Revenue Cycle Management Value Stream Analysis Order Entry to Claim Resolution. March 2012

Transcription

1 Revenue Cycle Management Value Stream Analysis Order Entry to Claim Resolution March 2012

2 Team Members PFS CAH HIM Bryan, TX Pt Access RMD

3 Reason For Action PROBLEM Current work flow processes are fragmented and inefficient which lead to inaccuracies, delays, and ultimately denials/lost revenue. Several key measures, A/R Cycle and DNFB are higher than Administration targets, which inhibits System fiscal growth and ultimately threatens our ability to meet our Mission to provide excellent healthcare to all. AIM Create and sustain an effective and efficient billing process by achieving 100% of targets by March SCOPE Physician Writes Order to Claim/Bill Adjudication (Resolution)

4 Value Statement Provide thoroughly documented information on the right account, resulting in the initial claim being clean and accurate and eliminating rework; thereby leading to prompt and proper reimbursement enabling us to offer excellent care to all. Key Requirements Abide by laws Adequate time Within the frame of Mission and Values Meet our ethical and religious directives Safety before efficiency Patient-centered and friendly Meet payers expectations

5 Initial and Target State Baseline Target People: Staff Satisfaction 3.65/5 4/5 Service: Clean Claim % Jan % 90% DNFB Jan Quality: Denials-All Jan % 0.45% Growth: Case Mix Index - MCR Feb Finance: Total Cash Collections YTD % 102% Days in A/R (New) Jan Aged A/R Buckets Days 365 Plus Days 29.9% 3.2% 20.0% 2.0%

6 Current State Numerous waits within the process (waiting for bill to drop, wait for response from payers) Manual inputs for charges and moving claims Multiple variations for generating claims Many redundancies in claim generation and collection processes High amounts of denials and increased Days in Accounts Receivable Patient Safety: Lost charts and Wrong patient information

7 Ideal State Attributes Patient pays upfront All orders entered every time at time of service Electronic Medical Record Charges flow from electronic documentation Patient discharged Account coded Clean Claim generated Sent to payer electronically Remit/Payment sent back electronically and posted to account automatically Patient portion is zero Claim resolved per contract

8 Future State Physicians educated on E-Sign for HIM Standardized chart reconciliation between Units and HIM Reduced pre-bill edits Standard method of charts to HIM Reduced Denials

9 Gap Analysis

10 Solution Approach Problem Root Cause If We Then We Timeliness and accuracy of charges Chart to HIM out of order Lack of standardization Create standard work Insure accuracy and timeliness Not assigned, lack of accountability Revise universal chart order and educate Reduce time for HIM and audits Chart elements missing Lack of standard work Educate staff Ensure compliance Scanned chart (assembly analysis) Pre-bill edit process is fragmented Lack of response from physician on queries Fragmented billing issue resolution process Rejected claims from payers Excessive claim underpayments Denials No Quality Control process Changes from multidepartments Lack of physician buy-in and accountability Lack of standard process, multiple variations Missing/Invalid demographics, coding, etc Payer discrepancies and billing errors Missing/invalid information and billing errors Create a Quality Control process Create standard work/process Create an escalation process Establish a standardized process Educate and create standard work Develop an identification and reconciliation process Develop an identification and reconciliation process Reduce rework and waiting time Reduce doing rework and extra steps Improve compliance Eliminate waits and rework within the process Reduce rework and increase collections Increase payment and reduce rework Increase payment and reduce rework

11 Rapid Improvement Event Priority Value Stream Steering Team: Kirk Cristy Charlotte Ferguson Myesha Turner Tamara Roberts Brian Stanford Beth Elder Unit Representative

12 Experiments Rapid Improvement Events 2012 RIE Title Process Owner May Timeliness and Accuracy of Marilyn Lange- RMD Charges July Pre-Bill Edit Process Kay Neuendorff- RMD September Denials: Clinical Teresa Johnson- PFS November Physician Query Process Judy Daniels- HIM 2013 February Billing Issues Resolution Process Teresa Johnson or Melanie Vickery- PFS April Denials: Nonclinical Tamara Roberts- PFS June Rejections Melanie Vickery- PFS August Underpayments Pam Thomas- RMD

13 Completion Plan RIE s Just Do It s Projects Timeliness and Accuracy of Charge Entry Pre-Bill Edit Process Billing Issue Resolution Process Clinical Denials Nonclinical Denials Rejections Underpayments Physician Query Process Lab: Miscellaneous added to Chargemaster ER Charge sheet reconciliation Lack of E-Sign use with Physicians Account cancellations (Ensure status change) No tracking tool for patient satisfaction with billing system Chart Order in MR Combining Departments (MR, RMD, PFS, CI) Pre-Bill edits PI

14 Insights What Went Well: Identified many issues and waste in process Good facilitation Good teamwork Good honest participation Gemba Everyone passionate and animated What Helped: Good team member mix Donuts and coffee Dia representing Critical Access Hospital and fresh eyes What Could Improve: Organized room Representation from a Unit Reduce repetition in VSA process What Hindered: Facility