient access process, it should not be considered a guarantee that a claim will be paid. The clean claim rate is just that a rate that shows how many claims are free of the errors that cause them to bounce back in the process. And this ensures that the claim will get at least part of the way, but does not ensure that it will necessarily be paid. While it is critical to run Data QA checks, it is also important to recognize that such checks are only one part of the process, albeit a critical one. So while Data QA checks will cover a lot of items that cause claims to be initially rejected by a payer, they can fail to cover some of the issues that cause certain denials, and payment errors to occur. Medical Necessity and Clinical Considerations As another essential check of patient access, determining and achieving medical necessity helps to prevents pre-bill errors and claim denials. Most of the focus on achieving medical necessity is typically placed on Medicare patients, although many other payers impose medical necessity requirements. Patient access processes that include medical necessity checking protect providers from lost reimbursements. Additionally, when medical necessity is not achieved, administration of Advanced Beneficiary Notices ( ABNs ) or other payer waivers allow a provider to collect non-covered amounts from patients, which should occur prior to or at the point of service. Information technology is available to check medical necessity and generate ABNs or waivers for non-covered services, which help providers avoid lost revenue. Patient Portion Estimation Decreases in what payers are willing to pay, the increasing volume of uninsured patients, and the growing number of Medicare enrollees all mean that the number and volume of self-pay accounts is growing. In the face of this growth, fewer selfpay dollars will be collected. A McKinsey study on healthcare payments conducted in 2009 put the estimate below 10% 2. With new challenges of increased regulation, decreased payments, and denials and delays due to ICD-10, this issue must obviously be addressed proactively. Many organizations have put processes in place to increase their self-pay collections both upfront and after the fact, but the effectiveness of those processes should be examined, as well as whether the right resources are being leveraged to produce a positive result. Simply generating a patient estimate, the accuracy of which can be quite suspect, is not enough to actually generate dollars. How much to ask for is just the first part of the process: Does the patient understand why they are being asked? Do they truly understand their responsibilities? Are there other resources available to help with this patient communication? 2 McKinseyquarterly.com.LeCuyer, Nick; Singhal, Shubham. Overhauling the U.S. Health Care Payment System. June Accessed at com/health_care/strategy_analysis/ Overhauling_the_US_health_care_payment_ system_2012 8

9 Challenges Surrounding Patient Access Continually changing demands create bursty environment The bursty nature of patient access creates peaks and valleys of work. This can be especially true in facilities where the case mix and payer mix are not consistent, constantly changing and challenging the amount and types of work required by access staff. Add to this the impact of additional and immediate work, such as sameday admissions, and the equation becomes ever more complex, sometimes requiring a continually variable staffing load. Healthcare Information exchanges (HIX) will add new complexities One aspect of the Affordable Care Act is the establishment of new Health Insurance Exchanges (HIX) 3. These exchanges will offer healthcare insurance to U.S. citizens and are offered in conjunction with a new requirement that all individuals must have a health insurance policy (much like state car insurance requirements for licensing and tags). HIX programs will be offered by the states, which are currently in the process of developing the technologies and rules for offering health plans in compliance with the new federal regulation. The constitutionality of mandating that individuals buy health insurance coverage is set to be tested in the Supreme Court in A pro-hix outcome will find over 40 million individuals coming into the health system who were previously in the uninsured ranks. The benefit design of plans sold on HIX will undoubtedly impact and shape technologies for point of service processing. Coordination with state HIX implementation efforts, and real time access to benefits and eligibility information should become part of the project plan and priorities to create a robust consumer / patient payment experience. Patient portion collection is tough Collecting up front dollars from the patient can be a time-consuming and arduous process, as it involves several key areas of expertise: Ability to correctly assess current eligibility and insurance status Ability to create an appropriate estimate Need to communicate the estimate and the patient s portion of it to the patient Process of collecting actual dollars from the patient Need to understand when to refer patients to Financial Counseling Each of these areas requires its own special set of skills and can, therefore, put an enormous burden on any one individual to accomplish all of these tasks with high efficiency. 3 Illinois Department of Insurance. America s Health Benefits Exchange: The Basics. December 14, Accessed at Documents/DOI%20HIE%20Webinar% pdf. 9

10 Collecting pre-access data with a single phone call is difficult A lot of information is needed from the patient, and sometimes collecting that in a single call is incredibly difficult, as the patient may not have all of the required information at hand. Payers may not always provide the right information up front Payers have some of the same problems as providers in updating data, and their goal is to quickly handle a provider s request and move on to the next. In some cases, providers will not getting the right information from payers. Weak scheduling systems are either not electronic or don t integrate well Information gathered through the scheduling process is often not checked for accuracy, scheduling systems do not always require compliance with each data point, and some scheduling systems do not integrate well with other systems. Of course, manually scheduled visits can have an even higher degree of noncompliance. Even if the system does a good job collecting data and enforcing compliance, this information still needs to be passed accurately to the core system and the access team. Patient portals are difficult to integrate with current systems While patient portals can be very effective ways to gather information from patients, if that information does not pass into the main information system efficiently and effectively, much of the benefit of collecting data from this method is lost. Interoperability of data remains an important key for turning patient portals into productive tools for the enterprise or practice. Difficult to get pre-authorizations and generate estimates Acquiring a pre-authorization, or generating an estimate, is dependent on knowing what services are likely to be performed and what the payer s contract with the service provider is. If a method does not exist to make sure this information is accurate and detailed, the process will frequently fail and, thus, the process behind this activity needs to be frequently scrutinized and adjusted. Patient Access Action Plan Next Generation Patient Access Check all the boxes In the business office, what needs to be accomplished is very clear, though the process is often quite murky. A claim must be collected or appealed, and repeated follow-up is needed to do so. In patient access, there are a series of tasks which need to be performed and this is where the process has the potential to break down. It is not uncommon to see three 10

11 or four tasks, such as eligibility, pre-authorization, etc., performed admirably, only to ultimately get denied because of a failure on some minor part of the process, such as not double-checking the demographic information on the patient, which changed since the last visit. More often than not, it is a simply matter of checking all the boxes. But again, we tend to put the burden on our access professionals to do this without proper tools, counting on their knowledge and expertise. But even the most skilled of these professionals can t possibly keep track of what is needed in each particular situation in addition to all of the nuances they need to know to handle each part of the process. This can be done through workflow, exception reporting, or simply through process management, but it must be done. Providers can increase their financial clearance rate substantially by ensuring that all boxes are checked for each piece of the patient access process flow, described in detail later in the process flow diagrams included in the last section of this paper. Attack the patient portion issue and bolster denial avoidance It is essential that the centerpiece of any patient access improvement process incorporates not only a holistic financial clearance approach, but the increasingly important issue of patient portion collection. Most of the steps taken to get more accurate data for patient portion collection will also assist with the other major objective of denial avoidance. Accomplishing those two objectives will mean fewer resources expended on recovering revenue that should have been collected in the first place, and will certainly mean more to the bottom line for the exact same set of services. Equally important in today s environment, patient satisfaction should improve, as patients will understand their obligations prior to service and receive fewer unexpected bills after services are performed. In order to do this appropriately, detailed and highly accurate eligibility data is needed, which requires: An eligibility system and process that is multi-tiered to obtain needed detail EDI Data collection like details of all 38 Patient Service Type codes which includes burn care, brand name prescription drug, coronary care, screening x-ray and laboratory. But there are times when an EDI connection will simply not deliver all of the information you need, so you may require another level of technology Screen scraping technology to get the detailed info And if that s still not going to give you enough to ensure that patient is eligible, there is more you can do Processes to drive phone contact with payer 11

12 Chief Complaint Cleanup to make sure that the chief complaints, which detail the reason for the visit, used as the estimation driver are accurate enough to create pricing estimates. This step is also the key to knowing when and how to get a preauthorization. The bottom line on eligibility is that the check needs to be thorough, every time. Outdated technology and processes will exacerbate this issue. Many times, the old EDI-only technologies are not enough and must be enhanced with additional technology and/or processes to cover aspects beyond eligibility. You simply cannot ask your people to figure this out every time. They need powerful, real-time technology enabled tools to support them. A process for conducting a patient friendly discussion around financial obligation This area is largely a training issue, but technology can certainly help guide the process via scripting and other resources. It can provide patient access staff with an understanding of what a particular patient is facing and how the patient should be approached in accordance with established policies. Feedback from denials to understand which charges are not getting paid as detailed A feedback loop to share denials information should be created, preferably one which is automated, but even a manual process is better than nothing. Too often, information gathered during the denials process does not make it forward to establish patient access rules for future denial avoidance. This represents a significant flaw in the entire revenue cycle process and should be viewed as a high impact process change. Feedback from collection rate for which policies worked, and which didn t It is critical to tie reimbursement success directly to the work in patient access. Payments specifically tied to a registrar, for example, can uncover issues with the way a particular person is doing their job. It can also show which policies around data collection, eligibility handling, preauthorization, etc., are working and which are not. It is common to track such things as patient registration errors and report on clean claims, but it is quite uncommon to see patient access miscues tied directly to first pass denials or payment delays. Technology to do this is available today. Your patient access team cannot make changes to improve reimbursement if they aren t aware of what s not working. 12

13 Attack the Patient Consumerism issue Implement faster processes (one call) In the technologies section of this paper, some of the available tools are discussed which can help providers accomplish more with less. For maximum efficiency, it is critical to automate as many processes and steps as much as possible, and implement changes which will allow staff to do more in a single call, whether that is to the patient or the payer. Patient access staff will still need to spend time on the complex registrations, so making sure the less complex cases are performed correctly with one call will improve efficiency. Let the patient help with rapid check-in (kiosks, portals and apps) Often, the patient is happy to do the work if simply given the proper tools. The implementation of kiosks, apps and web portals to collect data make the patient feel more cared for, while simultaneously decreasing the burden to gather this data. There are many excellent technologies available for both kiosks and portals. A popular example would be Kaiser Permanente s Patient s Like Me Portal. Be prepared when calling the patient on collections Patient access staff can sometimes get defensive with the patient when trying to collect dollars up front. This is natural; as they are trying to protect the organization and make sure it gets at least a portion of what it is owed. Providers should make sure the patient access team can use the patient portion estimation technologies efficiently and be able to explain the results to the patient. In addition, it is important that staff is prepared to have discussions around service delays, if possible, if such payments cannot be collected. Create a feedback loop on Patient Satisfaction around Revenue Cycle A tremendous amount of data is collected on the perceived quality of a patient s clinical experience and surprisingly little around their administrative experience. Most patients do not have an understanding of the intricacies of their medical care to know whether the care professional is handling the case in the best manner but the tendency of patients is to trust their care team. This trust does not extend to the administrative process, as even the least medically knowledgeable patient still understands basic concepts of customer service. There are generally more administrative touch points associated with a patient visit or stay than there are care touch points and they generally extend well beyond both ends of the care process for a given issue. So while a patient may not be able 13

14 to know if the particular treatment suggested by their care professional was the optimal course, they will definitely assume that the insurance denial letter they just received in the mail was due to some failure in the administrative process and they are often correct in that assumption. Patients can be lost from an institution quickly if they feel they are not treated well in this respect, in spite of the best clinical outcomes. As a recent study by the Beryl Institute put the lifetime revenue generation potential of a family for a single hospital close to $500,000, even small failures in this area which cause patients to look elsewhere for service can have a huge financial impact 4. Make sure patient access staff know when to offer Financial Counseling In an increasingly challenging economic environment, more and more people need help paying their bills. So the role of the financial counselor, and the knowledge needed to help patients, has been growing exponentially over the past few years. It is no longer a simple matter of deciding how to supplement payments from their particular commercial payer, or whether or not they qualify for a particular program. If providers are to ultimately get paid, a determination should be quickly made on whether the patient should receive financial counseling, what programs or options they may be eligible for, whether charity makes sense, and how to help them navigate it all. Importantly, patient access staff and management should be prepared to help them go through the process, and not simply point them in the right direction. This area represents an opportunity for banks and financial institutions to play a larger role in assisting healthcare providers in creating, structuring and perhaps even underwriting payment plans that can be offered to patients. There are currently several programs in place, especially around elective, cosmetic procedures. 4 The Beryl Institute. (2011). The Revenue Cycle: An Essential Component in Improving the Patient Experience. Washington, DC: The Beryl Institute. 14

15 Patient Access Technologies Chart Table 1 provides definitions for major components of the patient access process, along with a discussion of what systems are currently available to address each area. Item Description Considerations Eligibility Medical Necessity Checker Using patient demographics to verify insurance eligibility and coverage details. In the form of approval from third party payers to provide specified care in a particular setting; written or electronic assurance that the services provided will be covered under the terms of the patient s healthcare plan. There are certain restricted procedures that Medicare (and sometimes other payers) will not reimburse unless there is an approved supporting diagnosis. For these restricted procedures Medicare fiscal intermediaries make individual interpretations of the federal guidelines established to control payments for certain outpatient services. Local Medical Review Policy, National Coverage Decision (Determination (?)) and Local Coverage Decision (Determination (?)) (NCD/LCD) rules identify the diagnoses that medically justify restricted procedures. An NCD/LCD rule is the combination of a CPT/HCPCS procedure code and a supporting ICD diagnosis code. Medicare does not reimburse providers for restricted procedures billed without an approved supporting diagnosis. Medicare also prohibits providers from billing patients for restricted procedures, unless the providers properly document patient acceptance and/or understanding of financial responsibility. Providers who do not establish comprehensive compliance often will not be reimbursed for the services provided. Resources are available to manually look up NCD/LCD rules, but most larger providers opt for an automated system. Most automated systems are capable of identifying noncompliant diagnosis/procedure codes, these systems automate the identification of restricted procedures, NCD/ LCD rule testing, documentation of patient acceptance and/ or awareness of financial responsibility, and maintenance of the information needed to support effective compliance management programs. Resources are available to manually look up NCD/LCD rules, but most larger providers opt for an automated system. Most automated systems are capable of identifying non-compliant diagnosis/procedure codes, these systems automate the identification of restricted procedures, NCD/ LCD rule testing, documentation of patient acceptance and/ or awareness of financial responsibility, and maintenance of the information needed to support effective compliance management programs. Manual, batch and real time capabilities. Solutions can be integrated with Practice Management/HIS/and Scheduling? Eligibility systems to reduce any duplicate data entry. Direct payer connections, EDE clearing houses and Web Bot capabilities available. Important that returned results are easily legible and able to be retrieved for use in denial management. Co-Insurance Co-Pays, Out of Pocket calculations also often available. Medicare intermediaries update and/or expand NCD/LCD rules throughout the year. Accurate medical necessity testing requires that these rules be routinely updated in systems or reference manuals as updates occur. Most automated systems search for a rules match by combining restricted procedures with every available diagnosis. Restricted procedures without supporting diagnoses: For failed combinations, an Advance Beneficiary Notice (ABN) will need to be produced. ABN s must include patient signatures documenting patient acceptance of financial responsibility and the decision to bill Medicare as non-covered services. 15

16 Item Description Considerations Forms Development Electronic Signature Document Imaging/ Scanning Check Listing Staff Balancing Automated solutions for producing required forms for patient completion/information based on patient type, payer and service provided. In conjunction with many forms packages is the ability for patients to electronically complete specific forms. Scanning continues to be an important ingredient in Patient Access. Even with the rise of EMRs, there are many documents/items that enter a hospital that are not electronic. Further, given that all originating systems do not produce and deliver data capable of being used by other systems some type of scanning capability is necessary in all health care facilities. Manual or automated processes that track each patient encounter through its life cycle to insure that each step in the process is completed Staff balancing or Staff Capacity Planning is a tool to ensure that you continuously have the right number of staff from both a cost perspective and task accomplishment needs (pre access, insurance verification, patient registration), as well as a patient and physician satisfaction and safety perspective. Many different types of systems exist. Some capture data from a print stream of a face sheet and others use HL7 or other means of capturing patient data to allow creation and presentment of bar coded forms for patient signature or information. Some systems simply present a list of forms that a registrar can choose from while others have sophisticated business rule driven algorithms that dynamically produce the forms based on the type of registration being performed. Electronic signature devices come in many styles and configurations. Careful attention needs to be paid to the needs of the forms being completed. Simple signature pads, similar to those used in retail, are often not suitable for most healthcare applications. Facilities need to consider device selection carefully, key considerations include: Device configuration (signature pad, tablet, and external display), portability, security, price, workflow, form configuration, and infection control. Key factors to consider with document imaging include: batch (centralized) scanning vs. Decentralized/Point of Service (POS), scanning devices, storage and retrieval, item formats (plain paper, photo IDs, Insurance Cards), integration with other Hospital Information Systems, duplicate data entry (should be limited at all costs), item indexing both by patient and document type. Healthcare is awash in checklists. While EMRs are reducing the need for checklists in the clinical environment, many patient access departments still use paper checklists to ensure that each patient encounter is financially cleared. Recently, electronic checklists and workflows have replaced manual check listing and can often lead to improved patient/ physician and employee satisfaction as well as improved facility performance. Staff balancing has historically been a manual employee scheduling process typically performed by departmental managers or supervisors. However, more and more common is the use of a variety of software solutions being offered by different segments within a healthcare facility. Some solutions will be HR/Time clock based, others are offered by a facilities enterprise resource planning software and still others are offered by specialty department staffing solutions (i.e., Nursing) or even patient check-in and tracking solutions. Regardless of the origin of the solution their typically is some type of staffing resource management, historical work load component and scheduling capability. Basic systems will predict global staffing needs while more sophisticated solutions allow for the actual scheduling of your specific staff members based on staff member availability and qualifications and expected work load. 16

17 Item Description Considerations Denial Management/ Denial Avoidance Reporting IVR Technologies Patient arrival management and Kiosks** Patient Payment Portals** "Denial management" is the catch-all phrase for any process that can lead to cleaner claims and fewer denials from insurers. Denial management can be part of an entire electronic medical record/billing system, or it can be a "bolt-on" to an existing system. It can be a Web-based system that reviews claims, or it can be a manual, retroactive review of denied claims. Integrated Voice Response includes: Auto-Attendant: voice-driven auto-attendant to answer main office and department numbers. A voice-driven auto-attendant lets callers connect with the desired party by simply speaking the name of the person or department they want to reach. The auto-attendant then connects the caller with the appropriate employee, doctor, service provider, or department. Patient Notification: Most healthcare providers are looking for a solution to quickly deliver time-critical information to patients. IVR solutions enable instant delivery of time-critical information via outbound calls to any desk or wireless phone. This solution can be used to inform and remind patients of appointments, schedule openings, and medication requirements. Call Capture: Some systems are capable of recording calls. Different capabilities include, not only recording actual calls but, making a note of call attempts as well. This can be used for capturing patient, payer, and physician communication. There are a variety of patient arrival solutions in use in healthcare today. Solutions range from basic check in capabilities in registrations systems to sophisticated kiosk based way finding and automated registration and payment collection solutions. Typically used to automate the presentment of patient statements and allow patient balances to be paid online. While denial management is a required discipline for all healthcare providers, the focus should be on denial prevention. Denial management solutions range from reports/work-lists generated from failed claims to predictive technologies that flag combinations of payers/procedures that have high propensities for denial. Either way, solutions should focus on catching issues as early in the process as possible and provide easy to use capabilities for reducing/resolving denials at every touch point of a patient encounter. Whatever the use of IVR technologies it is important that the process is comprehensive and well thought out. Consideration include: HIPAA compliance, call abandonment, language preferences and much more. The slow adoption of Kiosks in healthcare is baffling to the army of consultants that are pushing kiosks to reduce headcounts and improve facility performance and patient satisfaction. However, the limited application of self-service kiosks in healthcare is not mystifying once the complexity of the patient registration process is taken to into account. Some of the key components necessary for a successful kiosk/self-service implementation include: Standard processes for all patient encounters Strong pre-service process to insure all steps complete prior to patient presenting Simple easy to use applications Patient payments portals are becoming more and more prevalent. They offer a number of distinct advantages to standard mail in payment capabilities. Primary advantages include: 24/7/365 unattended operation (both a patient satisfier and reduces staffing needs) Ability to automate payment arrangements Electronic bill presentment Automated cash posting To be successful: Offer ways for patients to contact you, including phone number, contact us form/ , and physical mailing address Include privacy policies Provide an FAQ section Make sure text is large enough and easy to ready Consider offering multiple languages 17

18 Item Description Considerations Patient Registration Portals** Charity/Third party pay qualification Allow patients to provide all pre-registration information online rather than waiting to talk to a hospital associate. Typically patient, payer and service information is provided online by the patient allowing the healthcare facility to perform all pre-service activities including, eligibility, pre cert/auth, medical necessity checking, price estimates, prior balance review, etc. prior to talking to the patient or the patient presenting Automated or manual solutions for running all self-pay patients through Medicaid. Also includes capturing patient demographics for identification of other 3rd party payment options. May also include the capability to pre-qualify patients for charity pending verification of required financial information from patients. Similar to payment portals: To be successful: Offer ways for patients to contact you, including phone number, contact us form/ , and physical mailing address Include privacy policies Provide an FAQ section Make sure text is large enough and easy to ready Consider offering multiple languages There are multiple solutions available for the identification and classification of patients for actual or presumptive charity care. Included in this is multiple solutions that use PARO (patient assistance rank order) scores to classify patients without their participation. Other solutions include credit based charity care analysis products. Identity verification Propensity to pay identification Identity verification solutions range from in-person proofing checking government-issued identification documents in a face-to-face setting - to use of knowledge-based authentication, a set of methods that confirm a person s identity through an electronic dialogue about facts that only the proper user should know and data is compared to databases of consumer demographic and financial information. Also, use of biometrics to uniquely identify patients previously enrolled and identified by other methods by unique biometric measures (Palm/Finger Print, Iris Scans, etc). Using patient financial demographics and third party verifications/calculations to classify patients as to the likelihood or ability to pay for the services provided. Healthcare facilities use a wide range of patient identification solutions. The most common being using prior patient visit information to validate current encounter information. Increasingly, healthcare providers are turning to biometric based patient identification technologies to validate patient identification and reduce healthcare fraud. Some facilities, in addition to scanning or copying photo IDs are taking photos of patients. While others are using biometric devices like palm vein and finger print technologies to positively identify patients that have enrolled in the technology. Similar to 3rd party and charity care analysis some healthcare providers are using this same process to identify which patients have a higher likelihood of paying their bills. This allows them to identify which patients are worth the resources to attempt collection and which patients should be written off or immediately classified as charity. 18

19 A series of example patient access process maps is attached to this report, showing the integration of information technology at various steps. These process flows present detailed steps of key patient access processes from the point of scheduling, to pre-registration and the actual registration or admission processes, through financial counseling and discharge to ensure financial clearance. The process maps are only examples and do not reflect processes of any particular type of hospital provider or best practice. Providers should develop and continuously refine internal patient access flows based upon on existing and planned information technologies, payer and service mix, human resource allocations, customer service strategies, and other key factors. The Time is Now to Focus on Patient Access Fundamentally, Patient Access needs your support now. Of course, there are substantial distractions of time and budget regarding ICD10, meaningful use of electronic health records, and all the other challenges that healthcare providers currently face but these only increase the urgency to make sure your patient access team has all of the tools they need to optimize their work. Since many providers do have a Patient Access department, it is essential that the department is supported by the vice president of revenue cycle or even the CFO directly. In addition, Patient Access should fully participate on revenue cycle teams and monthly meetings to voice issues. Also important, the business office should report to Patient Access on denial and collection outcomes, as well as other issues related to up front processes, to aid in improvement. Feedback loops are an essential strategy for quality improvement and they are often missing. Aside from these basic steps, it is essential to understand that the concept of Financially Cleared is complex to measure but must be monitored. Providers should challenge themselves to identify all the items that count toward Financial Clearance for each type of account within their individual facilities, and then begin to measure one new Financial Clearance task per month or quarter until the full list is complete. Following Pages: Appendix: Patient Access Process Maps 19

20 Map 1: Scheduling Process Flow Illustrating Information Technology Integration 22 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

21 Map 2: Pre-Registration via Phone Process Illustrating Information Technology Integration 23 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

22 Map 3: Pre-Registration On-site Process Illustrating Information Technology Integration 24 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

23 Map 4: Emergency Room Registration Process Illustrating Information Technology Integration 25 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

24 Map 5: Inpatient Admission Process Illustrating Information Technology Integration 26 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

25 Map 6: Outpatient Registration Process Illustrating Information Technology Integration 27 P age 2012 Healthcare Information and Management Systems Society (HIMSS)

26 Map 7: Financial Counseling/Discharge Process Illustrating Information Technology Integration 28 P age 2012 Healthcare Information and Management Systems Society (HIMSS)