patient access: the emerging front-end revenue cycle

1. Patient Access: The Emerging Front-End Revenue Cycle Christina M. Janus, MBA, RHIA Associate Director, Patient Access Services EOHIMA Fall Symposium October 9, 2010

3. Revenue Cycle Management Traditionally consisted of many tasks performed in the Business Office or back-end Weighted toward back-end collection & clean-up processes Lacked full pre-registrations to include patient estimates & point-of service collections Recent economic challenges and recognition of inefficiencies of prevailing processes led shift to front-end management of revenue cycle � specifically in the area of Patient Access Faced with decreased revenues & rising costs, providers find best practice technology solutions provide a way to improve patient access processes Opportunity to increase overall performance of Patient Access area to include implementing metrics, productivity & quality standards, elevate professionalism & increase customer satisfaction

4. External Challenges One of the first effects of a recession is decrease in elective procedures The ensuing 2001-2002 recession resulted in the lowest demand for hospital services ever1 Unemployment rose 4.2% to 5.6% back then. Then jumped to 4.6 % in 2007 and to 10.0% by the end of 20092 Increase in unemployment rate translates into greater demand for government health services Every 1.0% increase in unemployment rate equates to 1 million new Medicaid and State Children�s Health Insurance Program (SCHIP) enrollees and 1.1 million newly uninsured3

5. External Challenges cont. As healthcare costs continue to escalate, increased financial burden is shifted to the patient The average out-of-pocket expense for the insured has increased 4 times in the last 8 yrs, with the median PPO deductible at $1,000 in 2008 At the same time, the percentage of plans requiring deductibles also has increased significantly � 81% of PPO plans required deductibles by the end of 2008 Impact on providers is clear � patient balances represent a larger portion of outstanding receivables and will continue to be a growing concern for healthcare providers

6. External Challenges cont.

7. Internal Challenges Various ways patients enter healthcare facilities: Scheduled Walk-ins Referrals Emergency Admissions Recurring Each patient type may require a different process flow to ultimately provide care ;

8. Internal Challenges cont. Patient access staff often use multiple disparate systems to complete tasks The average patient access staff uses 6-10 different systems5 The process of registering and financially clearing a patient can take more than 5 hours4 Process is complex, time-consuming and fragmented resulting in inefficiency due to errors, bottlenecks, & duplicative effort

9. The Emerging Front-End Revenue Cycle Traditionally a back-end-heavy process where core activities often occur only after the point-of-service Significant amounts of time correcting errors, filling in missing information and coordinating benefits Inefficient process resulting in bottlenecks, black holes, missed opportunities, delayed cash, denials & increased bad debt The emerging front-end revenue cycle shifts many key tasks to the front end

10. The Emerging Front-End Revenue Cycle cont. Concept is not new Solutions must be fully integrated into the core systems of the organization Efficient workflow required Solutions must be comprehensive, addressing all areas of patient access; from pre-service patient estimation to point-of-service insurance & demographic verification to financial counseling & collections workflow

11. The Emerging Front-End Revenue Cycle cont.

12. MetroHealth Medical Center Located on the near west side of Cleveland, Ohio Comprised of: Major Medical Center Rehabilitation Hospital 2 Long-term/Skilled Nursing Centers Outpatient Surgery Center Network of Community-based Healthcare Centers Academic and Research Healthcare System Leader in Trauma � Level 1 Emergency & Critical Care Women�s & Children�s Services Rehabilitative Healthcare Services Comprehensive Medical & Surgical subspecialties Serving medical needs for over 170 years Affiliated with Case Western Reserve University of Medicine since 1914

13. MetroHealth Medical Center

14. MetroHealth Medical Center

15. MetroHealth Medical Center

16. MetroHealth Medical Center

17. MetroHealth Patient Access & Eligibility Services Patient Access/Admissions Services Inpatient Registration Centralized Bed Management Transfer Center (team member) Insurance Verification Main Office Reception Patient Valuables Securing & Follow-up Eligibility Services Pre-Authorization Financial Case Management Time of Service Collections Financial Counseling Patient Assistance Program Denials Management

18. Types of Admissions Scheduled Admissions verified and authorized via PAS and Pre-Authorization Surgical Chemotherapy/Radiation Therapy (Recurring/Series Patients) Rehabilitation

19. Types of Admissions Scheduled Admissions verified and authorized via PAS and Pre-Authorization Surgical Chemotherapy/Radiation Therapy (Recurring/Series Patients) Rehabilitation

20. Information Systems Siemens (SMS) OAS / Gold Registration, ADT, Census Insurance info & interview notes Epic Receives IP Registration data from SMS interface Outpatient Registration, EMR, Scheduling, etc. TeleTracking Hospital Bed Management System OnBase Document Capture System

21. Inpatient Registration 2009 Registration Statistics Full Admissions: 28,988 Babies Delivered: 2,969 Observation Stays: 9,154 Average Daily Census with Observation = 400 MPI and Data Collection Scheduled Non-scheduled

22. Inpatient Registration Cont. EMTALA � Emergency Medical Treatment and Active Labor Act Defined Role of Admitting Department COBRA � Consolidated Omnibus Reconciliation Act Defined

23. Inpatient Registration Cont. Physician Orders Referring Physician Attending Physician Consulting Physician Primary Care Inpatient versus Observation Orders 24 Hour Rule

24. Inpatient Registration Cont. Newborn Processing Processing of Newborns in ADT System Insurance Special Circumstances Adoption Non-US Citizens Under age mothers

25. Forms for Patient Admissions Consent for Treatment Signature valid for one year with the exception of inpatients with Medicare Notice of Privacy Practices Signature valid for unlimited timeframe unless major changes made to the document Important Message from Medicare Purpose: CMS & Joint Commission Standard for all Medicare admissions. Role of Patient Access, Care Management, and Social Work Admission Booklet Informational guide to reference services available at MH Patient rights and standards

26. Inpatient Insurance Verification SMS - HDX Common Working File Autofax Dedicated Payor Websites Centralized Verification

27. Patient Bed Placement Attributes Medical Condition Drives Floor & Service (per Physician Order) Equipment Needs, i.e., Telemetry, Sleep Apnea Boarders Gender Isolation � Infection and/or Social Monitor / Video / Sitter Prisoner VIP

28. Emergency Department Admission Request

29. Bed Control Centralized Bed Management Control of Hospital Beds Bed Assignment Goal: Assignments within 15 minutes Purpose: Streamline admission process Triage Nurse Physician in Command Transfer Center

30. TeleTracking: Pre-Admission Tracking

31. TeleTracking: Hospital Bed Board

32. About NAHAM � www.naham.org The National Association of Healthcare Access Management (NAHAM) is the only national professional organization promoting excellence in the management of patient access services in all areas of the healthcare delivery system. Patient access services professionals provide quality services in registration & all of its support processes to patients, providers, and payors through their healthcare experience. Patient access services include: Admissions, Scheduling, Registration, Patient Finance, Guest Relations and other related services

33. NAHAM Access Model

34. CHAA vs. CHAM Certified Healthcare Access Associate (CHAA) Designed to test associate-level individuals Certified Healthcare Assess Manager (CHAM) Designed to test manager-level or above individuals

35. CHAA Eligibility Requirements & Maintenance One year in healthcare or finance industry or successful completion of accredited college program in healthcare HS diploma or GED plus 30 professional development contact hrs. earned within the past two years; or an associates degree from an accredited institution Signature of one supervisor or course instructor 30 CE hours required to maintain certification; biannual renewal

36. CHAM Eligibility Requirements & Maintenance Two years management experience in healthcare or finance industry HS diploma or GED plus 90 professional development contact hrs. earned within the past three years; or a four year degree from an accredited institution in healthcare, business, or related field Signature of one supervisor or course instructor and one CHAM certified individual CE hours increased to 60 commencing in 2011; biannual renewal

37. National Healthcare Access Professional Week 2011 Sunday, April 3rd � Saturday, April 9th

38. Questions

40. References Catherine Arnst, �Healthcare: not so recession proof,� Business Week, March 25, 2008 Bureau of Labor Statistics, US Department of Labor, �Employment status of the civilian noninstitutional population 16 years and over, 1970 to date, �http://ww.bls.gov/web/cpseea1.pdf March 2010 Dorn, Garrett, Holahan and Williams, �Medicaid, SCHIP, and Economic Downturn: Policy Challenges and Policy Responses,� Kaiser Family Foundation and Urban institute, April. 2008 MedeAnalytics market research, Oct. 2009 Hooper, Cole, �Effective Revenue Cycle Management Begins at Access,� Healthcare Registration, May 2010, Volume 19 NO. 8