By Paul Shorrosh, MSW, MBA, CHAM

The perfect REFORM STORM is coming… are you ready?  Payment cuts, outcomes based reimbursement and affordable care are making it imperative for hospitals to do more with less.  But is that even possible?  Labor reductions and cost-cutting strategies slow down the spend rate, but do little to increase revenue, drive revenue cycle efficiency or reduce bad debt, and can decrease quality and patient satisfaction.  Meaningful Use incentives are helpful, but did the electronic medical record systems it helped pay for increase reimbursement per patient, net patient revenue, reduce bad debt or create new efficiencies in your revenue cycle?  Healthcare reform will eventually bring in more covered patients, but more resources will be needed to qualify, enroll and provide care for them and it’s likely that the reimbursement per patient will be lower.  So what is a Revenue Cycle Executive to do? 


Sometimes the answers to our toughest problems are found at our doorstep.  Every healthcare facility has an existing department with an extraordinary potential to impact both revenue cycle results and patient experience.  This quiet department is often overlooked and undervalued in the search for revenue cycle improvements and sustainability under reform.  If cost-cutting quick-fixes and patching up leaky pipes in a rework factory are exhausting you and your staff and effecting your culture and possibly patient satisfaction, or if you are ready for significant, sustainable revenue cycle results, take a good look at the front-end; Patient Access and more specifically, Pre-Access. 


It’s what you do BEFORE a storm that counts.  Before scheduled patients arrive for service, Pre-Access teams can identify and prevent bad debt before it happens and find financial solutions for the uninsured and underinsured.  They can assure first-pass reimbursement for insured patients, increase up-front collections, and improve wait times and patient satisfaction.  No other department in the hospital has this kind of potential.  It’s an ounce of prevention.  It’s playing defense.  Patients appreciate it.  And it’s just plain smart. 


The key is to conduct every clearance process required for payment prior to service, in the least amount of time and by the lowest level staff member possible.  This is a job for Patient Access and Pre-Access.  Below are 10 critical processes that your Patient Access department can do to produce significant, sustainable revenue cycle results: 


1.      Determine guarantor and verify patient identity and address

2.      QA all demographic, insurance and clinical data

3.      Verify eligibility on every patient, including private pays for Medicaid

4.      Screen for and capture required referrals, authorizations, certifications and notifications

5.      Screen for medical necessity and obtain required Advance Beneficiary Notices (ABN’s)

6.      Estimate and collect patient liabilities

7.      Determine propensity to pay and offer prompt pay discounts, financing or payment plans on uncollected amounts

8.      Pre-screen for Medicaid, Disability and Charity care and convert uninsured to payment sources

9.      Pre-register (ie; conduct all processes above) 90% of scheduled patients > 2 days prior to arrival

10.  Identify pre-registered patients at time of arrival for fast-tracking to reduce wait times, avoid delays and duplication, and improve patient experience


By far the best time to conduct these critical processes is prior to a patient’s arrival.  This means as many patients as possible must be scheduled by physician offices 2 days in advance, allowing Pre-Access the time to contact the patient, the payer, and perform their clearance work.  Each distinct process is complex, requiring time and expertise to complete.  Using semi-automated verification and communication processes, a pre-registration employee can process up to 20 patients per day.  At that rate, a hospital with 100,000 potential pre-registrations per year requires a staff of 20, providing a high cost to benefit ratio.  This is why hospitals to date have not adopted in-depth pre-registration across the board.  However, new technology is changing that ratio, enabling one pre-registration employee to process over 40 patients per day. 


A new generation of front-end technology combines three components; automated business processes, exception-based workflows and performance management systems.  Automating the above critical processes eliminates the manual time required and the risk of non-performance.  Exception-based workflows queue up only relevant, actionable issues that require intervention, removing the time required to review every payer authorization requirement, medical necessity rule, or eligibility response. 


But it’s not just efficiency that drives revenue cycle results.  Patient Access can be fast without being better.  Automation technology and exception based workflows are not enough.  How do we know the issues get resolved prior to service? This is where performance management systems close the loop.  Performance management systems work in tandem with process automation and exception-based workflows to enforce resolution of process failures prior to service.  For example, automated eligibility, propensity and charity screening processes identify an uninsured patient that qualifies for assistance.  This information is pre-loaded into the pre-registration work queue and employee #1 is alerted of the exception.  The performance management system allows visibility and resolution rate monitoring by managers, however if the issue is not resolved by the end of the pre-registration, employee #1 will receive a real-time alert and the opportunity can be escalated to a supervisor.  If the patient arrives two days later for service and the issue is not resolved, the performance management system will alert employee #2 at check-in that the patient qualifies for assistance but is still in a private pay status.  After the patient is registered the performance management system checks again to see if the issue was resolved, and if not, employee #3 will be alerted real-time as well as a supervisor via text and/or email.  In this way, performance management systems become the fail-safe to prevent fatal process failures from going unnoticed and unresolved prior to service. 


A performance management system will also include Key Performance Indicator (KPI) tracking.  Managers will be able to monitor failure rate and resolution rate by employee, making individual and team performance visible to management.  More advanced performance management systems will automatically assign training content based on each employee’s error pattern.  For example; if Joe Registrar’s POS collection to estimated ratio drops below acceptable thresholds, the system will assign him a course in collections, complete with a test to insure comprehension.  If the main admitting team has prior authorization or ABN failures that exceed acceptable thresholds, the system will assign each of them a course in authorizations or medical necessity resolutions.  Performance management systems will also alert an Access Manager if the number of patients waiting exceeds or drops below set thresholds to support real-time staffing reassignments.  Supervisors can also receive wait-time threshold alerts, triggering intervention and enhancing patient satisfaction.


A new generation of patient access technology is bringing efficiency AND effectiveness to the revenue cycle, just in time for the reform storm.  Investing in the front-end is like preparing for a storm that you know is coming.  And this storm is predicted to hit every hospital - in every town.  It’s not just any storm - it’s the perfect reform storm!  Consider yourself informed, and make preparations to survive and thrive.


Paul Shorrosh, MSW, MBA, CHAM

CEO, AccuReg Patient Access Solutions