Theodore Roosevelt, the 26th President of the United States, in a speech in New York on September 7, 1903 said, "Far and away the best prize that life offers is the chance to work hard at work worth doing." I would guess that Mr. Roosevelt was not talking about working as a patient access representative in a hospital, but I don’t see why his words would not apply.
As the beginning of the revenue cycle, patient access representatives clearly have work worth doing. As you know, if our work is not done correctly, the hospital can suffer financially and may be in a position where it can no longer provide care. Our work in patient access is critical to the overall success of any health care organization.
What can we do as patient access professional managers to ensure that our staff can"be the best that they can be"?
Patient access management provides some challenges in that the staff that we coach and mentor are spread out of different areas and work 24/7/365. There are several concepts that are important to help ensure success due to these challenges:
- Manage Pro-Actively not Reactively
- Provide Standards for all aspects of registration
- Hold staff accountable
- Provide consistent feedback
- Tailor training programs to adapt to a constantly changing healthcare environment
Healthcare managers, due to the nature of our business, tend to manage in a reactive manner. This practice is tempting, but has a negative effect long term as mangers can easily become"burnt out" from constant negative attention. I challenge all patient access managers to manage in a proactive manner. Anticipate problems, see trends, create data (more on this later) and spend time working on ways to address consistent problems.
It is difficult to evaluate staff without first establishing clear standards and expectations. If you ask most patient access staff their job function they might say something along the lines of"to efficiently and accurately interview my patient and enter that information into the hospitals information system." This statement is interesting to me in a department that does not have published standards and expectations. It leaves too much open for interpretation. Experience shows that creating standard methods of entry for each and every field within the registration reduces the overall error rate.
You need to be specific about the standards that you create. For example, take the address 123 Main Street. There are at least three ways to enter this:
- 123 Main Street
- 123 Main St
- 123 Main St.
It makes little difference which you pick as your standard, but a standard needs to be established and staff monitored and held accountable to that standard. We all know the importance of establishing eligibility at the time of service. A standard should be established that the response to can be scanned (or in the case of a facility that does not have scanning a copy) and should be placed in the patients physical or virtual folder.
Once the standards are established and you are managing more pro-actively you must make sure you build accountability into your evaluation process. It is human nature to be less careful with your work when you know no one is holding you accountable. For example, if the IRS never prosecuted those that did not pay their income taxes I venture to guess that very few of us would pay. In order to hold staff accountable you must provide constant and consistent feedback on their work. The feedback needs to be current (within 2 weeks of the registration) in order to have the intended impact.
Successful facilities incorporate the elements discussed above along with making sure that training is provided to address areas of deficit.
Registration Accuracy Tools
Providers and patient access managers and directors, in particular, have developed three popular solutions to create data sets in order to determine registration accuracy:
- Development and implementation of a manual account review process
- Purchase or development and implementation of automated account review software
- Outsourcing part or all of the review process
Each solution emphasizes the positive work done by the access representative and drives them to identify issues that lead to the root cause in order to prevent future errors. Patient access representatives make errors for the following five reasons:
- Simple data entry error (since it is a human-based process, these errors always will occur, but can be reduced through accountability)
- Lack of appropriate training
- Lack of the right tool required to obtain or validate information
- Representative lacks a good work ethic and is indifferent to his/her quality of work
- Representative tries hard, is conscientious and has been trained repeatedly, but does not possess the skill set required to be an effective patient access representative
The first three issues can be addressed through the solutions mentioned above. Issue number four also is easy to address through termination. Issue five is the hardest to deal with—not everyone possesses the skill set and abilities required to be an effective patient access representative.
Training in patient access is a vital element to success. Creating accountability and determining areas of opportunity for improvement are only the starting points. What you do with the data is where real progress is made. Training in patient access typically involves a short orientation and demonstration of how to enter information into the provider’s HIS, and then a preceptor period with an experienced staff member. The risk with this method is that there is no consistency in training, and no assurance that changes in process are effectively relayed to the new employee, or even to the preceptor. Experienced staff members may do things in different ways and may not adhere to one strict standard.
Solution 1: Development of a Manual QA Process
In order to hold staff accountable, many providers have developed manual quality assurance programs to determine registration accuracy. Generally during this process, an individual or team of individuals reviews a percentage of the overall registrations. The QA staff member is provided a copy of the face sheet, insurance cards, patient identification and any electronic eligibility response obtained. The reviewer then reviews elements in the registration to validate the data as well as the relationships between data elements, and provides an error count for each registration they review. Most manual processes have the ability to review 10 percent to 15 percent of overall registrations within a facility (sometimes this is limited to patient access and sometimes it can extend to those areas that still perform registrations but do not report to patient access). Best practices require that the data collected during the review process be translated into a scorecard for each individual registrar as well as the department as a whole.
Providers can then compare representatives working on the same shift and department to establish results and statistics for use in the department overall. This approach is effective in that it provides a method for establishing accountability among staff, as well as provides a mechanism for establishing the accuracy rate of the department and identifying areas of opportunity for improvement. This generally results in an increase in staff. However, the effectiveness is limited. Limitations include:
- A review of 10 percent to 15 percent will uncover large global issues within the department; however, it is difficult to discover less common errors or issues as they will manifest themselves over time.
- It is costly to have a dedicated staff member to the quality assurance process.
- The reviews are generally done post discharge and post bill drop, so these programs are reporting mechanisms and would still mean that the errors will cause rejections and denials, requiring re-work in the business office.
- There is the potential for skewed results as the quality assurance staff member may tend to underreport errors incurred by his/her colleagues.
Solution 2: Purchase or Development of Automated QA Software
In the past several years, a number of companies have developed software to perform account reviews modeled on the success of the manual processes. These software programs have advantages over the manual process in that they can provide 100 percent review of registrations for a given date of service. The programs generally are rules based (whereby the rules are set up by the provider) and they report back the results to the individual staff member on either a daily basis or a real-time basis. The representatives are then required to correct their error so that the billing process can proceed without intervention. Reports are available so that management can perform analysis on rules violated and errors created by staff. In addition, comparisons can be made between shifts, areas, etc., similar to the manual process. Because the software provides a 100 percent review, errors or issues that typically are less evident can be uncovered more quickly (assuming that the software is utilized appropriately by management). These programs have proven to be highly effective and provide a good return on investment (ROI) for providers. However, there are some limitations including:
- The software can validate that data elements are present in the correct format, but they cannot validate that the entries match to the patient.
- The software requires some maintenance to make sure that the rules remain current.
- Staff receives feedback on their work and must fix errors, which promotes an environment of continuous learning. However, if your department experiences high turnover, you will incur a constant flow of errors during each representative’s learning curve. This time period can vary from three to six months.
- Even if all information is correct, there is no guarantee that the claim will be paid by the payer. Rejections and denials still exist for eligibility and authorizations even if the information is entered and transmitted to the carrier correctly.
Solution 3: Outsourcing/Co-sourcing Part or All of the Review Process
In the past eight years, advocates have been implementing the previous two solutions. These solutions are effective in improving a patient access department’s output. However, they do not address the inherent problems present in patient access departments, including the problem of low-level/entry-level employees requiring intensive oversight of their work. Another challenge is the complex systems which along with the constantly changing environment within the healthcare industry makes training a never-ending process. Even with all the best practices and tools in place, payers still reject and deny claims. There is a hybrid solution, which provides the best of solutions one and two, and also provides additional benefits.
As discussed earlier, manual QA processes are labor intensive and require a significant commitment of resources, including human resources as well as desk space, computers, etc. This new model allows for 100 percent account review utilizing live resources. Typically this hybrid solution utilizes some blended-shore resources, leveraging both time zone and labor arbitrage benefits in order to accomplish the review economically and in a timely manner. It requires a partnership with providers to review typical areas of deficit as well as any area that the provider desires to focus on. The process begins with establishing a daily electronic file transfer and the following partial list of items are validated:
- All insurance information, including ID number, group number and proper selection of carrier and plan
- Demographic information, including patient and guarantor address, date of birth and social security number
- Encounter specific data, including physician selection and proper diagnoses present
- Authorization numbers, where required, including a review to ensure that the number provided matches the procedure performed
When errors are identified, they are corrected within the provider’s HIS prior to bill drop to ensure a clean billing process.
Providers have the ability to customize the areas of review and can change the parameters at any time. Scorecards are provided back to the provider on a minimum of a weekly basis. In addition, staff reviews the results of the scorecards and assists in identifying opportunities for additional education.
The final piece is the process for rejection/denials processing. For any claim that has been validated but is later rejected or denied by the payer, patient access staff will challenge this rejection/denial for the provider. This allows the provider to adjust staffing patterns and costs by reducing or redeploying resources required for the re-work necessary to process claims that have been rejected or denied.
A manager needs to have the right people in the right position doing the right things right. Through managing pro-actively and developing consistent ways to monitor and evaluate staff work on a current basis patient access managers will be able to provide document able evidence of changes they have made to improve the performance of their department.
About the author
Michael S. Friedberg, FACHE, CHAM is the Associate Vice President of Patient Access services at Apollo Health Street a leading provider of business process outsourcing to the healthcare industry. Michael is a member of the NJ Chapter HFMA, A founding member of the Patient Access Committee and is Co-Chair of this committee for the 2009-2010 chapter year. Michael can be at [email protected].
Opinions expressed in articles or features are those of the author(s) and do not necessarily reflect the view of the New Jersey Chapter of the HealthCare Financial Management Association, or the Publications Committee. The HealthCare Financial Management Association and the Publications Committee assume no responsibility for the accuracy or content of any article or feature on the website.