Both patient access and billing staff are part of the revenue cycle; however, they do not really feel like colleagues since they never see one another at work. That has changed at Stanford Children’s Health in Palo Alto, CA. “We’ve done a lot of work to create opportunities for roles to overlap,” says Shawn Tienken, MHA, director of revenue cycle operations.
It starts at the top of the department. Patient access and billing leaders (from both the hospital and professional side) meet for a few hours every Monday afternoon. “It’s a forum to talk out major revenue cycle issues, and how proposed changes might affect one side or the other,” Tienken explains.
Right from the start, new revenue cycle hires receive training that tells them where they fit into the process. “We try to lay some foundation,” Tienken says. Trainers explain how errors made at the beginning of the patient’s hospital stay (during registration) cause problems in coding, billing, and charge capture.
But it does not end there. Patient access staff learn about the “back end” very well by observing those employees at work. “That’s where people get exposed to the workflows of their peers,” Tienken says.
This familiarity reduces the temptation to complain about unproductive or mistake-prone counterparts. Sometimes, it even leads to someone realizing he or she would rather work a different revenue cycle role. For instance, some billers really want to interact with patients. Similarly, registrars sometimes love the culture of the back end office and want to be a part of it. “Employees are encouraged to pursue open roles in those departments when they become available,” Tienken notes.
Revenue cycle managers are expected to provide coaching and guidance to staff who are seeking to change roles. This way, says Tienken, “they develop the skills necessary to succeed in their desired position.”
When any changes are planned for the revenue cycle, both the front and back ends want a chance to weigh in. Often, some unintended consequences are brought to light. For example, billers always want more specificity that can avoid denied claims. They do not realize that it causes delays in the registration process. “By adding more options for people to pick from, it slows things down, and increases the likelihood of errors,” Tienken says. Recently, billers wanted registrars to identify which medical group the patient was part of. This was because certain services needed to be billed to the medical group rather than the health plan. “Revenue cycle leaders weighed these billing needs against the additional complexity this would introduce to registration processes,” Tienken says.
The group brainstormed and developed ways to use automated tools to extract the information billers required. This prevented claims denials without making registration inefficient.
Even departments outside the revenue cycle want more information obtained at registration. Recently, clinical leaders complained that registrars were not always obtaining the referring provider. They wanted this information to develop and enhance relationships with the referring community. “They said, ‘We want you to hard stop everything on the front end, so if you are not capturing the referring provider, this will make sure you do,’” Tienken recalls.
Patient access leaders objected, with good reason. They explained that the process just would not work in certain situations. For an inbound emergent transfer patient, the process change would affect clinical care negatively. This is because the “hard stop” would prevent the clinical team from placing necessary orders for the patient since the referring provider usually is not known at that point. The ensuing dialogue led to a good compromise. Registration staff are alerted to collect the referring provider but would not be stopped from proceeding without the information, if necessary. “Any missing records would be routed to managers for review and correction,” Tienken says.
On the other hand, patient access is seeking to automate some registration processes. Billing expressed some concerns about this, and asked for the chance to offer input before the system starts choosing which coverage should be applied. “We are seeing a lot of denials because the coverage is not being differentiated,” Tienken explains.
Mistakes made at registration are flagged to ensure only a correct and “clean” bill is sent. The person who made the mistake is the one who corrects it. “We don’t have people on the back end fix them. We push them right back to the front end,” Tienken says.
This process reinforces the “downstream” effect of registration errors on hospital revenue. “When people say, ‘How come you are holding onto $100,000 in claims?,’ we say, ‘Go talk to the front end leaders,’” Tienken says.
Patient access embraced this approach to fixing their own errors. “They have put in work queue volume tracking as part of their annual goals for staff,” Tienken notes. Patient access staff are fully informed on the volume and dollar value of the errors they make and how quickly they are corrected.
One reason for errors on the patient access side is constantly changing payer requirements. Sometimes, changes are made without patient access even realizing it. “The front end doesn’t necessarily have a channel to know the requirements are changing. Usually, the back end starts noticing denials,” Tienken says.
This is covered at the weekly meetings. For instance, billing leaders alert the front end that a process is needed to capture a specific piece of information for a certain payer. Recently, one managed care plan required referrals from a patient’s primary care provider prior to surgery, even if that same primary care provider had referred the patient for specialty consultation. “We needed to alert patient access staff to be on the lookout for the primary care provider referral,” Tienken says. Registrars no longer schedule surgery on short notice if the referral is not present.
Other times, the issue is that a medication or diagnostic test now requires prior authorization, or that authorization time frames are unacceptably long. Revenue cycle leaders have engaged in much discussion around payers not complying with their own contractual obligations where authorizations are concerned. “We see denials all the time that we don’t think are appropriate,” Tienken says. Revenue cycle leaders need to go through a time-consuming appeal process. Turnaround time for authorizations keeps growing longer. “We quite frequently see that as an issue,” Tienken adds.
The department just set a goal of getting a certain percentage of authorizations secured in advance. To achieve this, both sides have to work together. The front end has to keep the back end informed on obstacles with payers; billers have to report on “no auth” denials they are seeing. “If we succeed, everybody gets a bonus,” Tienken says.
Both patient access and billing staff are part of the revenue cycle; however, they do not really feel like colleagues since they never see one another at work. Bringing these groups together could lead to various improvements.
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