Transcript Document

MISSISSIPPI PRIMARY HEALTH CARE
ASSOCIATION
CONDUCTING AN
OPERATIONS ASSESSMENT
Presented by:
Michael R. Taylor, Precision Resources, Inc.
[email protected]
SESSION GOAL
Share tactics that equip attendees to
evaluate the effectiveness of their
health center’s operations and develop
resulting plans for improvement
SESSION OVERVIEW
Hypothesize Assessment Objective(s)
Analyze Relevant Information/Data
Refine Assessment Objectives
Observations - What to Look for
Document Outcomes
Develop Implementation Plan
HYPOTHESIZE ASSESSMENT OBJECTIVES
(SCHEDULING)
EFFECTS
Reports that staff is not helpful/courteous
POTENTIAL CAUSES
Individual’s demeanor is incompatible with job
requirements
Individual’s customer service training/
experience is inadequate
Increased volume of walk-in patients
Process is so cumbersome that it deters
patients from booking appointments
Insufficient phone lines cause unacceptably
long hang/hold times
Insufficient number of staff who book
appointments
Too many patients arrive for their
appointment unprepared/late
Patients are noncompliant
Scheduler(s) are not conveying critical
information (e.g., payment, insurance,
referrals, underlying logic for scheduled time)
HYPOTHESIZE ASSESSMENT OBJECTIVES
(REGISTRATION/DISCHARGE)
EFFECTS
Reports that staff is not helpful/courteous
POTENTIAL CAUSES
Individual’s demeanor is incompatible with
job requirements
Individual’s customer service
experience is inadequate
training/
Increased volume of denied claims because Staff don’t verify coverage before each
patients are not enrolled
occasion of service
Staff verifies coverage for current plans but
don’t update patient information in practice
management system
Less than acceptable cash collections
Patients are noncompliant or unprepared
Staff don’t request payment routinely
Staff don’t know when deductibles and or
co-payments apply
HYPOTHESIZE ASSESSMENT OBJECTIVES
(PROVIDER VISIT)
EFFECTS
POTENTIAL CAUSES
An inordinate number of Encounter Forms Providers are retaining Encounter Forms
are unavailable for daily charge entry, and/or placing them in health records
thus billing is decreased/delayed
Encounter Forms disappear after being
given to patients to return to the Registration
Desk for discharge
Payment is denied for a large volume of Provider coding is haphazard and training
claims because diagnostic and procedure might be required
codes are inconsistent
Provider productivity
acceptable
is
less
than Nurses/Medical Assistants don’t prepare
exam rooms between patient visits
Visits are prolonged because Providers
attempt to address all patient conditions
during one visit
HYPOTHESIZE ASSESSMENT OBJECTIVES
(CHARGE CAPTURING)
EFFECTS
POTENTIAL CAUSES
The amount and value of booked charges is All Encounter Form charges are not being
low given the average number of monthly entered into the practice management
patient visits
system
There is no daily reconciliation process or
internal control measure that ensures
appropriate charge entry/capturing
Charges haven’t been increased in five
years
The Encounter Form hasn’t been updated in
three years and, therefore, excludes new,
high demand services
HYPOTHESIZE ASSESSMENT OBJECTIVES
(BILLING/COLLECTIONS)
EFFECTS
POTENTIAL CAUSES
Payment for an unacceptable number of
claims
is
pended/denied
because
submitted patient information is incorrect
inconsistent with payers’ data bases
Registration staff don’t verify patient
information and/or ensure that it is
accurately entered in the practice
management system on each occasion of
service
There is no internal control process that
periodically checks the accuracy of claims
before they are submitted
There is growing backlog of bills that No staff is available to research, correct
require research and correction before the and resubmit old claims
resubmission deadline
There is insufficient oversight to ensure
that
staff
correct
and
resubmit
pended/denied claims in the prescribed
time frame
NOW IT’S YOUR TURN
• Take about 15 minutes
– Think about your health center’s operations
– Identify two functional areas where you’re fairly
certain that improvement is warranted
– Jot down one or two effects of each shortcoming
– Then list what you think the potential causes are
• The point is encourage you to think critically
and in detail about how your health center
functions
HYPOTHESIZE ASSESSMENT OBJECTIVES
(
)
EFFECTS
POTENTIAL CAUSES
HYPOTHESIZE ASSESSMENT OBJECTIVES
(
)
EFFECTS
POTENTIAL CAUSES
NOW IT’S YOUR TURN
SHARE!
ASSESSMENT OBJECTIVES
• Cumulative CAUSES:
– Are based, in many cases, on yet unsubstantiated
perceptions and/or anecdotal information
– Highlight where substantiating information/data
might be needed
– Don’t necessarily represent root causes
– BUT serve as a foundation to define initial
assessment objectives and areas of focus
ANALYZE RELEVANT INFORMATION/DATA
• Distinguish root causes from symptoms
• Identify and analyze information/data
necessary to substantiate/refute potential
causes, and refine objectives and focus
– Patient complaints
– Satisfaction survey results
– Call volume
– Encounter Forms
– Remittance Advices
– Encounter and patient volume data
– Financial management reports (e.g., financial
statements, aged A/R by payer
ANALYZE RELEVANT INFORMATION/DATA
• This is an ideal time to evaluate the adequacy of
management information, and the capability and
configuration of your practice management system
– Do reports provide sufficient detail to substantiate or
refute suspected causes?
– Are needed reports available/easily produced?
– Does the frequency of report production permit
appropriate monitoring?
– Who’s responsible for reviewing what reports and are
they aware and held accountable for those
responsibilities?
• Create an information dashboard to monitor key
operating functions on an ongoing basis
REFINE ASSESSMENT OBJECTIVES
• Use analytical outcomes to:
– Confirm, refute and refine assessment
objectives
– Inform the types of activities required to
substantiate potential causes and
conclude improvement initiatives
• What data should you analyze
• What operations functions should you observe
OBSERVATIONS - WHAT TO LOOK FOR
(WAITING ROOM)
• Signage should communicate:
– Patient rights and responsibilities
• Payment expected and due at the time of service
• Walk-ins will be seen in their order of arrival but only as
permitted by appointed patients
• Patients arriving more than 15 minutes late for
appointments will be treated as walk-ins
– Hours of operation
– The availability of discounted fees for qualifying
patients and how to apply
– Acceptable forms of payment
– Participating health plans
– Registration instructions
OBSERVATIONS - WHAT TO LOOK FOR
(WAITING ROOM)
• Cycle Time Durations
–Arrival to Registration
–Registration to Retrieval
–Retrieval to Provider Entry
–Provider Entry to Exam Completion
–Exam Completion to Discharge
• Facilities
–Attractive, functional, safe and clean
–Adequate, comfortable seating
OBSERVATIONS - WHAT TO LOOK FOR
(WAITING ROOM)
• Front Desk
–How many and to whom do they report
–Staff interactions with patients (e.g.,
welcoming, courteous, observant)
–Appearance of order or chaos
–Frequency and pervasiveness of interruptions
(e.g., telephone calls , other staff members,
visitors) and unrelated functions
–Frequency, timing and content of payment
requests
–Patient reactions to payment requests
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Staff interactions with patients (e.g.,
welcoming, courteous, observant)
• Appearance of order or chaos (e.g.,
designated locations for key tools and
resources)
• Frequency and intrusiveness of interruptions
–Telephone (related vs. unrelated)
–Other staff members (appropriate vs.
inappropriate)
–Visitors (vendors, sales people, deliveries)
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Payment requests
–Are requests made routinely
–When is payment requested
–How are requests made
–Are patient accounts checked for previous balances
–Do staff know when co-payments and deductibles
apply and the amount to request
• Patient reactions to payment requests
–Do requests seem expected
–Are patients prepared to pay
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Patient registration
–Is process confidential
–Are identification and insurance cards copied
–Is copy machine proximate and functioning
• Insurance verification
–Do staff inquire re secondary payers
–Is verification process quick, easy, reliable and
accessible
–Do staff check to ensure that verified plan
information is consistent with patient’s account
–Are notations made when coverage is verified
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Encounter Forms
–Are they numbered to permit subsequent
reconciliation
–Who handles them, before and after provider visit
• Health Records
–Are they available and complete for appointed
patients
–Can they retrieved quickly for established walk-in
patients
–Is production relatively easy for new walk-in
patients
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
•Health Records
-Is access to the central storage restricted to
approved staff
-Are Out Guides used and completed sufficiently to
identify the location of pulled charts
-Do most Out Guides indicate that charts were
pulled fairly recently
HEALTH RECORDS
-AreTHEY
records organized
reasonably to AND
locate key
ARE
AVAILABLE
documents (e.g., most recent H&P, progress notes,
COMPLETE
FOR
APPOINTED
medications list, etc)
PATIENTS
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Financial Counseling
–Are uninsured patients routinely referred by
registration staff
–Do uninsured, appointed patients usually bring
income documentation
–What do staff do when/if patients report no
income
–Do staff evaluate patient eligibility for public
insurance programs, either first or
simultaneous with center discounts
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Financial Counseling
–Is there a policy that requires periodic
recertification
–Is there a mechanism to alert staff when
recertification is required
–Does policy require patients to pay full charges
prior to eligibility determination or qualification
for center discounts
OBSERVATIONS - WHAT TO LOOK FOR
(BEHIND THE FRONT DESK)
• Discharge/Charge Entry
–Do staff conduct a daily reconciliation process that
accounts for:
• All Provider-completed Encounter Forms
• Collected cash and credit card receipts
–What does staff do if Encounter Forms are missing
–How soon after service are charges entered into
the practice management system for billing and to
determine patient liability
–Is an another request made for payment
–Are patients reminded again about any previous
balance
OBSERVATIONS - WHAT TO LOOK FOR
(SCHEDULING)
• Communications Content
–Who and how many staff perform the scheduling
function
–How do schedulers know the amount of time that
should be to assigned to each visit
–Is staff courteous, helpful and knowledgeable
–On average, how many times does the phone ring
before being answered
–On average, how long and how frequently are
patients placed on hold
–Are patient accounts checked for previous
balances
OBSERVATIONS - WHAT TO LOOK FOR
(SCHEDULING)
• Communications Content
–Are schedulers equipped with a current list of
health plans that the center accepts including copays, deductibles, referral/ preauthorization
requirements, non-covered health center services
–Are patients informed that payment is expected
and will be requested at the time of service
–Do staff communicate the minimum amount
patients should be prepared to pay
–Are uninsured patients informed that they must
provide proof of income to qualify for discounted
fees
OBSERVATIONS - WHAT TO LOOK FOR
(SCHEDULING)
• Communications Consistency
–Are patients instructed to bring proof of
identification and their insurance card, if any
–Are patients informed that they will be treated as a
walk-in if they are more than 15 minutes late
–Do staff know when co-payments and deductibles
apply and theirs amounts
–What tools are used to ensure consistent,
comprehensive communications with patients
(script, checklist, etc)
–Are schedulers equipped with a current list of
health center charges
OBSERVATIONS - WHAT TO LOOK FOR
(PATIENT VISITS)
• Patient Visits
–Do provider productivity levels meet acceptable norms (If not, why
–Are provider productivity standards communicated/reflected in
employment agreements
–What percentage of provider time is spent off-site (e.g., attending
inpatients, traveling between sites)
–Do providers prolong patient visits because they attempt to treat
multiple conditions during a single visit
–Do all providers use the same scheduling template
–Do providers submit legibly completed Encounter Forms in a timel
manner
OBSERVATIONS - WHAT TO LOOK FOR
(CODING)
• Documentation and Coding
– Do providers complete Encounter Forms appropriately and on
a consistent basis
– Who performs coding functions, aside from services listed on
the Encounter Form
– Is the Encounter Form updated frequently enough to ensure
that it includes current, commonly used procedure codes
– Do record notes seem to support selected codes
– Does the health center either employ or engage a professional
Coder who periodically reviews provider documentation and
coding practices
OBSERVATIONS - WHAT TO LOOK FOR
(BILLING)
• Timely, Accurate Submissions
–Are bills sent out/submitted within an
acceptable time from the date of service
–Are claims submitted electronically, wherever
possible
–Are sample claims spot checked periodically to
identify developing problems
OBSERVATIONS - WHAT TO LOOK FOR
(BILLING)
• Claims Backlogs
–Is there a backlog of unbilled claims
–Is there a backlog of previously denied or pended
claims that require correction and resubmission
–How significant is/are the backlog(s)
–Can claims values be sorted by dates of service and
by payer
–Is staff familiar with each payer’s claims submission
deadline
–Is there an adequate, ongoing effort to clear any
backlog(s)
OBSERVATIONS - WHAT TO LOOK FOR
(PAYMENT POSTING & DEPOSITS)
• Payment Posting
– Are payments posted to patient accounts within a
reasonable time of receipt
– Is posting done manually or electronically
– Is electronic posting possible
– Are denial reasons/codes posted to patient accounts
– Are prevailing denial reasons summarized by payer in a
periodic management report
OBSERVATIONS - WHAT TO LOOK FOR
(COLLECTIONS)
• Payment Deposits
– Is EFT in place, wherever possible
– Are deposits made within a specified time of receipt
– Who makes deposits
– How are timely deposits ensured
• Remittance Advices (RAs)
– Who reviews RAs
– Are RAs reviewed within a specified time after receipt
– What actions are taken when and by whom on pended and denied
claims
– Are and how are prevailing reasons for denied claims
communicated to other staff
OBSERVATIONS - WHAT TO LOOK FOR
(COLLECTIONS)
• Patient Payments
–Have/can historical cash collections be
determined by site as a basis to establish a
cash collections target
–Are cash collections reasonable given
encounter volume and payer mix
IT’S YOUR TURN AGAIN!
• Go back to the exercise you completed on pages
10 and 11
• What data would you analyze and/or operating
functions would you observe to substantiate the
“POTENTIAL CAUSES” you defined?
DOCUMENT PROCESS & OUTCOMES
• A written assessment report should document:
–Defined objectives
–Activities (the process that was followed)
–Conclusions, as supported by analyses and/or
observations
–Recommendations for improvement
• Share draft report with entire management team
to gain additional insight, buy in and refine
recommendations
DOCUMENT PROCESS & OUTCOMES
• Documenting Outcomes will:
–Help you digest and consider the implications of
assessment findings
–Highlight the need for additional information and/or
further investigation
–Assist in quantifying both the value of corrective
actions and the cost of implementing them
–Establish a foundation to develop an
implementation plan
DEVELOP IMPLEMENTATION PLAN
• Segment recommendations between
–Easy Fixes: relatively quick, inexpensive and
easily implemented actions that will yield near
term results
AND
–Longer Term Solutions: more complex initiatives
that will require a significant financial and/or staff
investment, inter departmental coordination and
cooperation, and/or major change to
organizational philosophy and procedures
DEVELOP IMPLEMENTATION PLAN
• Should include:
–Defined objective(s)
–Sequential implementation tasks
–Corresponding responsible party(ies)
–Benchmark(s) that will be used to measure
effectiveness
–Implementation time frame
–Required financial investment and likely return,
as appropriate
SUMMARY
• A well conceived and executed operations
assessment should yield the intelligence
you’ll need to:
–Improve patient satisfaction
–Increase patient throughput
–Enhance staff productivity
–Increase quality of care
–Improve collections and overall financial
performance
SUMMARY
• To achieve results, however, you’ll likely
have to:
–Revise policies and procedures
–Update staff job descriptions
–Re-train staff
–Modify information systems
–Educate patients
–Monitor performance
–Measure impact
QUESTIONS