It's time for patient access to obtain parity with business office
Outdated compensation model is costly
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Executive Summary
Patient access employees are under-compensated at many organizations, and salaries don't reflect the expanded role of patient access, according to revenue cycle experts. Present an analysis of these factors to administrators:
- the cost of failing to obtain correct information on the front end;
- the amount collected on the front end, compared to previous years;
- savings resulting from reduced back end staffing.
Salaries of patient access employees are too low in light of their greatly expanded role, and there are serious consequences if this under-compensation isn't corrected, argue revenue cycle experts interviewed by Hospital Access Management.
"Access has become very vital, but the perception in the industry hasn't changed to accept that yet," says Michael Hester, vice president of the revenue cycle in the finance department at Nationwide Children's Hospital in Columbus, OH. "There are still too many people who think access is just a meet-and-greet position."
Hester estimates that at least a 30% to 40% increase in compensation is needed for patient access employees in his department. "Patient access salaries need to be brought not just in line with the business office, but above the business office," Hester emphasizes. "My goal is that the front end will be a higher level than the back end."
Patient access leaders must make sure hospital administrators never forget the key role access plays in the hospital's financial well-being, says Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle management at Emory Hospitals in Atlanta. Short-changing patient access staff limits the organization's ability to retain and attract competent staff with the right qualifications, argues Kraus. "Just as a poorly paid business office is likely to be deficient in billing and collections, performance issues are likely to impact poorly paid, understaffed access departments," he says.
The biggest selling point for patient access leaders seeking to attain parity with the business office, or perhaps even pulling ahead of those salaries, is the shift in collections responsibility to the front end, says Kraus. This includes both point-of-service collections and accurate completion of patient financial records prior to billing to produce a clean claim.
"To do this well involves a level of staff training and expertise at least the equal of business office billing and collections staff," he explains.
Who they're putting in the front end
More than half of revenue cycle executives are now staffing the front end with their strongest revenue cycle employees, according to a recent survey.1 Steven S. Lazarus, PhD, president of Boundary Information Group, the Denver healthcare consulting firm that conducted the survey, says, "Some of the skill sets that are being moved to the patient access departments have historically been performed in the business office collections operations." Examples include financial discussions during appointment scheduling, pre-registration, and collection of more detailed demographic information.
The migration of financial counseling from the back end to the front end prevents unpleasant surprises with billing and collections because it puts a patient's finances in order prior to date of service, says Kraus. "The increase in responsibility and accountability applies across the range from entry-level staff to director," he adds.
Perform your own analysis
The outdated compensation model for patient access is clearly failing, argues Hester. "That's why we need to create a new model, with patient access no longer perceived as an entry-level position," he says. "There is a need to basically create an entire new job code within the industry, with a new salary range specific to that.
To demonstrate the return on investment that will come from increasing patient access salaries, Hester says to take these steps:
1. Increase the requirements for patient access roles.
Currently, most job descriptions for patient access focus primarily on entry-level customer service skills. "These are still critical, but inadequate in our current environment," says Hester. "The position is a dynamic, multi-faceted role that changes from day to day." Computer skills, independent thinking, a college degree, interpersonal skills, and conflict resolution skills are just some of the necessary requirements, he says.
"We need to market the value of the patient access rep," says Hester. "Make it more of a career path, instead of a 'Get your foot in the door until you find another job' type of position."
He says lack of qualified staff results in too much turnover, which is something that was financially acceptable when patient access was an entry-level position, but no longer. "If we can reduce turnover by just a couple of percentage points, that has a wide effect not just on the cost of recruiting, but also HR, and overtime to fill that vacant position while we are waiting for somebody to take it," Hester says.
2. Evaluate the potential cost of failing to getting the information correct on the front end.
"Denials will be reduced, and can be quantified," he adds. "Even taking a conservative approach of anticipating a reduction of bad debt by 20% and denials by 40% will still produce an ROI [return on investment] for increasing front-end salary ranges."
3. Evaluate the dollars collected on the front end, compared to historical trends.
"For every dollar we collect on the front end, we have just reduced our bad debt by 50 to 60 cents," says Hester.
4. Calculate dollars that can be saved by reducing back end staffing.
"Through the improvements on the front end, you should see a reduction of necessity on the back end," says Hester. "It is a reallocation of resources."
After patient access salaries are increased, FTEs on the back end can be reduced over the next 12 to 18 months, he says. If the front end is doing their job correctly, the back end's responsibilities should be relegated to verifying that payments were posted correctly, explains Hester.
"Nowadays, it's much more clear-cut that if you bill appropriately, you get paid appropriately," he says. "You don't need as high a technical skill on the back end as you did previously."
5. Present your analysis to senior leaders.
"Show them the positive return on investment, after you have put all those details together," says Hester. "Once they put the resources into patient access, everything else will fall in place."
REFERENCE
1. Boundary Information Group. The impact of growing patient financial responsibility on healthcare providers. June 2013; Denver. Available at www.boundary.net.
SOURCES
• Michael Hester, Vice President, Revenue Cycle, Nationwide Children's Hospital, Columbus, OH. Phone: (614) 722-2085. Email: [email protected].
• Pete Kraus, CHAM, CPAR, FHAM, Business Analyst, Revenue Cycle Management, Emory Hospitals, Atlanta. Phone: (404) 712-4399. Fax: (404) 712-1316. Email: [email protected].
• Steven S. Lazarus, PhD, President, Boundary Information Group, Denver. Phone: (303) 809-9337. E-mail: [email protected].
Compare salaries to outside industries
Look for jobs with similar skill sets
If you compare patient access salaries at your organization with those at other hospitals, the job expectations will be similar, but salary ranges are likely to be outdated.
"They are still going to be based on what the perception of patient access was, versus what it is today," says Michael Hester, vice president of revenue cycle in the finance department at Nationwide Children's Hospital in Columbus, OH.
Hester recommends a different approach. "You need to take different pieces of the patient access role —- the financial counseling component, the clinical aspect — and look at outside industries," he says. "Don't look at the title. Look at the skill set behind it." Here are some examples:
- the insurance industry, where employees handle eligibility and authorizations;
- the hospitality industry, where employees are expected to provide a high level of customer service;
- the collection industry, where salaries are typically low, but compensation includes commissions based on how much is collected;
- the coding industry, which reflects a skill set now required of patient access.
- "Compare salary ranges," says Hester. "Determine where you are in the market range and what the cost to the organization would be to change patient access salaries."
First step: Update job descriptions!
Show what staff actually do
Today's patient access employees are expected to interpret insurance identification cards, verify benefits, use various computer systems, perform real-time eligibility, obtain authorizations, and collect from patients, but salaries typically don't reflect any of these complex skills.
The first step toward increasing compensation for patient access is to rewrite job descriptions to reflect what employees actually are doing, says Michael Hester, vice president of revenue cycle in the finance department at Nationwide Children's Hospital in Columbus, OH. For example, the department soon will implement a price estimation tool that will change what employees are expected to do.
"This will put substantially more pressure on the patient access reps to ask for money from the patient, explain their insurance benefits, and why we expect copays and deductibles prior to services being rendered," says Hester.
Skill sets vary
Job descriptions don't always reflect the different skill sets involved in various patient access roles, which vary widely.
"You must consider the fact that patient access representatives have different skill sets, depending on what they do in the organization," says Hester.
Hester is rewriting patient access job descriptions at his organization. "Unfortunately, we currently have one generic job description that encompasses multiple positions throughout the organization," he says.
Patient access job descriptions should be updated at least annually, says Hester. "With technology and changes in the industry coming so quickly, the expectations are moving literally on a daily basis," he says.
Same job descriptions for front & back end
Salaries made equal
Several years ago, job descriptions for staff in patient access and the business office were made the same at Emory Hospitals in Atlanta.
"It equalized salaries and provided a career path," reports Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle management. Staff members are designated as patient accounts representatives I, II and III, and they can move up to coordinator, supervisor, manager, assistant director, and director.
"This approach hasn't resulted in staff moving seamlessly between the front and back ends," notes Kraus. "As jobs open up, staff can apply internally. Some cross over, but most stay on the side they were hired to."
Different skill sets
Matching job descriptions raised the question of whether patient access and the business office really needed to be separate, or whether these areas could be merged.
"Is it possible to develop a departmental model that does away with the distinction between the front end and back end entirely — and the internal staff animosity that it has engendered over at least the last 40 or 50 years?" asks Kraus.
Kraus points to several obstacles. "The front end and back end are pretty easily defined, and it is a traditional, deeply engrained concept," he says.
In addition, there are differing skill sets that attract certain people to one side or the other. "Even so, in the context of current revenue cycle operations and management, the time may be upon us to jettison the notion of separate staff to handle pre and post-encounter patient financial activity," he says.
Some individuals who make great business office employees aren't particularly adept at the people skills required for top-notch performance in patient access. Likewise, some potential members of the patient access staff members possess excellent people skills but don't have an affinity for the business side.
"These folks, bless their hearts, are no longer who access should be hiring," says Kraus. "Access needs staff who have it all, hence the justification for higher salaries."
Compare qualifications
Among the leading healthcare providers, patient access is well on its way to parity with business office staff, and in some cases, is already there, according to Kraus.
"If facilities experience a lag between increasing job expectations and salary adjustment, budgetary constraints are likely to be the most commonly cited reason," he says.
Kraus says to compare job qualifications for the business office with those of patient access staff. Then, compare patient access staff qualifications with real-life expectations of the job.
Finally, ask the question, "If expectations were lowered to match the current patient access job descriptions, what would be the consequences for business office and the bottom line?"
"Although it might be an ambitious and audacious undertaking, an access director could probably review such data and provide a compelling analysis," says Kraus.
