New team system speeds billing time

Workers cut across jurisdictions

Work teams that shepherd accounts from preadmission to post-discharge have streamlined workflow, reduced FTEs, and slashed billing time at UCLA Medical Center in Los Angeles, says Ruth Irwin, manager of patient administrative services for the department of admissions and registration.

Functions of the patient administrative services (PAS) teams are based on the center’s internal best practices and include portions of admissions, registration, utilization review (UR), medical records, and patient accounting.

As a result of consolidating those tasks, the average time it takes to get a bill out the door has been reduced from 30 days or more when the teams began operating in 1994, to 18.95 days in 1995 and 12 days in 1996, Irwin says.

When an outside consulting group came in to look at improving performance efficiency, the department began examining, among other things, the functions that were performed to get a bill out and how many days it took, she explains. "We found functions being duplicated."

After the consultant recommended consolidating these processes into teams, an improvement task force was able to map the best practices in each department, which later formed the foundation for training the new teams. The task force also identified these major problems:

• long waiting times before patients reached their rooms;

• multiple phone calls for a preadmission process;

• delay in getting patient charts to medical records;

• delay in initiating treatment;

• delay in billing;

• high number of days in accounts receivable.

Also as a part of the performance improvement initiative, nursing was moving patients with similar conditions together, and the decision was made to assign a PAS team to each of those patient units, Irwin says. Depending on the size and complexity of the patient population they serve, PAS teams consist of one or two financial counselors and one or two administrative service associates (ASAs). Teams also may have a senior admitting worker.

An ASA performs the multiple tasks mentioned above, while the senior admitting worker is a support position that covers preadmission and admission functions. PAS teams are based on individual patient units but report directly to the admissions and registration department.

The teams handle everything from the time the physician decides to admit the patient until post-discharge, Irwin says. "When the account leaves our department, it goes straight to the billers."

When the patient is discharged, the PAS team is responsible for retrieving the medical record from the nursing unit, doing all the abstracting such information as how the patient was admitted, the number of consults, operative reports, and other state reporting requirements and then sending the medical record directly to the coders, who code the account for billing. It then goes to the medical records department.

In the past, financial counselors would enter financial summaries, then patient accounts would hold the account for billing until all requirements were met, such as obtaining discharge summaries or hard-copy certifications, she says.

When all these functions were consolidated into the PAS team, patient accounting, utilization review, medical records, and coding decreased their staffs proportionately, Irwin says. There also was an overall decrease of 10 FTEs among the five departments involved, she adds.

The PAS teams initially processed all Medicaid continued stay reviews, but after a while it was determined that this was not an efficient use of time, so the task reverted to UR. However, the teams still handle Medicaid extensions for transplant patients.

PAS team members all of whom had to apply for their positions underwent an extensive, four-module training program, spending two to three weeks in each department whose duties they were taking on. Staff of those departments conducted the training. After about a year and a half, Irwin says, the admissions and registration department took over the training, with support from technical advisors from each of the other departments. This facilitates the incorporation of innovations and reinforces the best practices from each department.

Key to the program’s success was the development of a time line for the ASAs, showing when certain tasks had to be completed, because the team’s duties affect the operation of other departments, Irwin points out.

"Every other area’s performance is contingent on receiving work from us, so it was important to [establish] when discharge folders had to be processed, when the chart information had to be sent to UR, and when the medical record had to be in the coding department," she adds. "For example, for patients discharged yesterday, the medical record is required in coding by 1 p.m. today within 24 hours. This was crucial. We wanted to make sure we didn’t negatively impact the departments we were assisting."

Although the teams report to admissions and registration, they are stationed full-time on the nursing units and become part of the team on that floor, Irwin notes. "They’ve already dealt with [the patient] during preadmission, so if there is any question in-house regarding that account, the financial counselor is there to handle it."

PAS team members work with unit secretaries to obtain charts, and the admissions and registration department provides periodic inservices for the secretaries on issues such as proper chart order and the need to obtain medical records on a timely basis, she says. "We stress that what they do impacts reimbursement, that if the chart is out of order, [medical records] may miss something major and decrease the amount of money the hospital gets paid."

The inservices with unit secretaries are done in conjunction with a representative from medical records or coding, Irwin says.

^{Teamwork improves collegiality}

The task force that created the eight PAS teams continues to meet bimonthly, she says, and the ongoing collaboration has created a strong sense of teamwork and an atmosphere in which employees are "less likely to point the finger" at others. The task force monitors baseline performance measures and sets new benchmarks for the PAS teams.

Adding to the cooperative spirit is Partners in Excellence, the hospital’s incentive program in which teams throughout the facility are assessed on performance, Irwin says. Meeting certain goals brings cash bonuses. For this program, all 28 PAS team members, plus additional coding, utilization review, patient accounts, and medical records employees about 116 people are part of one team, she adds.

In addition to having a tremendous impact on account receivables, PAS teams have given the admissions department a different focus, Irwin says. As an example, she cites the answers department employees gave consultants when they were asked to name their primary goal.

Instead of offering a typical "admissions answer," such as "getting patients admitted quickly," the employees mentioned things like getting a totally secured account or getting maximum reimbursement for the hospital.

"Our staff is very focused on the receivables end," she adds. "They have a much enhanced awareness."

The PAS teams have prompted positive feedback from both patients and physicians, Irwin notes. Patients appreciate going directly to the floor upon arrival and dealing with the same employees during admission and for any follow-up questions or concerns, she says, and physicians know who to ask if they have questions about, say, home health coverage for a particular patient.

[Editor’s note: For more information, contact Ruth Irwin, manager of patient administrative services, department of admissions and registration, UCLA Medical Center, 10833 Le Conte Ave., Los Angeles, CA 90095-1734. Telephone: (310) 206-8529.]