standards for patient billing systems

2. Goals of the Training Review some standards of billing and collection systems to assure maximizing cash income Discuss the areas that directly and indirectly impact on the billing and collections process Share experiences interactively about approaches tried by participants that have resulted in improved processes and additional revenue Discuss issues related to improving provider productivity

5. Standards for Patient Billing Systems Written Policies and Procedures with Board approval (including registration & certification) Annual Review and adjustment of fee schedule Patient Statements sent monthly Encounter forms entered at front desk Staff person to field billing questions Installment plan system Registration entry data validation Patient info verified at each visit Providers attend coding workshops Billing staff attend coding workshops

6. Standards for Patient Collections Systems Written Policies and Procedures approved by the Board Dunning Notices (30,60,90, etc.) Staff person designated for collections MIS supports notes on system Total balance requested at each visit Track % of collections at front desk Front desk and billing staff attend collections workshops Procedure to restrict services for chronic non-payers

15. Standards for Claims Billing Systems Written Policies and Procedures for Claims billing approved by Board File claims electronically Daily check of encounter form information and patient insurance status Management report of claims filed by payer Claims s/b filed daily, weekly, bi-weekly Insurance staff attend regular billing trainings provided by payers Staff person designated to review and advise others of 3rd party bulletins and correspondence

16. Standards for Claims Collections Systems Dunning notices and f/u with payers on past due claims Log denied claims; management report Work denied claims by paying payer; priority denial codes Aged report of outstanding claims Staff develops relationship with payers; documentation of calls/contacts Denied claims are routinely reviewed with provider staff Insurance processing staff attend insurance billing workshops offered by payers

27. SESSION GOALS Discuss operational issues that affect provider productivity. Review primary systems flows to identify potential trouble spots. Identify system approaches and methodologies to help alleviate trouble spots.

28. FACTORS AFFECTING PROVIDER PRODUCTIVITY Sufficient service/patient demand Provider supply and availability that reasonably match demand Operating infrastructure (e.g., staff, practice management system) and processes that facilitate moving patients efficiently through the system

29. UNDERSTANDING OPERATIONS Health center management must perform detailed, systematic analyses to understand operations and how they affect productivity and performance. Anecdotal information, assumptions, or �the way we�ve always done things,� will give a misleading picture of how a health center functions and what needs to change to improve performance. Various tools are available to measure operational performance in each health center department. Once management understands its operations, it can begin to develop effective solutions for improvement.

30. SIMPLIFIED PATIENT-TO-CASH FLOW CHART(THE BIG PICTURE)

31. UNDERSTANDING THE MAJOR PROCESSES Some of the steps on the preceding flow diagram represent a complex series of actions and decisions. Every action step and decision point has a potential bottleneck or pitfall. Avoiding those pitfalls and bottlenecks is what makes health center operations run as smoothly as possible. Health Centers must collect the right data to identify and determine how to correct deficiencies in order to improve performance. In the more detailed flow charts that follow, each arrow represents what can be measured.

32. UNDERSTANDING THE MAJOR PROCESSES(THE COMPONENTS) APPOINTMENT SCHEDULING

33. APPOINTMENT SCHEDULING

34. IMPACT OF APPOINTMENT SCHEDULING ON PROVIDER PRODUCTIVITY Management should: Ensure a steady flow of patients for providers Providers see the patients who are presented to them Consider provider-specific no-show and walk-in rates to estimate the number of daily appointment slots that should be double or triple-booked for each provider Conclude provider schedules (i.e., availability) and scheduling templates (i.e., standard time slots by clinical specialty for each appointment type) as policy Deviation from this policy should require the Chief Medical Officer�s approval Don�t put Schedulers in the unenviable position of debating scheduling issues with providers

35. IMPACT OF APPOINTMENT SCHEDULING ON PROVIDER PRODUCTIVITY Management should: Maximize the amount of time providers are in clinic seeing patients Conclude provider schedules (i.e., availability) and scheduling templates (i.e., standard time slots by clinical specialty for each appointment type) as policy Deviation from this policy should require the Chief Medical Officer�s approval Don�t put Schedulers in the unenviable position of debating scheduling issues with providers Time slot length is impacted by operational efficiency

36. IMPACT OF APPOINTMENT SCHEDULING ON PROVIDER PRODUCTIVITY Management should: Determine how walk-ins will be treated (e.g., designated urgent care provider(s), designated appointment slots, worked in between scheduled patients, etc.) Monitor each provider�s patient throughput to determine if walk-ins routinely cause unreasonable delays for appointed patients Determine the distribution of new, established, appointed and walk-in patient visits over the course of a typical day in order to match provider availability Determine the impact of walk-ins on patient flow

37. IMPACT OF APPOINTMENT SCHEDULING ON PROVIDER PRODUCTIVITY Scheduling staff should make every attempt to schedule the next available appointment that meets patient specifications. Practice management system should have an built in algorithm that facilitates the identification of �next available� slots. Access is determined by looking at third next available appointment Provider productivity and time to 3rd next available appointment should be correlated

38. IMPACT OF APPOINTMENT SCHEDULING ON PROVIDER PRODUCTIVITY On a regular basis, the front office manager and/or business manager should: Review and monitor the scheduling of patient visits; Check that appointments are being double/triple-booked, as appropriate; and Review the impact of special requests on appointment scheduling (e.g., unanticipated provider schedule changes). Schedulers should fill the full day�s schedule. Don�t stop scheduling appointments early. Use same-day appointment to fill open and cancelled appointment slots.

39. SELECT MEASURES FOR APPOINTMENT SCHEDULING Average Number of Rings Before Calls Are Answered/Call Drop Rate/Rate of Calls Placed on Hold/Average Hold Time - Measured at Peak and Non-Peak Times Percentage of Reminder Phone Calls (where contact is made and where language precluded communication)/Postcards Completed (mailed versus returned) No-Show Rates By Provider (for new and established patients) Waiting Time from Registration to Provider Visit (scheduled appointments and walk-ins separately) Percentage of Walk-Ins and Same-Day Appointments Average Appointment Wait Times (Urgent, Routine/Well and Non-Urgent Sick Visits) Percentage of Unfilled Appointment Slots

40. UNDERSTANDING THE MAJOR PROCESSES(THE COMPONENTS) PATIENT REGISTRATION

41. PATIENT REGISTRATION DETAIL

42. IMPACT OF REGISTRATION ON PROVIDER PRODUCTIVITY Objective - To quickly and accurately register the maximum number of patients who present for care Ineffective registration processes cause throughput bottlenecks and provider downtime. Waits to register, for insurance verification/eligibility determinations, for medical record, for clinical staff notification and patient retrieval Effective processes enable staff to perform key tasks easily, quickly and accurately Accurate and complete patient paperwork Collect/verify patient identification, demographic information and insurance coverage Ensure collected information is consistent with that in practice management system and in payer�s database Retrieve record, notify clinical staff and collect co-payment

43. POTENTIAL BOTTLENECKS IN REGISTRATION Overabundance of walk-in versus appointed patients Majority of patients who require demographic information updates Insurance verification methods that are not automated (dependent on telephone calls) High number of patients whose insurance coverage is determined to be inactive ________________________________________________________ What are the root causes and impacts of these bottlenecks? ________________________________________________________ What is the impact, in number of patients who could be seen, if bottlenecks were eliminated?

44. IMPACT OF INTAKE/REGISTRATION ON PROVIDER PRODUCTIVITY Training, monitoring and feedback are essential. High turnover of front desk staff is common. New staff frequently have limited, if any, relevant experience. Existing staff adopt bad habits (e.g., shortcuts, omitting key tasks). Curriculum should be based operating policies and procedures Include common scenarios: They might not encompass every situation a Registrar encounters but they can establish expectations and parameters. Proper completion of the Registration Form is crucial Make the form self-explanatory or routine to minimize misunderstanding and personal interpretation. Inform staff that they are responsible to ensure proper completion Ensure that the correct patient is being recorded in the system Insurance coverage verification Use an on-line systems, whenever available Aggressively screen uninsured patients for coverage eligibility

45. SELECT PRODUCTIVITY MEASURES FOR REGISTRATION Average Number of Patients Registered Per Hour Per Provider Average Time(s) to Complete Patient Intake (for new, established, appointed and walk-in patients) Average Wait Time in Registration Error rate(s) A key element of a practice management system should be its ability to associate each transaction with an individual. However, the system must be configured and used so that it accumulates the right information. When this is so, management can analyze each user�s performance.

46. UNDERSTANDING THE MAJOR PROCESSES(THE COMPONENTS) PATIENT SERVICE

47. PATIENT SERVICE DETAIL

48. POTENTIAL BOTTLENECKS IN PATIENT SERVICE Charts not available or incorrect chart delivered to clinical area Exam rooms not �turned over� timely Provider running behind � not ready for the patient High number of patients found ineligible for their coverage ___________________________________________________ What are the root causes and impacts of these bottlenecks? ___________________________________________________ What is the impact in number of visits that could have been completed if bottlenecks were eliminated?

49. ROLE OF CLINICAL SUPPORT STAFF IN CAUSING/REDUCING BOTTLENECKS Objective - To prepare facilities and patients for a productive visit with a provider as quickly as possible Clinical support staff (e.g. nurses, medical assistants) impact patient flow and provider productivity. They should: Understand and perform their job functions (e.g., retrieve and prepare patients in a timely manner, prepare exam rooms, maintain exam room supply inventory); Have supervision who monitors performance and resolves issues that negatively influence performance; Be organized in a workable staffing model (i.e., nurses versus MAs) that has a sufficient complement. There is not a �right� staffing model � instead health centers tend to equalize the cost of these staff by the skill level mix (i.e. CHCs with a nurse staffing model tend to have less clinical support staff per provider).

50. ROLE OF PROVIDERS IN INCREASING THEIR PRODUCTIVITY Objective - To provide the highest possible quality of care to the maximum number of patients Providers should: Direct questions/comments/requests regarding appointment scheduling to the appropriate manager, not the staff person who performs the function. Discuss schedule changes with the Chief Medical Officer as soon as possible (and secure approval, as appropriate). Arrive at work at least 15 minutes before their first appointment each day (everyone needs prep time). Avoid working in walk-in patients when it causes unreasonable delays for those with an appointment. Resist the natural tendency to treat all the conditions of medically complex patients who have been noncompliant (e.g., repeat no-shows) during a single visit. Establish a protocol to identify and then reschedule noncompliant patients.

51. ROLE OF PROVIDERS IN INCREASING THEIR PRODUCTIVITY Providers should: Minimize time devoted to non-patient care activities Occasions requiring long travel times (e.g., between care sites) during the middle of the day Administrative time Time off during peak volume cycles Organize records so that basic patient facts (e.g., diagnoses, medications, treatment plans) can be easily identified. Consistently document care, at least sufficiently to support selected diagnostic and procedure codes, before each patient is discharged. Maintain an ongoing dialogue with support staff regarding ways to increase the team�s collective productivity. Share impediments to increased productivity with management and jointly conclude ways to eliminate them.

52. UNDERSTANDING THE MAJOR PROCESSES(THE COMPONENTS) MANAGEMENT

53. ROLE OF MANAGEMENT IN INCREASING PROVIDER PRODUCTIVITY Management will be most effective when they enable, not dictate, increased provider productivity Incentive compensation Will encourage increased provider productivity Will not remove operational impediments that suppress it Make start the conversation about, or make the providers stakeholders in, removing obstacles to productivity Operating processes that are clearly defined, thoroughly understood and consistently carried out are key

54. ROLE OF MANAGEMENT IN INCREASING PROVIDER PRODUCTIVITY Monitoring staff conformity with defined processes is required to ensure continued compliance. Measure process time Measure cycle time Identify bottlenecks Review exam room utilization Review patient satisfaction surveys Directly observe patient flow Identify space needs of operations Review health center space layout Review provider schedules and appointment scheduling Create a continuous feedback loop that informs ALL parties. Oftentimes the best forum for communication is facilitated peer-to-peer interaction.

55. RESULTS Efficiency gains (cycle time reductions) will yield greater productivity for all staff, better patient satisfaction AND improved financial performance.

56. Benchmarking

60. Internally Developed Benchmarks

61. Improving Your Revenue Cycle

62. Improving Your Revenue Cycle