front end alignment: patient access aaham wednesday, may 15, 2009
TRANSCRIPT
Front End Alignment:
Patient Access
AAHAMWednesday, May 15,
2009
Scheduling Pre-registration Admitting Areas Insurance Verification Case Management Utilization Management Financial Counseling
The Revenue Cycle
Clinical Departments use the information to identify patients, order clinical services, and retrieve medical records.
The Business Office uses the information to gather charges, create bills, and develop reports about services rendered at the Hospital.
First impressions are crucial and the Patient Access staff is often the first staff encountered by patients.
Many other departments depend on the information that is entered into the system during the registration process.
Patient Access and Revenue Cycle
First Impressions Relationships
Patient Access ProcessesPre-Point of Service ProcessesSchedulingBed ControlPre-registrationPre-admissionInsurance VerificationPre-certificationAuthorizationReferral Process/ManagementFinancial Counseling
Point of Services ProcessesRegistrationUp-front CollectionsAdmissionsObservation Management ED Function - Inpatient ED Function - Outpatient Cash Posting
Minimize points of entry into the system Standardize processes, procedures, and
expectations Referrals are required before scheduling, when
applicable All elective admissions and/or surgeries requiring
pre-certification must have pre-certification obtained before a bed or surgery reservation is confirmed
Route all at-risk appointments through pre-registration Pre-registration function handle elective, urgent, and
emergent priorities
Scheduling
Centralize pre-registration function Consolidate management structure and have the
majority of staff in one location Have a presence at departments/clinic to perform pre-
registration functions Standardize processes, procedures, and expectations
All staff follow same processes and procedures Maximize utilization of online eligibility systems
Organize staff around general service categories Staff develop proficiency in broad service areas Easier to cross train staff and cross-coverage
opportunities
Pre-registration
Insurance Verification Quality Productivity Number of pre-registration accounts at admit
and at24-48 hours
Number of emergency admits within 24-48 hours Number of due diligence complete Identify field in system reportable – touched,
untouched
Centralize Standardize (documentation, expectations) Computerize Supervise
Monitor progress twice a day - move accounts
Insurance Verification
Medicare Secondary Payer refers to situations where the Medicare Program does not have primary responsibility for paying a beneficiary’s health care expenses.CMS has mandated that providers must determine whether Medicare will be the patient’s primary or secondary coverage. The Medicare beneficiary is required to answer a specific set of questions to determine which insurance coverage is primary. CMS states that providers should retain MSP questionnaires for 10 years. This is consistent with the length of time the government may conduct investigations related to the False Claims Act.
Medicare Secondary Payer (MSP)
MSP ExamplesThere are seven instances where Medicare may be the secondary payer to other insurance coverage:Employer group health insurance for the working agedAutomobile coverage, homeowners’ policy, product liability, or property claims that provide liability coverage for personal injury or medical expensesDisability coverage for beneficiaries under the age of 65 who are covered by a large group health plan.Worker’s Compensation insurance for work-related injuries/illness. The Black Lung program, responsible only for covered Black Lung services.Services authorized for payment by the Veterans Health Administration. Employer group health plans for the first 30 months of coverage for beneficiaries who have been diagnosed with End-Stage Renal Disease.
Advanced Beneficiary Notices
Advanced Beneficiary Notices (ABNs) are a provider’s attestation that beneficiaries have been informed that a given service will not be covered by Medicare and will therefore be billed to them.
The notice must clearly explain why the facility feels Medicare will not pay for the service.
The notice must be provided before the procedure or service is performed and far enough in advance for the patient to make an informed choice.
ABN RequirementsAt a minimum, the ABN should include:The patient’s nameThe patient’s Medicare ID numberThe service(s) that will not or may not be coveredThe specific reason(s) the department believes the service(s) will not be coveredA statement notifying the patient of his/her financial responsibility if Medicare denies payment
While not required, the ABN does include a space for the estimated cost of services.
Typical ABN Services
Advance Beneficiary Notices are used for services that are normally considered Part B Medicare services:Physician ServicesLaboratory TestingMammography/Diagnostic Imaging Services
Non-Covered ServicesMany services are not covered under the Medicare program, such as services related to self-administered drugs. Specific items/services that are considered not covered under the Medicare program include:Routine foot care Tests for fitting hearing aids or the hearing aids Personal comfort items Cosmetic surgery Dental care and dentures Most eyeglasses and eye exams Custodial care
Hospital Issued Notice of Non-coverage
The Hospital Issued Notice of Non-coverage (HINN) is another type of Advance Beneficiary Notice used by hospitals for inpatient services.
HINNs are generally used to notify a patient that a previously covered inpatient stay is no longer considered medically necessary after a specific date of service, and therefore the patient may be billed for the services after that date.
Standardization of patient registration pathways and processes
Streamlined flow of information with minimized variation Using IS to facilitate collecting patient information Ensuring that the patient is questioned only once per
day, regardless of number of encounters within organization
Insurance is always verified upfront Patients are offered payment options
Centralized Ancillary Registration Patients given “passports” to ancillary testing sites Waivers, ABNs, etc. are processed at registration
Registration
Health Savings Account (HSA)
A Health Savings Account is a special account owned by an individual used to pay for current and future medical expenses.HSAs are used with a “High Deductible Health Plan” (HDHP) Insurance that does not cover first dollar medical expenses (except for preventive care)Minimum deductible of $1,100 for individuals, $2,200 familyAnnual out of pocket of $5,600 for individuals, $11,200 family
http://www.ustreas.gov/offices/public-affairs/hsa/
Preventative Care
Safe harbor list of preventive care that HDHP can provide as first-dollar coverage before minimum deductible is satisfied:Periodic health evaluations (e.g., annual physicals)Screening services (e.g., mammograms)Routine pre-natal and well-child careChild and adult immunizationsTobacco cessation programsObesity weight loss programs
Eligibility for HSAs
Eligible If:Covered by an HDHPNot covered by other health insurance Can’t be claimed as a dependent on someone else’s
tax return
Ineligible with any of these Medical Benefits:Medicare or TricareFlexible Spending ArrangementsHealth Reimbursement Arrangements
Other Coverage Allowed with HSAs
Specific disease or illness insurance and accident, disability, dental care, vision care, and long-term care insurance
Employee Assistance Programs, disease management program, or wellness program These programs must not provide significant benefits in
the nature of medical care or treatment. Drug discount cards Eligibility for VA Benefits
Unless you have received VA health benefits in the last 3 months
Obtain all authorizations, consents, and assignments
Establish Standardized Patient Admissions Pathways
All elective patients go through main Admissions areas All newborns admitted through Obstetrics Unit All elective OR patients who do pre-admit main
Admissions go through OR admissions on day of surgery
Observation patients are appropriately placed and monitored Coordination with case managers Hospital definition of observation and protocols for
physician orders
Admissions
Performance Expectations
Sample Job Description:1.Perform patient registration
2.Provide insurance benefits interpretation counseling
3.Maintain medical terminology skills and knowledge of third-party payer regulations
4.Perform patient and customer relations
5.Patient Identification/Arm Banding
6.Receive payments for services rendered/POS Collections
7.Complete other duties as assigned
% of pre-registered patients’ insurance verified prior to date of service
% of insurance verified within 24 hours of patient admission
Percentage of visits with unverified registration
Quality measure (random quality samples) threshold of 1% accuracy
Number of accounts in pre-bill edits with front end issues
Percentage of Medicare accounts with a completed MSP form
Measuring Performance
Front-end related denial rates Denials due to missing
referral/ authorization Denials due to
missing/incorrect pre-certification
Denials due to missing/incorrect insurance information (FSC flow)
Denials due to missing/incorrect demographic information
Number of returned statements Patients without referrals for
services requiring a referral
Examples of Process Measures:
Difficult Conversations Patients may feel
that you are being pushy or aggressive if they feel you aren’t listening to them.
Often it may be as simple as your tone of voice or facial expression.
Tactics for Difficult Conversations: Listen and ask questions Concentrate on the bottom line Backtrack: “Let me get this
right,” “Are you saying that….?”
Clarify and focus on solutions Know your stuff Be positive and flexible Respect personal space Permit verbal venting
Required weekly Set standard and stick to it Five per employees per week Weekly reporting to Director (department,
highest, problems) Use accounts others identified errors on Don’t expect 95% or not auditing right accounts Keep the form simple Individual meetings Hold staff accountable
Quality Assurance
Celebrate success
Non-punitive
Weekly updates on progress
Show them the money
Need to know denials
Show them their denials
Consider lessons through working own denials
Tracking and Feedback
Weekly staff meetings – no exceptions Weekly meeting between all cycle leaders
VP involvement Shared leading Honest statements: I, how, what Report sharing: identify common language
early on Share weekly goals and success stories,
celebrate accomplishments Spin-off small groups for focused issues
Solutions
Quality Audits Reviewers Staff
Weekly Sharing Leaders (each other and staff)
Common Reporting Can I read and understand another
department’s report Do I know when to compliment
Accountability Starts with Me
Questions?