In a time of increasing patient payment burdens, many hospital revenue cycle teams are exploring patient access best practices in an attempt to get a handle on accounts receivables. Some hospitals have doubled point of service collections. How do they do it? We take a comprehensive look at patient access best practices including systems, denials, pre-registration, and training for teams dealing with patient financial discussions.
Patient Access Systems, and RCM Pain Points
In a recent article in Becker’s Hospital CFO Report, their team asked around 20 industry insiders about “pain points hospitals feel”.
James M. Lyons, President and CEO, SSI Group shared: “Everybody in our industry is faced with the payment burden being shifted to the patient. This is a cash flow business, and when you have shrinking reimbursement every year… having that claim pass through the process the first time is a benefit to cash flow.”
In a nutshell, it’s all about collecting payments efficiently and avoiding denials. And more patients now have to dig deeper in their pockets to pay. In June of this year, RevCycle Intelligence reviewed a recent study by TransUnion that found “Total hospital revenue attributable to patient financial responsibility after insurance increased 88 percent between 2012 and 2017”. The article also observes that, “despite the challenges bad debt poses to providers, a significant portion of provider organizations do not have a comprehensive strategy in place to recoup revenue stemming from past due patient financial responsibility.”
In a related article for Nasdaq.com, the concept of “the patient is the new payer,” was raised since, “as costs continue to rise for patients, uncompensated care – a combination of bad debt and charity care – is also rising. According to the American Hospital Association’s 2017 Hospital Fact Sheet, uncompensated care increased by $2.6 billion dollars in 2016, the first increase in three years. The continued trend of increased PBAI has amplified bad debt exposure to providers, thus significantly contributing to the rise in uncompensated care.”
“At a large academic medical center, we were able to increase monthly POS collections from $1.4 million to $3.3 million in six months through the launch of a ‘Compassionate Collections’ class. Using a scenario-based curriculum, we taught employees how to have the conversation with patients in a respectful manner. We found gaps in training for staff not reporting directly to the revenue cycle. We were training how to post payments in the EHR and not teaching how to ask for payment. They are two different things entirely,” explained Rebecca Haymaker, director of Epic services at Parallon Technology Solutions. — From a recent tip we found in Becker’s CFO Report.
Is your billing system “broken”? In this comprehensive article we look at both systems that work, and those that could work a lot better. Regarding broken systems, Modern Healthcare, first noting that patient payment amounts are on the increase due to high deductible insurance plans, recently analyzed a report by TransUnion that revealed, patient payment represents a growing share of health systems’ revenue, putting consumers and providers in precarious positions. We’ve seen similar challenges and solutions for these problems at our hospital clients, so we’ve gathered some of the latest strategies and tactics for you in this article
Denial Management… for Patient Access Best Practices
RevCycle Intelligence has reported that, “claim denial rates ranged between 0.54 percent and 2.64 percent for major private payers, while Medicare denied close to 5 percent of claims, according to the American Medical Association’s health insurer report card. As a result, claim denials cost healthcare organizations about 5 percent of their net revenue stream.” Add to this a startling finding that “approximately 65 percent of claim denials were never corrected and re-submitted to payers for reimbursement (study by Medical Group Management Association)”.
In the same article, the best way to address this is suggested with an eye on technology that helps hospitals avoid denials up front. “Upgrading or installing patient scheduling and registration systems is critical to preventing claim denials. About 90 percent of claims denials were preventable, the Advisory Board reported. Common denials reasons, such as incorrect patient demographic information or incomplete insurance verification, can be solved through patient registration systems.”
SSI’s David Mistkawi, VP Access Management Solutions, delivered a recent webinar focused on reducing denials starting up front at patient access. Below, one of Mistkawi’s slides from the presentation shows how traditional processes result in a several month process for collections when an emphasis on back end collections is in place.
From a webinar by SSI’s David Mistkawi, VP Access Management Solutions, showing typical slow results of 1-5 months for Hospitals to get paid. Mistkawi showed how emerging technology for hospital patient access systems featuring point of service collections is shortening the payment period and yielding better margins. This is a key solution in patient access best practices.
Mistkawi explains that great gains can come when hospital revenue cycle teams flip this long backend focused process around. He calls it “flipping the pyramid” that comes when the patient access team focuses more on patient financial clearance. When you begin to collect a portion of accounts receivable (AR) upfront, your overall AR days to collection are reduced. Improvement from 45 days to 40 AR days will provide a one-time release of over $680K into the system.
According to a 2017 study of SSI hospital clients, Mistkawi emphasizes that improvement from 45 days to 40 AR days will provide a one-time release of over $680K into the system, on average. Taking that number down to 35 days will strip out $1.4M in costs from the system. Now you have cash that can be used to buy needed medical equipment, a new parking structure for increased patient satisfaction or improved revenue cycle software and workflow automation solutions.
As you look for the proper solution to address your patient financial clearance objectives, a few points need to be considered.
- An enterprise solution that can tie together the entire revenue cycle
- One that is HIS agnostic and fully integrates into your system to provide real-time status of a patient’s visit
- An encounter based workflow that is exceptions based
- That begins with the patient/guarantor information needed to start the process towards achieving full financial clearance
- And offers best patient access technology solutions for:
- Address and ID validation
- Patient benefits confirmation
- Automatic Med Necessity confirmation for all Medicare patients
- Notification of Admissions
- Prior Authorization
- Federal Poverty Level & Patient’s Propensity to Pay
- Multiple means in which a patient can pay for the services before and after discharge.
- Proper report automation so that users and managers can spend their energy on exceptions to achieving patient financial clearance.
With such a focus your organization can better address potential Patient Access denial pitfalls upfront. The financial gains can be tremendous. The SSI Group has considerable expertise in this area with proven tools for your patient access solution.
In a recent case study for one of our hospital clients we learned that “without access to eligibility verification tools, claim denial rates at Unity Health – White County Medical Center were elevated. In fact, as the organization began analyzing their processes, they discovered their technical denial rate was eight percent, versus one percent – or lower – for a leading practice. While this may not sound like a dramatic difference, it equated to a noteworthy $2.7 million per month at risk for the hospital. With this knowledge, Unity Health – White County Medical Center quickly identified a need to alter their practices in order to establish denial prevention strategies on the front-end of the revenue cycle, rather than waiting to address potential issues on the back-end when it is often too late.”
- Your SSI reporting team has published a series of articles to help you with managing hospital payment denials with strategies and tips to reduce them.
Hospital Point of Service Collections
In addition to the accuracy that reduces denials, we have seen a number of clients improve their overall revenue cycle management return by focusing on point of service at patient access. We recognize that the pressure on healthcare financial executives exists from all angles. An increase in patient financial responsibility, growth in bad debt, need to reduce operating costs–together, these factors demand a more proactive patient access approach to maintain a healthy cash flow. It is why we continue to evolve and improve our SSI Patient Access Director solution.
The solution that doubled point of service collections: Jon Neikirk, executive director of revenue cycle at the three-hospital, Milwaukee-based system, explained that a major part of the solution was creation of the “Financial Engagement Department.” Their three-member team has “a director of financial engagement, a project manager, and a trainer, and its annual staffing cost is about $250,000.” And, “creation of the Financial Engagement Department was necessary because Froedtert’s revenue-cycle team did not have a significant leadership role for registration and scheduling staff.” — from a case study from Froedtert, a Wisconsin health system
Writing for HiTech Answers, Jamie Gier lists five best practices for what she calls “centralizing patient access”:
- Implement Real-Time Integrated Orders – Embed electronic orders and automatically match orders with scheduled appointments to eliminate delays and frustration from phone tag, lost orders, and faxing.
- Embrace Front-End Revenue Cycle – ensure medical necessity is met, insurance eligibility is verified and authorizations and orders are obtained prior to the scheduled appointment, leading to higher reimbursement and fewer denials.
- Explore Consumer Self-Service – Enabling patients at their convenience from any device to self-schedule appointments at all locations across the network is key to remaining competitive.
- Add Provider Self-Service – Offer providers convenient self-service/correspondence tools to reduce inbound call volume, improve productivity and reduce network leakage.
- Implement Appointment Reminders – To limit the rate of no-show appointments, which is as high as 30 percent nationwide, health systems must integrate automated patient communications directly into the patient experience.
These are great ideas, but we often hear questions about how to educate staff and empower them to maximize point of service collections. For some hospitals the HIT tools are there but not the needed staff training. We like a recent tip we found in Becker’s CFO Report. “At a large academic medical center, we were able to increase monthly POS collections from $1.4 million to $3.3 million in six months through the launch of a ‘Compassionate Collections’ class. Using a scenario-based curriculum, we taught employees how to have the conversation with patients in a respectful manner. We found gaps in training for staff not reporting directly to the revenue cycle. We were training how to post payments in the EHR and not teaching how to ask for payment. They are two different things entirely,” explained Rebecca Haymaker, director of Epic services at Parallon Technology Solutions.
Central to hospital point of service solutions is a focus on the patient’s needs. And, sometimes the point of service happens before a patient sets foot in your facility. Patient Engagement HIT offers a long, thoughtful article on patient pre-registration with some good tips after first noting that, “if handled incorrectly, this series of initial touch-points can lead to a number of ongoing issues, including overwhelmed patients who may decide not to pursue their care at a facility that is chaotic or disorganized.”
The article goes on to note that “Pre-registration requires significant coordination between several moving parts, says the Healthcare Financial Management Association (HFMA). A high-functioning pre-registration system usually includes: a dedicated unit, team, or staff member depending on practice size; integrated systems and processes between scheduling and pre-registration; a policy of postponing services if the patient is not preauthorized or pre-registration is incomplete; available financial counseling.”
Does your facility have a dedicated “new patient coordinator” (NPC)? That’s another recommendation that emerges in the article. Once you have an NPC, and after determining practice-wide goals and protocols, organizations can create a “pre-registration script”. The NPC will use this script when talking with patients to ensure the staff member does not miss a certain prompt or forget to ask the patient an important question.
Inevitably, financial conversations with patients are part of an efficient point of service collection process. Health Leaders Media recently detailed a case study from Froedtert, a Wisconsin health system and teaching hospital, showing how they doubled point of service co-pay collections.
Jon Neikirk, executive director of revenue cycle at the three-hospital, Milwaukee-based system, explained that a major part of the solution was creation of the “Financial Engagement Department.” Their three-member team has “a director of financial engagement, a project manager, and a trainer, and its annual staffing cost is about $250,000.” And, “creation of the Financial Engagement Department was necessary because Froedtert’s revenue-cycle team did not have a significant leadership role for registration and scheduling staff.”
Froedtert’s Financial Engagement team assists with:
- Development of training material
- Providing supervisory reports for registration and scheduling staff leaders
- Teaching supervisors how to hold their staff members accountable
- Conducting training sessions, including remedial training
Training is the central key to this solution and features e-learning courses as well as in-person instruction. Role playing is also part of the education process. The final part of the training is with registration and scheduling staff on how to use a trifold billing brochure to acquaint patients with multiple elements of Froedtert’s patient financial experience.
We think this case study illustrates some of the best approaches we have seen with our own clients including education for relevant staff and designating a strong leader/team to implement new processes.
- The AMA (American Medical Association) offers an online training module on adopting a good patient pre-registration process (CME credits available)
Best Practice Recommendations for Patient Access
The Advisory Board, a healthcare consulting firm, recently published a list of strategies for best practices in patient access. Stating that “the average 350 bed hospital stands to gain $22M by achieving best practice in the revenue cycle, and it all starts with the front-end,” they list a few key take-aways from a recent summit they held:
- Access starts with a clear vision and sponsorship (the structure of the “ownership” of patient access is crucial)
- You can’t get anywhere without your physicians on board
- Metrics are easy to get—insights are much harder. 45% of the summit group stated that there are just too many metrics and data sources to track; after that, 33% said the biggest challenge is in making data actionable.
- You don’t have to tackle everything at once (start with a pilot project or two)
These are a good start, to which we would add — your access “vision” should include clear guidelines for upfront collections and a mandate for same. A central of that puzzle is patient identification. Health Leader’s Media published a recent post with six ideas on how to tackle this:
- Double, triple, quadruple check: Consider going beyond two-factor authentication (using three or four factors such as adding home address is more effective).
- Hear it from the patient: Asking patients to verbally state their authentication factors is more effective than having registrars ask “yes” or “no” questions to verify information.
- Photo ID: Adult patients should be required to present a driver’s license or some other form of photo ID.
- Confirm accuracy: patients should read their wristbands to confirm the accuracy of their registration and also on the registrar’s computer screen.
- Take patient photos: Healthcare organizations should consider taking photos of patients and including those images in medical records to deter medical ID fraud and helping clinicians to see that they are treating the right patient.
- Registration kiosks: these can take a patient’s photo, they can match images of a patient to a photo ID or photos in a database, and they can require patients to verify their demographic information.
We also found a PDF slide deck from NAHAM’s (National Association of Healthcare Access Management) 40th Conference and Expo. covering best practices and standards. Key concepts include positive patient identity, smart automation of workflow, smart analytics and increased database integrity.
- SSI Access Director System: SSI Access Director helps patient access teams focus their efforts on addressing front-end revenue leakage by moving tasks traditionally completed by the billing office to the front-end of the revenue cycle. In doing so, payment problems can be proactively resolved before they occur, maximizing revenue and enhancing the patient experience as a result.