More cash, fewer denials with roving registrars
Decentralized registration program works
Shands Hospital at the University of Florida gradually is changing the face of registration and, in the process, improving the financial health of the Gainesville-based organization, says Beverly Varshovi, associate director of admissions.
The change started five years ago when registrars were placed in the hospital’s ancillary departments and continues this year with the rollout of registrars to the physician offices and clinics that are not owned by the hospital, but rather associated with the University of Florida College of Medicine.
The shift away from a traditional outpatient registration department — where any patient new to the system passed through a central area — began in 1997, when a continuous quality improvement (CQI) team took a hard look at financial functions in the outpatient arena, she notes.
With the change in payer mix as HMOs became prevalent, failure to get pre-certification for accounts was resulting in large financial losses for the hospital, adds Tim Carney, assistant manager of outpatient financial arrangements.
"Nothing was being pre-certed on the outpatient side unless the physicians did it, and they were doing it for their procedures but not for [hospital procedures] like MRIs [magnetic resonance imaging]," Carney says.
The 18 or so employees who worked in outpatient registration were calling patients in advance of their appointments to get demographic information, but were not verifying accounts, he notes. "When they called patients and asked for insurance information, they were getting the layman’s version, which might mean the wrong insurance or the wrong plan code."
While the inpatient side — where financial representatives had handled all accounts for many years — had a denial rate that was less than 1%, Carney says, the outpatient denial rate was closer to 50%.
Varshovi did a CQI presentation illustrating the money being lost to outpatient pre-certification denials and the cash she believed could be collected at the point of service, she says. "I initially asked for 22 full-time equivalents to be added or upgraded [to financial representatives] and decentralized to these locations."
Upgrading to financial representative, Varshovi says, means that in addition to data collection, account creation, and minimal electronic verification, the employee’s duties also include verification of benefits and eligibility, precertification, estimate of charges, point-of-service collections, and sponsorship referral. The latter, she explains, means that if the patient can’t pay, the financial rep takes a credit card application or, based on the person’s income and liabilities, determines if he or she is eligible for Medicaid, Medicare, Supplemental Security Income, or another aid program.
After getting approval for an eight-person pilot project that began in July 1997, she came back to hospital officials in January 1998 with the results, she adds. "They were so pleased that they asked us to roll out the program in six months, instead of the two years we had proposed."
"We had to find an additional 15 staff members — making a total of 23 — and it took us about eight months to do that," she says. "There were a number of things involved in each placement [in an ancillary department]. We were moving into clinical locations, and the people there didn’t always look at it as a collaborative effort. You have to build relationships."
Despite a lack of space and clinicians’ concerns that services were being delayed, Varshovi notes, the program was very successful. In 1997, point-of-service collections for her entire department — inpatient, outpatient and emergency department registration — totaled $900,000, she says. In 2001, the figure was $4.4 million.
In 1997, the hospital wrote off $3.3 million in denied payments due to lack of pre-certification, Varshovi adds. That figure was down to $1 million in 2001. Through April, precert denials for 2002 had totaled only $322,000, she notes.
The next step
Two years ago, Shands decided to take the next step in its decentralization process, Varshovi says, which started with empowering the staffs of the clinics that report to the College of Medicine. "We spent last year training up to 300 staff members to issue a patient identification or medical record number so their patients don’t have to go through us [to be registered]."
That process, she explains, involves creating a master patient index screen with 25 data elements, including name, date of birth, race, home address, and other key elements. "They can’t create a full account, because we don’t want to take up space in the database with accounts that have a zero balance."
The creation of this kind of account, Varshovi says, signals that the person is known to the system but has not used hospital services.
Up until this point, she notes, any patient new to the Shands system — even if no hospital services were involved — had to go through the hospital registration process to get a medical record number.
"Before, there were 128 people who could issue a new ID number and they all reported to me," Varshovi says. "Then there were 300 additional people who could issue an ID, and they didn’t report to me. We want to see if we had an increase in duplicate medical record numbers as a result."
Although her department will track the accounts — following up if there is a match on three or more data elements — with the support of the information systems department, she notes, no results were available as yet.
Reducing the number of superficial accounts and data collection by 50%, she explains, allowed the remaining outpatient employees who had been doing telephone registration to become candidates for financial representative positions in the next phase of the decentralization process.
Those employees — after passing an eight-week training session to upgrade their skills — became eligible to perform the same functions in the physician clinics that their outpatient colleagues did in the ancillary departments, Varshovi says.
Putting financial representatives in the clinics, she adds, will relieve the long lines that sometimes occur when patients from several different specialty clinics line up at the lab to receive services. "We wanted to place [financial reps] at the site where the tests are ordered, if the volumes warrant it."
At the dermatology clinic, which orders two tests a day, the placement isn’t needed, she notes. But a surgical specialty clinic or a pediatric clinic warrants two financial specialists, Varshovi says.
Another benefit of having financial reps on-site at the clinics, she points out, is that they can try to keep patients from having tests done at laboratories that are not included in their insurance plans.
"If we can be in the clinics where the tests are ordered, we can tell the patients where they need to go and educate the physicians as to what the [managed care] contracts call for, so they will stop sending patients to [labs] where contracts are not honored," she adds.
Shands began placing financial reps in the clinics in May 2001, Varshovi says, and was to finish the process in July 2002.
A success story
Part of the education piece, she notes, has meant serving in an advisory capacity to physicians and notifying them that Shands will not be paid if it performs a particular test. "You have to understand, this is a culture in which physicians have been king and can do what they want, and suddenly we’re telling them they can’t move forward."
One of Varshovi’s favorite success stories about the physician education effort has to do with a patient who was referred to Shands’ nuclear medicine department for testing. The drug that was to be used cost $1,200, she says, and the procedures another $3,600.
"When the [financial specialist] saw that it was self-pay, she looked for other options," she adds. "She explained to the physician that the patient would have to pay for this, and that it would take a long time [to do so]."
The physician said that while the expensive drug was necessary, a series of less expensive tests could be substituted for the ones he had originally ordered, she says. In the end, the cost for the tests was reduced from $3,600 to $800.
"The physician would never have known [that the patient would have incurred the expense] if we hadn’t told him," Varshovi adds.
The education process is ongoing, she notes. "There are still things [physicians] don’t understand — how they can be contracted with a payer when the hospital is not." And sometimes, she says, the physician will elect to have tests done at Shands regardless of payer considerations.
"Our medical records are on-line, so any of the tests done here, [physicians] can pull up on-line," she adds. "They send a patient to X-ray, and two hours later they can see the results. If they send the patient [to another facility], they can’t do that."
In such cases, Varshovi says, the financial reps inform patients and have them sign a waiver. "They need to know up front, so they can work out a way to pay."
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