Coding needs priority in new access department
Training, coding issues addressed
When Anthony M. Bruno, MPA, MEd, took on the challenge of creating an access department at Presbyterian Medical Center, part of the University of Pennsylvania Health System (UPHS), one of his first hires was Colette Howerton, who became the new manager for outpatient access services.
A longtime employee of UPHS, Howerton most recently had worked as an admissions supervisor in another of the system’s hospitals. Her mission, explains Bruno, was to improve and expand centralized outpatient registration services.
Basically, Howerton has taken a two-pronged approach, he says, providing registrar support in high-volume outpatient registration areas while incorporating small ancillary areas into central outpatient registration.
When she arrived, Howerton says, all outpatient registration was centralized in one area. Patients endured long waits, and registration quality was often poor, mostly because registrars had not had the training they needed to handle the coding associated with different medical specialties, she adds.
The health system’s orthopedic clinic in particular was plagued with problems, Howerton notes. "Patients were getting tied up in a queue in central registration. The complaint was that patients were waiting an hour to register to get an X-ray, another hour to see a physician, and then another hour in radiology."
Shifting a registrar from central registration to the orthopedic clinic, after providing the needed training, greatly reduced that turnaround time, Howerton says. Not only is the chief of orthopedics "ecstatic" at the streamlining of that operation, Bruno notes; removing those patients from the central registration queue dramatically shortened the wait time in that area.
Howerton also has put in place a preregistration system for patients undergoing magnetic resonance imaging, CAT scans, and gastrointestinal services so they don’t wait so long when they arrive for their appointments, she says. Another benefit is that technicians also spend less time waiting for patients to come back to the treatment area, she adds.
The Philadelphia Heart Institute (PHI), part of UPHS’ cardiology operation, was another area in which Howerton stationed a registrar, he says. The new registrar joined an existing employee who had been splitting her time between registration and tech work, Bruno adds. "The problem there was poor registration, bills going out the door incorrectly and being rejected."
The specialized coding required for the echocardiograms and other procedures done by PHI created a particular challenge, he notes, because registrars had to recognize unacceptable codes and contact physicians for changes or clarification.
To ensure the repositioned registrars wouldn’t be missed as much from their original posts, Howerton says, she rearranged work schedules and lunch breaks to ensure more coverage during high-volume times of day.
"The people there were sufficient, but it was a question of how and where to use them best," explains Raina Harrell, who recently joined UPHS as manager of revenue cycle. "One of the first people [Bruno] hired was a manager for training, and [that individual] immediately trained the registrars from A to Z. Once it was decided that a person needed to go to an area, specialty training was created for that person."
That training included classes, as well as computer modules with accompanying tests, she adds.
"We have also taken away registration duties from smaller ancillary areas such as phlebotomy and physical therapy," Howerton notes, because the registrations performed there are more generic.
Results have been dramatic, she says. "The overall error rate for inpatient and outpatient registration is going down. Before, it was at 7%, but since the new fiscal year began July 1, 2002, it’s gone down to 2%, with a 1% rate for outpatient registrations."
Future projects, Howerton adds, will include a reorganization of the flow of information in the infusion center, where chemotherapy is done.
That area presents its own set of challenges, Harrell notes, including the need to authorize coverage for six months, or six visits, for example. Questions to be addressed include: "How long is the precert good for? How many referrals are needed? Is this one covered?"
Registrars must check to make sure a patient’s insurance coverage hasn’t changed, she adds, because with drugs priced at $2,000, mistakes can be particularly expensive.
Looking at systems issues
Harrell, who has worked with Bruno at three other health care organizations, will provide another piece of the access department puzzle. Harrell has been charged with overseeing the improvement of all systems — anything having to do with the flow of information. "You can’t make the system work if the people don’t work," she notes.
Harrell says her focus will be on cleaning up errors created by staff or the computer system. For example, she is addressing the categories of "DNFB," which refers to patients who have been discharged but not sent a final bill, and "OPEX," or outpatient exception reports, which cover outpatient accounts that have not been billed.
"What I’ve been doing is looking at things that didn’t go the way we expect them to go," she says.
"There are IDX systems in our physicians’ offices that interface with [the hospital’s] SMS system, which is for patient registration and billing," she notes. "We have a Cerner system in our laboratory for order entry and results placement, and a PA RAD system in the radiology area. That’s a real challenge. The information going from registration to billing is another challenge."
"What I do is look at the flow of information from one area to another," Harrell adds. "I will monitor error reports and transmission control errors and see what information passes from one system to another and if that system is matching information correctly. Did the same information come out when passed to the next system?"
The larger the DNFB and OPEX reports, she points out, the fewer the bills going out the door, the higher the days in accounts receivable, and the less money that is being received in a timely fashion.
"We’ve developed monitoring tools for those two reports, to see how well the hospital is doing, and if [the efforts] bring down overall billing days," Harrell says.
"There will be a report that can be shared on a weekly basis with the different departments that affect the fact that the bills are not dropping," she says, "like medical records, the business office, or any area that does charge entry, like the emergency department. It will say, These are the accounts you have been holding. Can you help us correct these errors?’"
Many of the tools Harrell is using were developed in Microsoft Excel and are put on a shared drive that can be accessed by employees in any of the affected departments. "They can be downloaded, so you don’t have to hand them out to people," she notes.
"We’re also working on a project that has to do with reimbursement for hospital-based physicians," she says. "When a patient has a physician office visit and the physician practice is owned by the hospital, there is a charge the hospital can recover."
The process is called "maps," Harrell explains, "because we map’ what the physician did, the charge for which the hospital can bill. We get paid and give the physician the money, so we pay them either way. We need to make sure we get reimbursed for all of the services."
Maintaining the chargemaster is crucial to making sure the hospital is being correctly reimbursed, she points out. "We’re in the process of going over the accounts of the past year and a half and asking, Did we bill appropriately? Did we get reimbursed?’"
The problem that can occur, Harrell says, has to do with the charge entered by the physician office. "They put a code into IDX indicating what they did — whether it was just an office visit or something additional — and the information has to come across to SMS and match to a code saying, This is what the hospital gets paid.’"
As with anything else, she adds, codes are not good forever.
"The real thrust for [Harrell] will be the revenue cycle," Bruno notes, "looking at reducing our days in accounts receivable and bringing in more cash. The maps’ project is a huge one and should be bringing in a lot of revenue."
"We’re also looking at level one claim edits," he says. "When we put claims in through software called EZ Claim, it edits out any errors, so we’re not sending faulty claims on to the payer."
If the registrar enters the insurance plan code and the identification number doesn’t match, Harrell adds, the software will catch it.
When Anthony M. Bruno, MPA, MEd, took on the challenge of creating an access department at Presbyterian Medical Center, part of the University of Pennsylvania Health System (UPHS), one of his first hires was Colette Howerton, who became the new manager for outpatient access services.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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