Can you justify automating quality assurance?
Tool becomes access staff's 'best friend'
Some patient access departments are finding they need to put technology investments on hold due to budget cuts, but automating quality assurance (QA) just might be an exception.
Within the first three months of implementing an automated QA system, the patient access department at Orlando (FL) Health was able to drop a day off its bill hold tables. "And that, of course, equates to significant dollars," says Craig Pergrem, MBA, CHAM, corporate director of patient business. "Through that drop of a day in the bill hold, our system paid for itself."
Pergrem says he considers the automated QA system "one of the greatest learning tools we have in the organization. Every single day our access folks log in to their activity from the day before which we will soon have in real time and they are educated on what their activity was from that day. If you look at that from the standpoint of a new person who is still finding their way through all the things they need to know, it becomes their best friend."
In this way, access staff are clued in to the mistakes they are making, without the embarrassment of being approached by a supervisor. "It all becomes part of their job. Once they correct the mistake, we have found they rarely create it again because they remember how it all happened," says Pergrem. "That one fact alone justifies the cost involved in having a QA product."
100% of registrations are reviewed
Denise Helm, director of patient access at St. Rose Dominican Hospital in Las Vegas, says her department is implementing an automated QA system. "There are admitting error checks that are built in," she says. "In addition, the system will provide us with the reports and the ability for more efficient and effective QA."
A single individual serves as the department's trainer and QA person. After she trains new hires, they fax their productivity sheets to her, and she performs QA and provides feedback to the managers.
"In a perfect world, we would have enough resources to QA 100% or even a percentage of everyone's work," says Helm.
The benefits of the automated system, she says, will include holding employees accountable and more accurate account information, which hopefully will result in clean claims and faster turnaround time for payment.
With the automated tool, 100% of registrations at Orlando Health are reviewed, compared to only 10% that were reviewed with manual audits.
Front-end audits are important for a number of reasons, says Kristy Summers, manager of quality assurance and revenue management. These include timely reimbursement, consistency between points of registration, regular training, and performance feedback for financial counselors.
"These benefits can be seen through a manual or an automated audit. The difference, of course, is in the impact," says Summers. "The ability to review 100% of registrations has a much greater impact than the 10% sample the manual audit provided."
Pergrem says that after the system was implemented, "we saw an immediate change in our accuracy, both from a financial and a morale standpoint. When you look at critical errors causing a bill to not drop, you are looking at dollars that are delayed in getting paid. It only takes one small error to really begin to add up."
Pergrem also reports that there was a "huge shift in the morale of the access departments. They saw their quality scores were high, and they became part of the process flow that runs through a revenue management area."
Learn more about your errors
According to Stephanie Benintendi, patient access director at The Children's Hospital in Aurora, CO, "The issue we have faced historically is that we really didn't have the processes in place to get that information down to the frontline staff level. We never really knew if we were doing a good enough job to get the bills out the door."
About four years ago, the patient access department went through a revenue cycle engineering process, which moved processes from the back end to the front end.
"So we now know on a weekly basis what our errors are, and we are the ones responsible for working them before the bills actually go out the door," says Benintendi. "The down side is, the system doesn't tell me the person who created the error. We just know in general how each area is performing."
Reports revealed that the weekly error rate was much higher than it should be. "We have a weekly goal of about half a days' worth of revenue or charges. We should not have dollars in excess of that. If we are anywhere close to that, then we are obviously doing something wrong," says Benintendi. "And we were pulling one to one and a half days' worth of charges sitting in our bucket waiting to be fixed." She approached individual staff members to ask what could have been done differently, and they told her that they needed to see the big picture.
When doing computer training, the different fields may have made sense to staff, but when staff came face to face with actual patients, the information often was omitted. "In the line of duty, they'd get nervous and would forget everything they are supposed to ask. There were multiple data points on each screen, and when you are not sure what's going on, you forget all that stuff. Staff needed to see how the data fit into each process."
To address this, the department changed the way its new hires were trained. The problem, says Benintendi, was "we were spending almost four full days of training on the front end as soon as they walked in the door. We found that we were training too much, too soon."
The training schedule was adjusted. New hires now spend at least 40 hours on the job shadowing before going to training. After staff complete the training, they spend another 40 hours with a mentor practicing what they learned in training, to make sure they are following the right process.
Data ID's a costly problem
At The Children's Hospital's patient access department, data revealed that staff often failed to ask a child's parents for his or her date of birth a piece of information that is necessary to process the claim.
"We didn't realize that because we didn't get the subscriber's date of birth, it was holding up hundreds of thousands of dollars in billing a week," says Benintendi. "Now, we make sure it's covered not only in training as a very specific line item, but also by giving a competency test at the end of training, to make sure they understand the importance of it."
Every week, Benintendi gets a report that breaks down every single error and dollars associated with that error. For errors involving a missing subscriber date of birth, the department is now at zero dollars and zero accounts.
Patient access staff are now charged with identifying and correcting errors such as these. "Within our department, we have a career ladder with three levels. Anyone with a Level 2 or higher is going in and fixing those errors," says Benintendi.
These staff members are taught to look for repeated mistakes made by individual patient access staff, such as putting down the wrong group number of a Medicaid patient.
"They might say, for example, 'I notice Mary keeps making the same mistake,' and can go to the supervisor so that she can get some one-on-one training," says Benintendi.
A quality review process is done by looking at five accounts per person per month. These are scored based on whether the accounts have all the required information and corresponding elements. "If not, they check whether there is documentation to show why they didn't get it," says Benintendi.
A weekly report on errors is sent out to all of the staff so that they can see what mistakes are being made and where improvements have been seen. The trainer does reviews at 30, 60, and 90 days. "By the time they make it to the 90-day probationary period, they are at, or close to, meeting the quality standard," she says.
Turnover is very low
To keep staff current on payer requirements, an insurance analyst on the hospital staff notifies them about key changes. In addition, all staff are required to take a refresher class two to four times a year. "If patient access staff don't get it right, the hospital doesn't get the revenue," says Benintendi.
Benintendi credits her department's success to dramatically decreased turnover, which she acknowledges is partly due to the economy. In the admissions department, voluntary turnover was just 3.23% last year, compared with previous years with turnover in the 20% or 30% range.
Another reason for the low turnover, though, is a revamped career ladder program. "We made a very strong effort with this," says Benintendi. "We had a career ladder in place for four years and had very little utilization of it. So we did a big campaign to move people through."
Currently, 15 out of 38 staff members have participated in the career ladder and successfully moved up to a Level 2. This gives them a 6% increase in their base pay.
Staff often complained that they wanted more responsibility and were unhappy because they felt they were not progressing. "We started pushing back, and telling them 'There are a lot of things you can do to move up within the department,'" says Benintendi.
One way to move up is by taking the Certified Healthcare Access Associate (CHAA) examination offered by the National Association of Healthcare Access Management. The department offered to pay for the certification of any staff member. "If they took that test and passed it, they had to do a little presentation in front of the staff at a meeting, such as on a policy we weren't following very well," says Benintendi.
Other requirements include being cross-trained for all the different areas in the patient access department, taking a medical terminology test, and exceeding a copay collection goal by at least 10%. "Many staff members had already done most of those things, except for the CHAA. We told them, 'You are just one test away from the next level.' Since our campaign, we have lost only one person, who transferred to grant writing."
[For more information, contact:
Stephanie Benintendi, The Children's Hospital, 13123 East 16th Avenue, B080, Aurora, CO 80045. Phone: (720) 777-8021. [email protected].
Craig Pergrem, MBA, CHAM, Corporate Director, Patient Business, Orlando Health, 1414 Kuhl Avenue, Orlando, FL 32806. Phone: (321) 841-8261. E-mail: [email protected].]
Some patient access departments are finding they need to put technology investments on hold due to budget cuts, but automating quality assurance (QA) just might be an exception.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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