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?