Tired of 'reactive' stance? Emphasize the good you do
Then ID areas of deficit, consultant says
A turning point in Michael Friedberg's tenure as patient access director at an inner-city, multi-hospital system came when he "got fed up" with the reactive management style.
"The problem faced is that patient access representatives are generally among the lowest paid and least formally educated personnel," explains Friedberg, FACHE, CHAM, a manager with Besler Consulting in Princeton, NJ.
Access representatives make an average of $12 an hour — just slightly more than hospital housekeepers and in the same range as Wal-Mart cashiers and pizza delivery people — yet are charged with a complex array of skilled tasks in which accuracy and confidentiality are key, he notes.
To adjust for that disparity, access leaders have become very reactive in their approach, Friedberg suggests. "If someone from patient accounting says, 'We have 12 accounts where the ID is wrong,' or 'The nephew of [a VIP] came in and you registered him as self-pay,' the access manager typically reacts to that by saying, 'We're dumb' or 'We got it wrong.'"
Tired of taking that stance, he decided to develop a system that would do two things — "emphasize the positive, good work we're doing and identify areas of deficit for increased training."
Access representatives, Friedberg notes, make errors for five reasons:
- They make "honest" mistakes, such as those caused by wrong keystrokes.
- They lack proper tools.
- They are not trained properly.
- Despite trying hard and getting lots of training, they're just not right for the job.
- They don't care about their jobs and have no pride of ownership in their work.
"The ones who don't care, the lack of training and tools, are all easy to address," he says. "There is a way to address keystroke errors, but you can't fully eliminate them.
"The hard ones," Friedberg adds, "are when you realize at a certain point that it just won't happen for them — but those are few and far between."
As part of becoming more proactive, he says, patient access managers should create a set of key indicators that are reviewed regularly by hospital leaders both inside and outside the access area. (See related article below.)
'No need to wait' for VP's call One important way to take a more proactive approach to managing an access department is to create a set of key indicators that are reviewed daily, weekly, and monthly, says Michael Friedberg, FACHE, CHAM, a manager with Besler Consulting. "Some call them 'scorecards' or 'daily dashboards' or 'KPIs' [key performance indicators]," he adds. "If you look at the same set of indicators every day as a manager, you will begin to notice trends or 'normal values' in the data. "If you see variation to those 'norms,' then you must begin to question if this is simply an outlier or if it is a trend due to a change," Friedberg notes. "For example, if you routinely measure patient wait time to be registered in your area and it has been seven to 10 minutes for a consistent period of time, and then jumps to 14-17 minutes for a few days, this leads you to question why. "Have you been short-staffed? Did you implement a new requirement? Did the volume spike due to some other provider discontinuing a service that you had to pick up?" What he is suggesting, Friedberg continues, is that there is no need to wait until there is a phone call from the vice president of nursing to say that procedures are delayed due to a slowdown in outpatient registration to figure out why. "You will get the phone call anyway," he adds, "but isn't it better to respond by saying, 'I am well aware of what is happening as I track this indicator daily; we have investigated, and here is what I am doing to address the problem.'" |
Along with being reactive as opposed to proactive, access leaders also "never really build in accountability," he says. "Even if a mistake made on an inpatient account costs thousands of dollars in delayed payment, or because a payment is not received, [the person responsible] is not usually notified of the error. It's just a black mark on the whole department."
With that in mind, Friedberg says, he made accountability one of the cornerstones of his quality assurance (QA) program, but with a positive approach.
Getting away from the defensive stance that access leaders often take, Friedberg put the emphasis on the things his department was doing right, he says. "One example: The medical records director catches the CFO in the hallway and says, 'Last month, the access people created 75 duplicate medical record numbers, and each of those cost us an hour of work.'"
When the CFO e-mailed him, asking what he was going to do about the problem, Friedberg recalls, "My proactive approach was, 'Yes, we did that, but we've also started to notify [the medical records department] when we know we've made a mistake, rather than waiting for it to be found, which is why more [duplications] have been reported.'"
Additionally, Friedberg pointed out to the CFO that the access department created 15,000 medical records during one month, and that 75 — or 0.5% — duplications was not a bad error rate.
"I told him that we are always striving to do a better job, but that other matters required my more urgent attention," he adds. "I didn't hear from him again."
QA, training 'hand in hand'
In designing his QA and training program — "they go hand in hand," he emphasizes — he took 15 specific items within the registration process and weighted them to total a 100-point score. "Most, but not all, of the items were related to billing. Picking the right insurance carrier and plan was more important than the Medicare Secondary Payer questionnaire, although both are important." (See checklist.)
"Then we started to review a minimum of 10% of registrations for each registrar," he adds. "Using Excel spreadsheets and roll-up reports, the overall score and areas of deficit were obvious quickly, by department and individual."
There is also a quantity score, which looks at the number of registrations done in a month divided by the hours worked, Friedberg says. "That number is not the number of registrations they can do in an hour, but is a number you can use to compare people in similar departments and on similar shifts."
Work done by a registrar on the 3-11 shift in the emergency department, for example, is compared to work also done on the 3-11 shift in the ED, he says.
"We were able to get interesting data, and we were able to create interesting questions," Friedberg says. "In some cases, it was easy to see where the deficits were, and we created training classes to address those. We were able to make comparisons, create standards, and initiate accountability."
In all cases in which he used the program, he notes, "the percentage of clean claims went up, the denials went down, and the reputation of the department changed."
Theoretically, in the same system and using the same tools, the ED registrar at Hospital A should exhibit roughly the same registration quality as any other ED registrar in the system, Friedberg says. "If not, it doesn't mean one is bad and one is good; it just gives you the right questions to ask."
"Is one registrar too fast, one too slow? Is one slow but gets everything right, and the other going so fast to make up for [the slow registrar] that she is missing items?" In those situations, he adds, "you make proactive management decisions as well as create training."
As an alternative to processes like the one he developed, there are a number of companies that offer automated QA systems, Friedberg says. "There are advantages to both [manual and automated systems], but the advantage of the electronic is that you can audit 100% of registrations that way."
"The downside [of an electronic system] is that this work is sort of 'touchy-feely,'" he adds. "It can tell you that the insurance ID number is filled in correctly and is in the right format, but not whether it actually belongs to that person."
In the next six to nine months, Friedberg says, electronic QA systems will be available that can go out and check eligibility and other insurance information.
On the other hand, manual processes give departments the ability to be flexible, he says. "Different states have different requirements. I had a client in Pennsylvania, where the local Blue Cross Blue Shield provider was matching the subscriber name to whatever was submitted by the hospital and, if it was not an exact match, rejected it, saying, 'We don't know who that person is.' That's the game they play."
In such instances, Friedberg advises, target the QA on that item.
In New York, there is something called a UT (utilization threshold) authorization for Medicaid patients, he says. "You have to get that number in order to bill. My New York client created that as a focal point.
"My feeling is that [access departments should] first of all, create accountability, and second, manage proactively as opposed to reactively," Friedberg emphasizes. "If you have the time and money to do an automated system, great, but anything is better than nothing."
When he first began speaking on the topic of quality assurance a couple of years ago, he recalls, 5% or 10% of his listeners might raise their hands when asked if they had a dedicated QA resource.
"Now about 50% of the hands are raised, but I question how effective those programs are," Friedberg says. "I have concerns about how they do it. I still say something is better than nothing, but those that do have something should look at how formalized it is.
"One person might say, 'Yeah, we review accounts — the supervisor eyeballs them,'" he says. "I just did a project where that happened, but when I looked at the accounts, at a variety of factors, I found a lot of things that were concerning."
One of the keys to a successful program is picking the right person to oversee the QA process, Friedberg says. "Good registrars do not necessarily make good trainers. [Trainers] have to be detail-oriented, outgoing, enjoy writing, and be accepted by the staff as a good registrar."
If you choose the wrong person, "it will delay or doom the program to failure," he says. "If you pick Suzie and everybody knows she is a bad registrar, it hurts the integrity of the QA process."
There are still many departments where the training of new access employees consists solely of having them sit next to a veteran registrar, but the tide is turning, Friedberg notes.
"Hospitals that have spent time and resources and increased staff in patient accounting departments have started to realize in the last five years that an equal investment on the front end is a good place to focus," he says. "It removes or relieves rework that accumulates on the back end."
(Editor's note: Michael Friedberg can be reached at [email protected].)
A turning point in Michael Friedberg's tenure as patient access director at an inner-city, multi-hospital system came when he "got fed up" with the reactive management style.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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