Improving receivables is hospital’s goal
Improving receivables is hospital’s goal
ReCOUP looks at entire revenue cycle
As public hospitals nationwide face an unprecedented revenue crunch, finding ways to improve receivables is the name of the game. With that in mind, Minneapolis-based Hennepin County Medical Center (HCMC) is taking a comprehensive look at its entire revenue cycle, including registration, charge capture, coding, and patient accounting.
A big part of what HCMC calls ReCOUP — Revenue Cycle Operations Update Project — targets the hospital’s outpatient registration practices with an eye on increasing accountability, says Lynn Weeber, director of admissions.
"Right now we have a very decentralized reporting structure and, with that, you end up with a lack of consistency," says Weeber. "What we’re trying to do is find an organizationwide approach to bringing best practice standards."
HCMC is being assisted in the project by Strategic Services Group (SSG), the consulting arm of Malvern, PA-based Shared Medical Services, she notes. A key finding has been that centralization of registration responsibility is critical for accountability, quality, and best practice introduction, Weeber says, and the decision has been made to implement an enterprisewide reporting structure.
Registration shortcuts
With staff at the hospital’s outpatient clinics doing multiple clinical and financial tasks, she points out, there was simply not enough time to consistently perform a complete registration, she adds. The fact that a few clinics have 40% to 50% non-English-speaking patients is a contributing factor, Weeber says. "Because clinical tasks take priority, as they should, we believe shortcuts are taken during registration."
Simply put, the ReCOUP registration objective is to collect quality and timely patient demographic and payer information with minimal manual intervention, she notes. To meet industry best practice standards, Weeber adds, HCMC will expand certain features, including:
• preregistration;
• full registration for all patients;
• financial screening;
• compliance with government regulations, such as the federal Medicare Secondary Payer Questionnaire and compliance with state privacy laws by having patients sign an information disclosure form.
The hospital will add other features, including:
• on-line insurance verification;
• consistent corporate training for anyone with registration responsibility;
• feedback from patient accounting.
That feedback, Weeber explains, will include an outpatient exception report that will list claims with insufficient registration information to bill, such as those missing an insurance identification number. The claims will not be sent until the information is added. "We’ll do it right the first time."
Reducing manual work
At present, she says, each claim is manually reviewed by patient accounting staff. If they can find the missing insurance number, for example, they add it. If not, they change the bill to self-pay status and send it on. Weeber says the new system is expected to result in less manual review on the back end and less manual rework.
The outpatient exception report will be used as an education tool, she adds. "We might change our training to address something we weren’t aware was a problem." The process also could uncover a system problem, such as information not flowing to the right financial field, Weeber points out. Already, she notes, the new focus has revealed problems that are not related to registration.
The idea, Weeber says, is that a series of data quality screens, beginning with preregistration and financial screening and backed up with full registration interviews every two months, on-line/real-time insurance verification, consistent training for staff and feedback from the back end, will help HCMC meet its goal of optimizing revenue.
Her department verifies insurance now by looking at one computer screen, finding the information, and then keying it into a registration screen, she says. The hospital is reviewing products that are "truly electronic data interchange," Weeber adds. "They interact with the registration system so that the information from the payer flows into the registration screen without data entry."
Assisting patients in applying for financial assistance, which is routinely done for inpatient admissions, is now in the pilot stage for outpatients, Weeber notes. "Feedback, getting information from the back end, is the other big piece," she adds. "One part of that is the exception-based reporting — holding an account from billing until it is corrected."
HCMC has identified certain levels of service it wants, she says. "A full registration interview means everyone [is] capturing data in the same manner, so that when you look in the various fields, you get what you are expecting."
Under ReCoup, HCMC will have three levels of registration. Level one registration areas will have these characteristics:
• The registration sites are centrally located in an outpatient setting serving one or more clinics.
• Staff report and are accountable through the enterprisewide reporting structure.
• Staff are dedicated, performing registration or finance-related duties.
• Service areas employ a team approach.
To implement its plan to have dedicated full-time equivalents in level one registration areas, HCMC will look at reassigning or redeploying staff, she says. "Now staff are rotated through multiple tasks, including registrations. Where there are now five employees who occasionally do registration, there may be one or two who are dedicated to registration." (See chart, p. 91.)
Qualifying criteria
To qualify for level one, a registration area must meet one or more of these criteria:
• currently hold registration responsibility;
• have high patient volume;
• have high revenue production;
• be in close proximity to a portal or another level one partner.
"Portal" is the name HCMC uses for central registration points established during its own pilot project before the SSG consultants came on board, Weeber says.
Registration staff in level one areas will perform these functions:
• full registrations, express registrations, and patient check-in;
• area registration error correction, including working the outpatient exception report;
• on-line insurance verification;
• high-level financial screening;
• self-quality audits;
• full preregistrations, generated from calling patients prior to scheduled appointments and from phone bank calls.
Some registrars will be selected to serve as core trainers for all outpatient areas, she adds.
Level two registration areas will be those that are not centrally located but serve clinic populations, she notes. Staff in those areas will report to the director of registration through a dotted-line, matrix relationship, Weeber says, and will continue to do multiple tasks, performing registration and clinical duties. They will be responsible, however, for meeting registration standards, she adds.
To the next level
In those areas, the clinic manager and director of registration will jointly direct staff. The areas will meet one or more of these criteria:
• medium or low patient volume;
• medium or low revenue production;
• nonstandard hours of coverage to volume ratio;
• lack of close proximity to a level one location.
Registration staff in level two areas will perform the same functions as in level one, but they will not serve as core trainers or finance contacts. Those staff also will have clinical duties that will be assigned by the clinic manager.
Level three areas, Weeber explains, are those where the patient’s visit is secondary to a primary encounter, as when a physician refers the patient to have an X-ray. In those cases, which typically involve the laboratory or radiology, she adds, "we just want staff to get the patients to the registration experts. A level one registrar will do a post-registration interview, perhaps by speaking to the patient by way of a phone bank or by calling the patient the next day.
ReCOUP will be rolled out to some areas within four to six months, Weeber says, with full implementation in about 18 months.
"We’re basically looking at the entire revenue cycle and recognizing that registration is a big piece of that," she notes. "You can focus on the back end, but you will not see the bang for the buck that you expect. It’s been the biggest eye opener for our administration to see that the revenue cycle isn’t just a single area but involves several facets of the hospital. All of us working together will make the difference in the bottom line. That’s been the biggest gain we’ve had in this project."
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