Schegistration A Patient-Focused Approach

1. SchegistrationA Patient-Focused Approach Cathy Gragg Revenue Cycle Manager Tucson Medical Center

2. ABOUT US • One of the 300 largest hospitals in the country and the largest in Southern Arizona. We are the largest single level facility in the US with nearly 27 miles of combined hallways • Licensed for 609 adult and skilled nursing beds, 62 psychiatric beds (Palo Verde Mental Health Services) and 90 bassinets • Serve more than 37,765 inpatients and 114,929 outpatients annually • Over 1,000 physicians represent 60 specialties, from anesthesiology to vascular surgery • TMC HealthCare is Southern Arizona's regional nonprofit community hospital • TMC's campus also serves as home to the Tucson Orthopedic Institute, the Cancer Care Center of Southern Arizona and the Children's Clinics for Rehabilitative Services

4. OBJECTIVES • Review the importance of a centralized model • Review the issues that we were trying to solve • Describe the obstacles we encountered that drove the need to make this change • Review the process we implemented and how we automated the patient interview at the point of scheduling • Benefits realized • Lessons learned

5. WHERE WE STARTED • May 2006, implemented EPIC’s Cadence Scheduling system • September 2006, implemented a centralized scheduling model (user security changed)

6. New Teams formed:CENTRAL SCHEDULING TEAM • Purpose for Creating the Team • Issues identified • Call Wait times and Abandonment rates • Scheduling needed input from departments in order to schedule complex procedures • Schedulers needed resources • Created new staffing model • Like processes grouped • Gain efficiencies with centralization • Ensure that all service lines were represented

8. Central Scheduling - New Staffing Model

9. PRE-ADMIT TEAM • Purpose for Creating the Team • Issues identified • Team members separated physically • No visibility to workload productivity • Gain efficiencies with centralization • Like processes grouped • Integrating pre-service would fully support the organizations needs • Identified an opportunity for physical space • New building space became available

10. Pre-Admitting Team – New Staff Model

11. PROCESS IMPROVEMENTS STILL NEEDED • August 2007, kicked off Central Scheduling Process Improvement Committee • Objective - Centralized access point with multiple portals transparent to the customer. One transaction to complete scheduling an appointment

12. Potential Causes Technology/Equipment Education-office staff Communication No contact info Order not confirmed with phy. Registration not available after scheduling completed Can’t ID requested test Pt. unaware test has been ordered System resource sharing Prep instructions Registration not available when needed by departments Wrong test ordered Pt. wants to clarify w/ physician Wrong pt tele # Doesn’t meet SOC, ie; sedation or anesthesia Order needs clarification Why does Central Scheduling need more than one contact with physician’s offices and patients to complete the OP scheduling process ? New patient Confirm appt w/ pt Order does not meet requirements Unable to reach pt on 1st attempt No prior auth. Order incomplete CS staffing ability to respond to all calls Pt. will not schedule due to no prior auth. Order element missing Pt. refuses to schedule Scheduling request after 4 PM Order incorrect Appointment time not soon enough Order cannot be located Specialty procs. Bx, etc Pt. not ready to schedule Compliance requirements Scheduling Coordination Revenue

13. Process Improvements Implemented

14. IN SCOPE • Walk-ins with Rx in hand • Same Day/Next Day cases • Targeted Physicians • Patient requests to schedule with department • Reschedule cancellations, no-shows • All dissatisfied patients /MD’s with CS process • Call to stay with initial location of call (CS or VL) • MD offices who’s patient has not been scheduled > one week • Patient’s with Rx who were incorrectly scheduled 24 hours in advance • “Series” patients OUT OF SCOPE • Routine cases not meeting In Scope criteria • All In Scope criteria beginning in Central Scheduling Process Improvements Recommendations

15. PROBLEMS WE STILL NEEDED TO RESOLVE MISSING PATIENT INFORMATION; • AFS staff not always the first point of contact • Missing patient information or inaccurate information • Unable to reach the patient prior to their appointment • Late add ons • Duplication of efforts • Entry into two systems

16. PROBLEMS WE STILL NEEDED TO RESOLVE cont… VERIFICATION COVERAGE/BENEFITS; • Decreased time from time appt scheduled to appt time • Data in EPIC different than what was in legacy system • Ineligible for coverage listed • Not a covered benefit – requires financial clearance • High deductibles / co-insurance identified – requires financial clearance

17. PROBLEMS WE STILL NEEDED TO RESOLVE cont… AUTHORIZATIONS; • Inability to obtain auth early enough • Customer dissatisfaction • Numerous calls to physician offices for patient info • Patients delays and financial clearance issues

18. PROBLEMS WE STILL NEEDED TO RESOLVE cont… DUPLICATION OF EFFORTS; • Schedulers would ask similar information that registration needed • Registration would call the patient • Patient perceived this as a duplicate call

19. SPECIAL CONSIDERATIONS FOR SCHEGISTRATION • Central schedulers needed to be trained to collect guarantor, and coverage information. • Department schedulers need to be trained to collect demographic information. • This may increase the length of calls for all schedulers, thus impacting bandwidth for the Central Scheduling department. Scheduling time will be impacted but will be balanced by a more streamlined registration process

20. HOW WE GOT THERE • May 2010, Implemented EMR • New Security for staff added • Realocation of personnel • Automated schegistration for Central Scheduling

21. User • Central Scheduler • *Registration representative * Cannot schedule into all OP areas • Role • Order transcription • Referral Management (authorization) • Schedules for all OP areas including completing registration to include: • Demographics • HAR creation (if appt w/in 48 hours) • Create / edit guarantor • Add / edit coverage Schegistration Model – Security changes

22. PROGRAMMING CHANGES - SCHEGISTRATION • Added new programming point to jump the scheduler into registration before appointment entry when the patient has unverified registration info; • Demographics / guarantor - new or elapsed • Created new programming point to fire after appointment is made to jump the scheduler into registration if the appointment is scheduled within 48 hours. • Scheduler creates the account

23. PRIOR STATE CURRENT STATE Collection of demographic, guarantor, and coverage information is moved up to the time of scheduling. Afterwards, this process will result in two distinct workflows: Appointments within 48 hours (one-call): Scheduler collects demographic, coverage, guarantor information and create the account. The scheduler checks eligibility via real-time eligibility. Appointments scheduled past 48 hours: At the time of scheduling, the scheduler will collect demographic information. After scheduling, registration staff will collect, review and verify coverage and guarantor information as well as create the account. The registrar communicates co-pay information to the patient and collects via the phone if possible. If unable to collect the copay over the phone, the patient is instruction to pay the copay at the sign in desk. • Central scheduled into outpatients departments. • After the scheduling, registration contacts patients to collect demographic, guarantor, and coverage information. Some of this information may be verified at the time of this pre-registration phone call, although it is possible that not all of this information is verified during this call. • If there are eligibility or co-pay issues/information that needs to be communicated, the patient may be contacted again.

25. BENEFITS REALIZED • Enterprise system allowed for schedulers and registration staff to work within the same system • All users had access to same information, including where the authorization would be entered • Implemented hard stops for missing financial clearance • No Auth • ABNs • Financial Waivers

26. BENEFITS REALIZED cont. Pre-schegistration Post-schegistration Call times Avg talk time = 3:26 min Percentage of pre-registration at point of scheduling = 21% • Call times • Avg talk time = 2:56 min • Percentage of pre-registration at point of scheduling = 7%

27. LESSONS LEARNED • Need to broaden scheduling access for all registration staff • Department schedulers do not collect demographics • RTE (real-time elig) needs to be complete for ALL high volume payors • Documentation overlaps proved to be problematic – i.e., schedulers document in referrals while registration documents in FYI and Acct Notes • Only works well when scheduling with the patient • Still issues with obtaining Auth from physician offices for appts made inside 48hrs of DOS

28. QUESTIONS

29. CONTACT INFORMATION Cathy Gragg – cathy.gragg@tmcaz.com Revenue Cycle Manager, Enterprise Wide Scheduling