Managing Receivables

Through Patient Access Ingenuity

Managing Receivables

Through Patient Access Ingenuity

3

About the Organization

• Cedars-Sinai Medical Center:

886 Licensed Beds in Beverly Hills, California (purchased Marina Del Rey Hospital in 2015)

243,040 Annual Patient Days (665 per day)

697,539 Annual Outpatient Visits (1,911 per day)

47,320 Annual Admissions

88,422 Emergency Department Visits

11,625 Full Time Employees

$659,947,000 FY16 Community Benefit ($21,785,000 in direct charity care)

4

Registration Department Management Organization

Main Admissions

and Lab

Financial

Clearance and

Steven Spielberg

Building

Cancer Center

Auths

Eligibility

Pre-Admissions

Training and

Quality Assurance

Samuel Oschin

Cancer Center

Emergency

Department

Imagining and

Breast Center

AHSP and Mark

Goodson Building

Registration Department

Management Organization

One Director and Eight Managers.

Registration

Organization

•

5

Where We Started

The Challenges – Immediate and Long-term

• Inexperienced, untrained staff with very low morale who felt they were in dead end jobs

• Days in Receivable at 120

No standards or goals relative to Patient Access’ responsibility concerning production of a clean bill

First Pass Yield (the percentage of bills that clear all edits and produce a clean bill) at 20%

Declining Monthly Cash

Upfront Cash Collections of $4,000.00 per month ($48,000 per year)

• Customer Service

Waits and Delays

Decentralized Registration

• Poor Organization Structure

Misalignment of Staff and Volumes

Decentralized Authorizations

Decentralized Outpatient Scheduling

• No Solid, Applicable Training

• Duplicate Medical Records at 15%

• Paying an Outside Vendor for Eligibility Services

• Challenging Technology

Operating on a DOS System AND a Looming Computer System Conversion

• Space

6

Poor Organization Structure

• Centralized registration staff within buildings whenever possible rather than trying to

staff every clinic

• Built a solid leadership model of leads, supervisors, and managers who were subject

matter experts in each of their areas

• Completed an in-depth study of how long each registration took, determined how

many registrars it took to staff each area and staffed accordingly, which had an

immediate positive impact on customer service and waits and delays

• Eliminated overage of staff in some areas and were able to augment staff in others

without losing staff

• Completely redesigned the Financial Counseling Department and eventually eliminated

that department and replaced it with the Patient Financial Advocate Department

• Emphasis was now more focused on obtaining authorizations in a central effort and

the PFA Unit became the “safety net” for data integrity prior to the bill dropping

• The PFA Unit also provides financial clearance assistance house wide

7

Solid Applicable Training

The problem:

• Training was virtually non-existent at the beginning of the project

• Very few staff level employees were proficient in PC usage and navigation because the DOS

System had only recently been moved to a PC based system

True Story: When asking a staff member to “right click”, she moved the mouse to the right

side of her computer!!!

• Data integrity was deplorable

• Bills had to have human intervention prior to going to the carriers/patients because they

couldn’t pass the edits electronically

• No upfront cash was being collected

• Employees were feeling unappreciated and moral was low because the only feed back they

ever received was bad

8

Solid Applicable Training (continued)

• The fix:

• Develop a training department within the Patient Access Department (This will pay for itself!)

• Create an attainable career ladder with monetary reward for perfecting competency

• Develop a specific training criteria targeting practical application within the department and relative

to every day operations. Establish acceptable, achievable standards and monitoring system. Current

modules include:

Customer Service Study Skills/Testing Strategies

Registration Fundamentals Forms and Consents

RQI/What is it/How to use it Non-government Insurance

Government Insurance MSPQ

Advanced Insurance Insurance Verification - ABNs

Cash Collections Medical Terminology

Respect in the Workplace

• 13 Modules Total

• Train, Track, Trend, Revise

9

Solid Applicable Training (continued)

• Staffed with trainers who were subject matter experts and possessed excellent

verbal, written and presentation skills and had up-to-date technological skills

• Develop a grading scale for each learning module

Each module has an associated test at the end of training for that module

The tests are done on the computer and the grades show on the computer at

the end of the test.

Each participant may retake each test one time only and only up to three

modules.

All staff are made aware that failure to pass the training will mean the

employee may not continue in the Patient Access Department

• Seek input from the participants and continually improve and update the

curriculum

Career Ladders

Career Ladders

Career Ladders

Career Ladders

Career Ladders

Career Ladder Qualifications for Each Level

15

Career Ladder

2016 Eligibility Criteria

Hire date prior to June 1, 2016

Successful completion of probationary period (6 months)

QA score of 98% at Discharge

Ability to work in more than one area

Meet all attendance, tardiness, and KRONOS standards

Meet the productivity expectations of your manager and supervisor

Assist with backlogs and coverage for VHT/SICA/ALP

Volunteer to serve on committees

Assist coworkers

No corrective action during October 1, 2015 to September 30, 2016,

includes Written Counseling and above

Passing Competency Score To move up the Career Ladder

One must be performing at the

next level:

AR 88% or higher AR 60% - 69%

PAR I 90% or higher PAR I 70% - 79%

PARII 92% or higher PAR II 80% - 89%

PARIII 94% or higher PAR III 90% - 100%

March 2016

17

Monthly QA Trend by Department

(Four out of eight departments displayed)

Date July 31, 2015

Pre-Admissions Inpatient PFA Outpatient

REVIEW Ending Pre-Verifciation % Acc. % Acc. Admissions % Acc. % Acc. Registration % Acc. % Acc. Registration % Acc. % Acc.

MONTH Date Cases Errors FY16 FY15 Cases Errors FY16 FY15 Cases Errors FY16 FY15 Cases Errors FY16 FY15

JUL-D7/31/2015

3130 13 99.6% 99.2% 3042 8 99.7% 99.8% 18328 86 99.5% 99.5%

JUL-B 26844 158 99.4% 99.4% 2740 3 99.9% 99.8% 3346 2 99.9% 99.9% 16698 25 99.9% 99.9%

AUG-D8/31/2015

3367 25 99.3% 99.0% 3474 14 99.6% 99.7% 19264 105 99.5% 99.6%

AUG-B 25723 194 99.2% 99.2% 3210 17 99.5% 99.8% 4063 3 99.9% 99.8% 21155 23 99.9% 99.9%

SEP-D9/30/2015

3094 28 99.1% 99.3% 2467 5 99.8% 99.6% 17910 92 99.5% 99.4%

SEP-B 26047 180 99.3% 99.3% 2770 5 99.8% 99.6% 3047 5 99.8% 100.0% 16944 23 99.9% 99.9%

OCT-D10/31/2015

2771 21 99.2% 99.3% 2789 8 99.7% 99.8% 19174 74 99.6% 99.5%

OCT-B 29331 200 99.3% 99.3% 2409 6 99.8% 99.8% 3113 9 99.7% 99.9% 18618 28 99.8% 99.9%

NOV-D11/30/2015

2553 21 99.2% 99.6% 2845 10 99.6% 99.7% 15466 60 99.6% 99.3%

NOV-B 25517 154 99.4% 99.3% 2479 5 99.8% 99.8% 3647 8 99.8% 99.7% 17861 25 99.9% 99.9%

DEC-D12/31/2015

2638 18 99.3% 99.3% 2668 5 99.8% 99.6% 16694 91 99.5% 99.3%

DEC-B 26361 132 99.5% 99.2% 2324 2 99.9% 99.9% 2875 3 99.9% 99.8% 14828 20 99.9% 99.8%

JAN-D1/31/2016

2143 22 99.0% 99.4% 2745 10 99.6% 99.6% 17086 105 99.4% 99.3%

JAN-B 27023 162 99.4% 99.2% 2073 3 99.9% 99.8% 2888 4 99.9% 99.7% 17383 36 99.8% 99.9%

FEB-D2/28/2016

2568 25 99.0% 99.6% 2750 10 99.6% 99.6% 16358 108 99.3% 99.3%

FEB-B 25957 221 99.1% 99.2% 2351 2 99.9% 99.8% 3456 8 99.8% 99.7% 17220 16 99.9% 99.8%

MAR-D3/31/2016

3188 23 99.3% 99.5% 2673 7 99.7% 99.6% 18903 102 99.5% 99.5%

MAR-B 27701 170 99.4% 99.2% 2903 5 99.8% 99.9% 2983 4 99.9% 99.9% 16913 16 99.9% 99.9%

APR-D4/30/2016

2752 23 99.2% 99.6% 2502 7 99.7% 99.8% 17521 87 99.5% 99.4%

APR-B 28357 141 99.5% 99.2% 2552 1 100.0% 99.9% 2706 3 99.9% 99.9% 18020 29 99.8% 99.9%

MAY-D5/31/2016

3115 24 99.2% 99.6% 2600 7 99.7% 99.6% 16874 70 99.6% 99.5%

MAY-B 26023 116 99.6% 99.3% 3099 7 99.8% 99.9% 3202 4 99.9% 99.7% 19027 28 99.9% 99.8%

JUN-D6/30/2016

3085 21 99.3% 99.2% 2632 4 99.8% 99.8% 18126 92 99.5% 99.6%

JUN-B 29151 149 99.5% 99.4% 2702 4 99.9% 99.8% 2778 1 100.0% 99.9% 15660 17 99.9% 99.9%

Billed Totals 99.4% 99.3% 99.8% 99.8% 99.9% 99.8% 99.9% 99.9%

Average Period

18

First Pass Yield

• The problem:

Only 20% of the bills generated passed the electronic edits to move to the

carrier

80% of bills originating in Patient Access had to be manually touched before

advancing to the carrier

Reimbursement was delayed or denied due to poor data quality

19

First Pass Yield (Continued)

• The Fix:

• Identify what we were missing by understanding the missed edits

• Used our trainers to QA accounts for these edits

• Our trainers then worked one on one with staff and incorporated the new

information in the training curriculum.

• At first QA was manual and scores were published on the sample

• In 2006 an electronic product was implemented and provided 100% QA

• While the new system was not infallible, there was an instant and sustainable

increase in the first pass yield

20

Average First Pass Yield Progress

(Recorded in January for the Previous Year)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

JAN-03 JAN-04 JAN-05 JAN-06 JAN-07 JAN-08 JAN-09 JAN-10 JAN-11 JAN-12 JAN-13 JAN-14 JAN-15

Annual Avg First Pass Yield

21

Upfront Cash Collections

• The problem

On average, up front cash collections were around $4,000. per month

($48,000 per year)

Staff did not know how to determine what to collect

Staff was not trained to ask for cash and many were uncomfortable asking

Staff honestly believed that $4,000 per month represented a great collection

effort

22

Up front Cash Collections(continued)

• The fix:

• Again, training, training, training! The staff was required to go through cash

collections training on how to ask for money

• They were taught to “assume” payments would be made by phrasing the

question as “How will you be taking care of your co-pay today?” instead of

“Would you like to pay your co-pay today?

• The staff was also trained on how to explain that the request for co-payment was

a condition set forth by their insurance carrier and NOT the hospital

• The staff was also empowered to take partial payment with a promise to pay

within 30 days

• Tracking of collections was instituted by units within Access and results were

published within the department and monetary incentives were implemented for

success

23

Upfront Cash Collections (continued)

$-

$5,000,000.00

$10,000,000.00

$15,000,000.00

$20,000,000.00

$25,000,000.00

$30,000,000.00

$35,000,000.00

$40,000,000.00

FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016

Goal Actual

Revised Incentive Plan in 2014

24

Cash Collections vs Departmental Expenses

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

FY 08 FY 09 FY 10 FY 11 FY 12 FY13 FY14 FY15 FY16

Total Collections

Total Expenses

60%

80%

100%

120%

140%

FY 08 FY 09 FY 10 FY 11 FY 12 FY13 FY14 FY 15 FY 16

Percent of Expenses Collected

25

Duplicate Medical Records

• The Problem:

No face to face verification of data

Staff selecting WRONG patient when several patients with the same name were

indexed (Example: John Anderson (31 in index)

No approved search method in place

No validating software

26

Duplicate Medical Records (continued)

• The Fix

Created a standard for search. We now search in this order:

Telephone number (patient change addresses but usually not phone

numbers)

Name

Date of Birth

Address

Ask patients to verify information. Do not feed patients the information

If one or more pieces of information do not match and cannot be resolved,

create a new MRN and report to QA Analyst for verification. Note the system

that this may be a duplicate

The QA Analyst then does the research and, if appropriate, merges the

records after discharge. (Physician will be advised of both records if the

patient is in-house)

27

DMRs vs Avoidable DMRs

28

Space Constraints

The Problem

• While we now had the right number of staff for each unit, not every department

had the physical space in which to house the staff

The Fix

• Explore options such as desk sharing, shifts, etc.

• Those options were not viable because often the tasks required were only able to

be accomplished during business hours

• Finally, the decision was made to experiment with utilization of telecommuters

for telephonic tasks that did not require face to face interaction with the patient

• Criteria was developed to decide which employees would be offered the

opportunity to work from home

• Our legal department developed a contract for the telecommuters to sign

obligating them to all the same confidentiality and work ethic rules we require

from on-site staff

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Telecommuters Eligibility Requirements

• Must have reached PAR II status

• Must be in the department at least two years

• Must have 99% QA scores consistently one year prior to becoming a telecommuter

• Must have NO counseling during history with department

• Must be able to pass annual competency test

• Must be willing to work from home for a minimum of one year

• Must be willing to have home workspace inspected by leadership

• Must be willing to purchase renters insurance (if applicable) ** This is because the

hospital provides all equipment to the telecommuter

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Telecommuter Program Outcomes

• There are currently twelve telecommuters working at home for the Access Department

• Six of them have been home for eight years

• Two of them have been home for six years

• Two have been home for four years

• Two are new to the Telecommuter Program.

• Telecommuters are required to resolve 40 accounts daily. The typical productivity for

our telecommuters is resolution of 50-70 accounts daily, depending upon the

complexity of the account

• The telecommuters have always been and continue to be our highest producers of

quality work

31

Newest Initiatives

•Implementation of “Scheg/Reg”

•Centralization of Cancer Center

Authorizations

•In-house Eligibility

32

Implementation of “Scheg/Reg”

• The problem

Patients complained of too many phone calls prior to arrival for their appointment

Patients also complained of having to give the same information to several

different callers

• The Fix:

• A unit was created to schedule appointments and pre-register the patient all in one

call

The unit started with four high volume clinics

Every scheduler was required to spend two weeks in each clinic learning the

practice

Templates were built to accommodate each physicians’ individual schedule

preferences

Once the unit was operating at it’s highest level of accuracy, two more clinics

were added and have been operational for three years

Two more clinics are scheduled for addition to the unit this fiscal year.

Important note: This project was FTE neutral

Because this is an enhancement to the physician practice, physician satisfaction

has improved and they have become supporters of concept

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Outcomes of ‘Scheg/Reg” Implementation

• Patient satisfaction scores went from 80% to 94% in the first year. Currently

sustained at between 94-96%

• Data integrity improved significantly because trained registrars were doing the

input

• The physicians began to see “Scheg/Reg” as an enhancement to their practice

• Registrars enjoyed learning the new scheduling skill which was apparent on the

Employee Satisfaction Survey

• There is more ownership of the account by the schedulers

• Authorizations are timely and on a work queue

34

Centralization of Cancer Center Authorizations

• In July of 2015 Authorizations for the Samuel Oschin Comprehensive Cancer

Center were centralized into a team of six people

• People with experience in cancer center authorizations were recruited and

trained

• Each staff member was assigned three Cancer Center physicians

• Our goal was to reduce Cancer Center denials by 10% in the first year of

operation

• Denials were reduced by 15% between July 2015 and July 2016

• Denials in August and September of 2016 are the lowest in the documented

history of the Cancer Center

35

Bringing Eligibility In House

• For many years, Cedars-Sinai paid an outside vendor and a contingency for all collected

Medi-Cal accounts

• In 2015, an analysis was presented to senior leadership and the decision was made to

bring the process in house

• Cedars hired a Department of Health Services eligibility worker for on-site approvals

and three highly experienced intake workers

• The department saved the organization $4.7 million in the first year of operation

• Note: Because the department is relatively new and approval times with Medi-Cal

differ greatly from case to case, the data is not yet available to determine the

percentage of increase in approved cases

36

In Summary

• Major Change/ Improvement takes time, so make sure goal timeframes are realistic

• All the success achieved by this facility could not have been achieved without the

investment in solid, applicable training

• Performance Standards are critical. Standards should be attainable but a stretch

• Track performance and be sure the staff KNOWS you are tracking it. Report it to staff every

month.

• Watch for trends – both positive and negative. Be diligent. Often a very small adjustment

can create great improvement

• Celebrate every success

• View poor performance as an opportunity to retrain –until that effort is exhausted.

37

The Future