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Tracking registration errors, boosting accuracy rates: one facility's success

PARC Daily Report, June 22, 2006

Hospital executives and managers often consider the patient access area the leaky, vulnerable part of an otherwise sturdy hospital foundation-where unqualified staff consistently and carelessly make registration mistakes that cause long-term reimbursement headaches.

Clinical staff rely on accurate emergency contact information and correct documentation of the patient's chief complaint by the registration staff. The patient business services group also relies on accurate information so reimbursement can occur, and patients expect hospitals to be the correct payer.

The initial perceived Band-Aid is to fix registration problems at the back end-an expensive task that is loaded with rework. That approach is almost always fruitless and doesn't address the root cause of the problem or lead to permanent process improvements.

In 2003, officials at Beebe Medical Center (BMC) in Lewes, DE, invested in a better system to develop baseline data, educate staff, and track and correct errors to create a win-win situation for all the major customer groups.

Three years later, BMC has made significant improvements in sending clean bills to payers, which has resulted in millions of dollars' worth of increased revenue. It reduced rework by cutting denials, sliced registrars' error rates in half, and developed new educational tools for the more than 200 people who perform registration in many decentralized locations.

Fielding a starting team

In the summer of 2003, BMC officials divided the business office into a new model, with two directors responsible for the major components of the revenue cycle. The director of the front end and the director of the back end work closely to meet the organization's strategic goals for patient safety, customer service, and financial viability.

BMC's vice president of information services selected Barbara Moulinier, MA, CHAM, who had previous experience in risk management, case management, utilization review, and Joint Commission on Accreditation of Healthcare Organizations compliance, to manage the front end of the revenue cycle for preregistration, inpatient insurance verification, and registration functions.

"I was seeing firsthand how registration errors affected the clinical staff, such as my case managers, and also the staff in patient business services," says Moulinier. "I was always a process improvement person and I realized the staff really needed to perform the registration functions correctly the first time so each of us can use that information to support patient safety goals and financial goals."

The primary order of business under the new plan was to tackle errors from all angles. "We didn't have baseline data to show how many errors we made, who made them, and what kind of errors they were," Moulinier says. "We had dollars for denials and we knew our accounts receivable days, but that was all. We really needed to know the root cause of the errors occurring so we could make improvements."

To uncover that information, BMC formed a quality assurance (QA) team-a subset of patient access, comprising three employees whose initial responsibility was to figure out the baseline data and develop strategies to correct mistakes. This group was supported by members of patient business services, information systems, and clinical directors and their staff, with significant input from patient access staff as well. "Immediately, we wanted to expand our process to fix the errors before the bill dropped so that we could avoid denials and rework at the back end," says Moulinier.

That window is small, typically five days from the date the claims leave the facility, says Elsie Pfarr, CHAA, the QA training coordinator at BMC. "You have to review accounts, determine if errors have been made, educate the registration staff to prevent future errors, and make the correction all within this time frame," she says. "That's the first step."

Let's get it started

Pfarr and her staff started in August 2004. First, they looked at all 20,000 accounts from the previous month. They narrowed the search down to focus on the different screens a registrar touches during the registration process to see if they had entered all of the correct information, she says.

The QA staff issued error codes for each screen a registrar touches. A mistake on any screen could later turn into a denial or a potential safety issue. "We found that we needed to develop codes used by both patient access QA training staff, as well as patient business office staff, so that our decision support team could run reports from these error codes," Pfarr says.

The initial findings revealed that registrars from both the patient access department and the clinical staff were making a lot of the same errors, such as using wrong temporary addresses and emergency contact information. But Moulinier and Pfarr learned that, more than anything else, staff struggled with reading the more than 300 insurance cards that come through their hospital routinely.

"Most of the errors were in getting the plan code, policy numbers, and subscriber information correct," says Moulinier. "There were a lot of careless mistakes as well, until staff understood the value of accuracy and the importance of their job."

The careless errors soon ended. Registration staff focused on correctly completing the emergency contact information and inputting information correctly.

Complicating matters is the fact that BMC is located in a resort town, so many of the patients are vacationers passing through. Staff see hundreds of out-of-state insurance cards every month, so the task of educating staff on how to read this information was a challenge.

The BMC decision support team pitched in with monthly reports that Pfarr and her team then sent to the different supervisors and team leaders responsible for preregistration and registration staff across the organization. With this information, the decision support team could narrow the focus to see who created each account, what types of errors they made, and how many errors they made in a given month (turn to pp. 5-6 of the PDF of this issue to view sample reports).

This information is valuable from an educational standpoint and is not used to punish staff.

Initially, each of the 200-plus registrars, in multiple satellite locations and access points, received a summary of the report. "We did this for educational purposes," Moulinier says. "Once they are educated, the report is used to assess what errors are being made, and they help develop further educational materials to improve our processes."

Phase two

In the fall of 2004, BMC took this project to the next step by forming a committee of 20-25 liaisons to manage the operation at several different clinical satellite locations. This committee comprises representatives from each decentralized area. They meet monthly to review error reports and new insurance information, listen to guest speakers, and discuss the organization's achievements in meeting the strategic goals.

"We provide positive feedback on the improvements in our accuracy rates on a regular basis," says Moulinier. "The support has been invaluable in allowing team members to attend the meetings and actively participate in making improvements, which helped us improve patient safety and reduce our accounts/receivable days substantially.

"We have labs in numerous locations, and we have three team leaders who represent staff in those locations. They travel significant distances to attend these meetings," Moulinier says. "We needed representatives from all of the ancillary departments-lab, radiology, respiratory therapy, rehab, and others-to make this committee successful. We have been very successful in bringing together these individuals who make a difference not only clinically, but also financially by capturing accurate preregistration and registration information."

Educate, educate, educate

Educating staff is the focal point of the initiative. Error data affords the QA staff the ability to train registrars individually, based on specific problems the registrar is having.

The biggest problem BMC registrars have, Moulinier says, is reading insurance cards. To prove this point, Moulinier took samples of frequently used insurance cards to the executive staff meeting. She provided a list of plan codes and sample cards for each executive and asked them to select the correct plan code in 10 seconds or less.

"Quickly, they realized that the cards were difficult to read," she says. "It's hard to determine which plan code to use when multiple payer names appear on the card."

So Pfarr developed a reference book for all registrars at each entry point, visually identifying the key pieces of information located on the many different insurance cards that the registrars will see.

"I gave every department that registers patients a copy, and we update it every month and hand it out [to the department liaisons] at our monthly meetings," says Pfarr.

The book also helps facilitate the preregistration process. "Customers are reading the card over the phone, and they'll often have trouble reading it," Moulinier says. "So the person on the other end of the line has to know what [he or she is] doing and how to help the patient read the card correctly. It helps having these sample cards as they talk to the patients."

The training begins before the registrar comes in contact with a patient. Moulinier has a list of which jobs have registration functions. Every time a person is hired with registration as part of their job description, the employee must go through an orientation process. "We give them the basics," Moulinier says. "But it introduces them to the job."

Favorable returns

After 12 months, the QA team identified and corrected errors that led to more than $10 million in revenue, which the organization would otherwise have billed incorrectly. "We would have eventually gotten paid, but these bills went out clean and were paid sooner," says Moulinier. "There is certainly at least an hour's worth of rework per account that was avoided as well. Most importantly, however, was the significant reduction in [accounts receivable] days."

BMC registers more than 200,000 patients each year. Since beginning this program, the registrars' error rate dropped from 8% to 4%, and it continues to fall. "That is definitely a huge improvement," says Moulinier. "[The tracking process] improved our training and our focus on excellence. We still have a long way to go, but I think we'll get there."

For the past three years, BMC has won the Delaware Quality Award. Most recently, the patient access department has been one of the key support services identified in the application for that award and in achieving results that show improvements in work processes that support the strategic goals.

Staff grooming, career ladder other positive outcomes

Arguably the single biggest problem facing patient access managers is staff turnover. Hospitals typically won't invest more money to hire better candidates with more experience, so often, managers settle for employees with little or no experience and usually no desire to work a low-paying job for very long.

This issue was a concern for officials at Beebe Medical Center in Lewes, DE, before they began tracking registration errors to determine who was making what errors and how often the registrars were making them.

"Many new hires will leave as soon as their 90-day probation is over and they can transfer to another position in the hospital," says Barbara Moulinier, MA, CHAM, director of patient access at Beebe Medical Center.

Education being the center of their error-tracking initiative, Beebe officials unveiled an incentive program to facilitate staff education.

"One of the things I saw when I was in risk management was that the registrar position didn't require medical terminology [knowledge]," Moulinier says. "They'd spell words wrong and use the wrong diagnosis all the time."

As the director of patient access, Moulinier now requires her staff to have medical terminology knowledge and earn the medical Certified Healthcare Access Associate (CHAA) designation within two years of their hire. "This gives them a career ladder and a way to be rewarded for their education and commitment to excellence," she says.

Beebe pays for the first two tries at the qualifying exam the first year, but if employees fail both times, they must pay their own way the second year. "Fortunately, we have not had that occur yet," says Moulinier.

Over half the staff are now certified, along with Moulinier, who is a certified healthcare access manager. "We've had a 98% pass rate the first time," she says.

What's better is that the human resources (HR) department has supported the initiative. The CHAA designation would normally mean a two-grade pay increase. But the HR department approved the promotions after the staff had learned medical terminology and were enrolled in the CHAA course.

"That's unheard of," says Moulinier. "We have a great HR department that truly sees the value of education as a means to accomplish our strategic goals. We immediately reduced our staff turnover and were able to keep our wonderful team members in the department."