Is it time for refinement of how we view access?
Is it time for refinement of how we view access?
Combining walk-ins, preregistration called failure
If everyone who wanted to travel by air walked up to an airline counter just before the flight and said, "How do I get to Cleveland?" the airline industry would have some serious problems. Instead, the majority of passengers have scheduled and paid for their flights well in advance, enabling one or two airline clerks to check in 150 people in 30 minutes or so.
The health care industry should take a lesson from that scenario, suggests Jack Duffy, FHFMA, corporate director of patient financial services at ScrippsHealth in San Diego. Profit margins at the nation’s hospitals dropped from 6% in 1997 to 4% in 1998 to 2% in 1999, he points out, raising the question of whether "what we do in the name of convenience" is still a workable option.
"There is no bottom line in health care," Duffy says. "Where is capital formation coming from in the future? Do we eat into reserves? Depend on philanthropy?"
With such burning questions in mind, Scripps is looking at an entire redesign of its five-hospital system, aimed at reducing more than $50 million in annual overhead by revamping the expense department, he says. Using a methodology called patient accounts receivable cycle (PARC), Scripps is taking a close look at its front-end processes, Duffy adds.
"What is startling is that when you begin this review, you find that in some organizations — and this is true at Scripps — less than 50% of the total registrations are done by staff reporting to an access department," he says.
"[Registration] is scattered all over in part-time jobs, in the endoscopy lab, the catheterization lab, the radiology department. You think you know what’s happening in your building, but you don’t." (See related story on a Minneapolis hospital, p. 89.)
The combination unit clerk/receptionist/registrar who works in the cath lab won’t benefit from programs like Scripps’ nine-day boot camp on registration functions, he points out. "Their training may be an hour. The access department has limited control over the education and quality process, and it shows up in the error rate."
When Scripps leaders reviewed processes using the PARC methodology, Duffy says, they strongly concluded that services associated with preregistration, insurance verification, authorizations, and prearrival collections needed to be back-office functions.
"It’s a refinement, a recognition," he adds. "We’re saying that our attempt to mix walk-in traffic and at-service collection with preregistration out of the scheduling queue has failed."
The persistent nature of walk-in traffic is constant interruption, Duffy points out. "You always have to sacrifice in favor of the patient in front of you. If, at the end of the day, the walk-in traffic has all been serviced, but the preregistrations, etc., are partially done, or not done at all, that bleeds into billing as an incomplete record, rejections, or rework. It goes all the way through to bad debt."
The goal has always been to have patients registered in advance so they can simply check in and have their service performed, he says, but the ways in which that goal has been approached have not been successful. "We have 55 points of registration on five campuses. That’s too many. You end up with fragmented jobs. A lot of registration people spend less than 10% of their time on registration. They often sacrifice content in favor of keeping the lines moving."
Part of the global planning to address the issue involves a customer contact center that may bring together 20 or so distinct functions and use the Internet and sophisticated telephony to streamline operations and enhance customer service, Duffy says. (See guest column, p. 87.) "We’re looking to the design of the contact center to give additional tools and resources that will affect this process in the future."
The center will include "world-class telephone software, with features like scheduled call-back so customers can return calls at their convenience, semiautomated appointment reminders, automatic capture of credit cards, and e-mail presentation of bills and information on preparing for a service or treatment," Duffy notes. Such a center, he adds, is also likely to have a nurse call line and other services yet to be determined.
In the short term, however, Scripps is targeting the problem with what the organization calls an "easy win," a solution that can be implemented within 90 days with little capital expenditure. That solution, he says, will be to draw eight or 10 employees and a supervisor from the current access staff to form a preregistration telephone center. Those employees will be responsible for taking all accounts of scheduled patients and working them electronically.
At the preregistration center, which will be in production by September, employees will receive information about upcoming patients and determine benefits, obtain authorizations, find out if there is a co-pay and, if so, how the patient wants to take care of it, Duffy explains. The patient will be offered the option of using a credit card or of having the amount deducted from a checking account, he adds.
"In some departments, as much as 60% of preregistrations are never completed until after discharge, and then it’s rework," Duffy points out. "This is where the risk comes in. We have 4,000 registrations a day at Scripps. Some are never done, and the accounts age to the point where they have no value. They fall through the cracks."
Estimates are that between 2% and 4% of hospitals’ gross revenue is never collected because of such slippage, he adds. "We haven’t created a structure to consistently collect that revenue."
To keep financially healthy, Duffy suggests, hospitals must do just that. "The real profit will come from marginal activity."
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