Menu Item: Workflow Analysis and Improvement Unity Health Care, Inc th Street, SE Washington, DC Name: Angela Duncan Diop, ND Title:

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1 Menu Item: Workflow Analysis and Improvement Unity Health Care, Inc th Street, SE Washington, DC Name: Angela Duncan Diop, ND Title: Vice President Information Systems

2 Executive Summary Unity Health Care, Incorporated is a Federally Qualified Health Center, serving nearly 95,000 underserved residents in 30 sites throughout the District of Columbia. In 2009, Unity implemented an electronic health record (EHR). Prior to implementation, we had an inefficient paper based process for handling claims. Our goal was to develop a system that would utilize the EHR to resolve outstanding claims efficiently, decreasing the amount of time required to process claims. In this intervention, the EHR is being used as a collaborative tool. It is allowing two groups who previously did not directly work together, providers and medical claims processors, to merge their processes, resulting in clean, quickly submitted claims. Three years after implementation, the number of days of revenue in accounts receivables has declined 28%. This has made available $1.3 million of cash for operations that would not be available without this improvement. Background Knowledge Unity Health Care, Incorporated (Unity) is a Federally Qualified Health Center (FQHC) serving low-income, homeless, and uninsured residents of the District of Columbia (District). Founded in 1985, Unity is a 501(c) (3) non-profit organization and is the largest private organization providing primary medical care to homeless, low-income, and uninsured District residents. We served over 95,000 patients in The population we serve is racially and ethnically diverse and largely minority. Substantial health disparities and poor health outcomes exist among our patients, highlighting the need for accessible and comprehensive primary care services. Prior to the implementation of electronic health records (EHR), we used a basic practice management system, but most of the processes were on paper. Our billing and collections were paper based; as a result there were inherent inefficiencies. Managing outstanding claims was daunting. In 2008, the days of revenue in accounts receivable was 67.6 days. In order to better meet the needs of the communities we serve, in 2009 Unity implemented an EHR and integrated practice management system, throughout our 30 sites and various programs. Currently, about 230 providers and 900 employees use the system. The EHR has helped Unity to improve efficiency, effectiveness, patient safety and quality of care, which has ultimately improved clinical outcomes and business processes. Local Problem Being Addressed and Intended Improvement In 2008 we had an inefficient paper based process for handling claims. The process consisted of the following: 1. Encounter forms for patient visits were created by providers at the sites. 2. The encounter forms were given to the patient registration clerks (PRC) who would interoffice mail them in batches to Patient Financial Services (PFS), a centralized charge entry department run by our Medical Services Revenue Manger (Revenue Manager). 3. PFS would input these encounters into the practice management system. Significant lag time was intrinsic to the process due to batching and transit. It could take as long as a week for PFS to receive batches from some sites. It was not uncommon for encounters to be held at a site for corrections, left in the paper chart or even lost. The volume of encounters required considerable manpower to process by hand and could take 3-4 days to be put into the system once they reached the central office. The transit time for the paper encounter could take 1 P a g e

3 up to 14 days before it was sent for billing. If an encounter never reached the central office, PFS would have to recreate the encounter by cutting and pasting and send it back to the medical records (MR) department at the site. At the site MR would pull the chart and send it to the Health Center Director at the site to correct or recreate with the provider. In addition to requiring a lot of time to process, this paper system resulted in a significant number of financial adjustments due to coding problems, collections problems and untimely filings. Design and Implementation After the EHR implementation, we were really excited about the potential that we thought the EHR had to streamline the revenue cycle. Now that the technology was in place, our goal was to develop processes to leverage this tool to resolve outstanding claims efficiently in order to get paid faster. The project was led by our Revenue Manager working with the Revenue Cycle team. This team was created shortly after the EHR implementation, with the purpose of bringing together multiple disciplines to work on issues negatively impacting the revenue cycle. Core team members are VP Clinical Support, Deputy Medical Director, VP Information Systems, Assistant VP of Finance and Executive VP of Finance. The initial major steps of the project were as follows: 1. Configured the EHR to create claim statuses. This was done by the Revenue Manger shortly after implementation of the EHR. The claim statuses allow us to keep like claims together for better process management. 2. Created reports to track claims. The Informatics team developed structured query language (SQL) reports giving us the ability to report on and track claims status. 3. Created a new position. We created the new position medical claims processors (MCP). The MCP reviews all claims and assigns them to providers for correction if the claims have errors. They work with providers to make sure that the claims are clean before they are sent to billing. Initially the role was filled by converting the charge entry clerks from PFS (a role no longer needed after EHR implementation) to medical claims processors (MCP). 4. Designed workflow. Workflows were designed to improve the claims management process. The workflows were designed to utilize the EHR s ability to automate the claims review process, specifically the MCPs ability to: review claims return claims with errors to the provider who originated them allow the provider to correct claims allow the provider to return the claims to continue processing In the new process MCPs review all claims before they are sent to billing. If there is an error in the claim, they send a note with the claim to the medical director or the provider explaining the error. The claim will sit in the providers claims cue within the EHR until it is corrected and sent back to the MCP. Examples of the types of errors that are corrected in the process are claims that have missing E&M codes, missing diagnosis or wrong CPT codes. The EHR has enabled us to create claim statuses that we call buckets. The claim sits in a bucket until the person assigned to work on it (provider or MCP) has resolved it. The claim is then moved to the next bucket or in other words it is reassigned. This continues until it is finally sent to billing. 2 P a g e

4 5. Trained staff. The providers and MCPs were trained about the process. MCPs already received front office training, but we also began sending them to the EHR provider training, so they would understand what providers should do to create good claims. 6. Roll Out and Monitor. The process was piloted by our Deputy Chief Medical Officer (Deputy CMO). Then it was rolled out to all providers. The process is monitored by the Deputy CMO and the Revenue Manager by reviewing the claims status reports that were developed by the Informatics team. Medical directors work with providers who are not addressing outstanding claims in a timely manner. Providers and MCPs can get immediate feedback and monitor their claims by viewing their claims cue in the EHR. Initially, some providers did not embrace this change. The change in workflow was a significant cultural shift because previously there was no expectation that providers would play an active role in cleaning up claims after they were created. It was difficult to get providers to respond to claims that were assigned to them to be reviewed and corrected. Fortunately, we have a group of compassionate providers who really care about our patients. They want to use our resources efficiently so that Unity can provide care to as many patients as possible. Realizing this, the Revenue Manager revised the claims report. The first report only showed the number of outstanding claims. The new report showed the number and dollar value of the outstanding claims. By changing the report, outstanding claims received higher visibility and became a bigger priority to resolve immediately. How was Health IT Utilized The EHR is at the center of this intervention. Claims are now automated and generated by the system. The lag time has been greatly reduced, as claims can be sent instantaneously after they have been processed by staff. The EHR is being used as a collaborative tool. It is allowing two groups who previously did not directly work together, providers and MCPs, to work together to create and submit clean claims. The EHR has created greater accountability. Data is centrally stored, allowing us to generate reports to monitor who is responding to the claims assigned to them and the timeliness of their response. The EHR has improved our ability to track claims as they are processed. Now every step of the way we know where a claim is, what is needed to continue to process and how much time we have left to process. This has reduced the number of financial adjustments due to coding problems, collections problems and untimely filings. The EHR has enabled us to create claim statuses or buckets. Claims are also kept in buckets after they have been billed. This has improved our ability to follow up denials and appeals more efficiently. Value Derived/Outcomes Since rolling out this intervention we have seen a decline in the days of revenue in accounts receivable (AR). In 2008, the number of days of revenue in AR was 67.6 days. By December 31, 2011, this had declined to 49 days, a 28% decrease. (See Chart 1) This has had a tremendous 3 P a g e

5 financial impact because now $1.3 million of cash, or 1.6% of our operating budget, is available for operations that would not be available without this improvement. We have also seen an in increase in net revenue per visit, from $93.08 in 2008 to $ in (See chart 2)This increase is due to a number of factors that include this intervention as well as changes in payor mix. Also, bad debt as a percent of uninsured revenue has decreased from $41.8% to 33.3%. (See chart 3) The ability to create and track claims statuses with the buckets has increased accountability. MCPs are assigned to work claims by site, discipline or status. This system gives the Revenue Manager the ability to know the status of claims at any point in time. We created the MCP position then trained and transitioned nearly all of the charge entry staff members to that role. The irony is that we thought that we would not have a need for charge entry clerks post EHR implementation. But this turned out to be far from the truth. We have in fact grown the department from 12 to 15 members. We believe that the MCPs have greater opportunity for career growth then they did in their previous role and their job satisfaction has improved. The qualifications for the job have changed and now the MCP is a higher skilled position; not only do we train them to use the EHR, but also train them in coding. To date, 8 of the 15 staff have either become certified coders or are currently enrolled in training to become certified coders. One staff member has become an EHR analysts and trainer specializing in the practice management aspects of our EHR. (See Table 1) Lessons Learned The biggest lesson learned was the value of the team and how to work as a team to address issues that have broad organization impact. Prior to our EHR implementation, Unity was a hierarchical organization and that worked in silos. During our EHR implementation we learned how to work together in cross disciplinary teams. The Revenue Cycle team was created by the Executive VP of Finance and was modeled after the teams created during the EHR implementation. This project was languishing before it was brought to the Revenue Cycle team and was finally able to be addressed when representatives from front, middle and back offices began to work together on it. The biggest challenge with this project was that it involved a major cultural change for everyone, but especially for providers. This was the first time that claims were being assigned directly to them for correction. Previously, claims were returned to other health center staff who worked with the providers. This change meant that the providers had a greater responsibility for ensuring claims were accurate. Sending the claims back to the originator for correction is a great learning tool. We found that providers do not like having claims returned to them, so most learn quickly what they need to do to prevent rework. This project identified the need for additional coding training for the providers and MCPs. Since we started the project we have had annual coding training for providers and have incorporated coding training as part of providers new hire training. As mentioned before, many of the MCPs are becoming coders. 4 P a g e

6 We learned that it is important to plan as much as possible; however it is just as important be flexible and remain open to the possibilities that arise. We did not foresee the need for the role of MCP, but when we realized the need, we redeployed existing employees to fill the position. This was all occurring in the backdrop of the financial crisis and high unemployment in 2008 and Today the District has the second highest poverty rate in the nation at 23.2% 1 and the neighborhoods we serve saw some of the highest national unemployment rates, at over 20% 2, during that time. Considering all of this, we were grateful to be able to retrain and retain our employees. Financial Considerations This intervention was only possible after EHR was implemented. Our initial investment to implement the EHR was $5.5 million. We received $1.98 million in grants from HRSA for our implementation. This intervention was mostly funded through internal resources, through the conversion of positions already on staff. Coding training for providers and MCP cost at cost of about $10,000/year is associated with this project. A soft cost of this intervention is the cost of allowing people to commit to working on teams outside of their regular job duties. This was an agenda item of Revenue Cycle team for about two years. The team meets for an hour twice a month to address this and other revenue cycle issues. 1 Short, Kathleen, The Research Supplemental Poverty Measure: 2011 Current Population Reports November 2012, p DC Fiscal Policy Institute, Trends in DC s Employment Rate, July 6, 2010, p. 2 5 P a g e

7 Dollars Days Appendix Days of Revenue in AR Chart Net Revenue per Visit Chart P a g e

8 % Bad Debt as a % of Uninsured Revenue Chart Revenue Manager s Staff Table Staff Certified Coder or in training 0 8 EHR/PM Analysts Trainer P a g e