Referral, Authorization, Verification, Eligibility

Transcript Referral, Authorization, Verification, Eligibility

About Children’s Hospital Colorado

   Private, not-for-profit pediatric healthcare network Obtained Magnet status in 2006 In addition to one main campus facility  2 hospital locations within community hospitals   2 urgent care sites 1 urgent care site within another hospital   1 free standing surgery center 9 satellite specialty care centers     Level I trauma center Maternal fetal medicine program opened in March 2011 Ranked among top 10 children’s hospitals for over a decade Statistics  318 licensed beds  517,873 outpatient clinic visits (2011)  Celebrating over 100 years of commitment to pediatric care!

What is RAVE?

R- Referral A- Authorization V-Verification E-Eligibility

Structure of Patient Access

• Prior to RAVE go-live  Patient access included: • Admissions (Main and ED) • • Financial Counseling IV staff (6 FTE)  Inpatient, Ambulatory Surgery, and Observation patient populations • Both scheduled and non-scheduled cases • • Function as a safety net Accounts worked via Ontrac tool 5

Elements in Space

Org Chart Pre RAVE

Scattered Across the Universe

•

Where did everyone live???



Outpatient clinics

• • • Each reported to outpatient floor specific manager Team included scheduling, check-in/out, IV staff Worked floor specific accounts 

Administrative Pavilion

• In charge of obtaining authorizations for range of procedures   Radiology procedure authorizations Radiology required authorization prior to scheduling • • • Surgical initiation Cardiac DME Infusions 

Network of Care locations

Planet Deficiencies

• Processes were sub-par workflows • No dedicated back-up for these staff members • No dedicated management structure for IV staff 9

As the Planets Start to Align…

• Concept born 4 years prior  VP of Ambulatory Services   VP of Finance PFS   PAS Managed Care 10

Project Goal Statement

• Goal Statement The goal of centralization is to reduce the overall number of patient eligibility, no referral/authorization, non-covered services, late/no notification, wrong insurance billed and medically necessary denials The Children’s Hospital receives, and better align resources, training, education, and information to a single point of accountability within the organization. 11

Project Objectives

• • • • • Increase secured at admit rate across the organization to exceed 95% by the time the patient arrives for their scheduled appointment or admission. Currently, this rate is at 90% (per 4-week average as reported on week ending 8/27/10 IV Summary) Maintain staff productivity to consistently work 45 accounts per day per rep. Currently, this rate is at 50 across the organization (per weekly productivity rate week ending 8/27/10). Increase ‘days out’ in authorization rate (per 4-week average as reported on week ending 8/27/10 IV Summary): Goal: 0-3 days = 99% 4 days = 95% 5 days = 90%. Reduce overall denied dollars and final write offs by 50%. 12

The Jurassic Age….

Early Phases

• • On-boarding outpatient clinics to Ontrac (2008 2010)  Rolled out in phases • • Over 2 years Main campus and network locations On-going meetings with management (2008-2010)  To discuss centralization of IV 14

Early Phases continued

• • HR Meetings (Oct 2010)   Employee transfer Job descriptions   Reporting Structure Career Ladder • Promotion Ladder Insurance Verification.doc

 Work from home model Ongoing Management Meetings (Oct 2010) 15

Early Phases continued

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Blending the “Families”

 • • • • • • Monthly PSC meetings (Oct 2010) • HR Involvement  Communication Tool for staff • SBI (Situation, Behavior and Impact) Training  Team life cycle (Forming, Storming, Norming, Performing) Team building Learning process flows Naming department Committee creation Management Structure IT Resources 16

Neanderthal Stage

“How centralize IV, Gorg want know” 17

RAVE go-live structure

Our New Home…

Gorg like!

Me too!

RAVE Begins

• Go live 4/6/11 (27 employees) (Phase 1)  Gained Efficiencies • Merging worklist • Cross training  High Volume   High Dollar Radiology Auth • Scheduling prior to authorization allowed • • • Back-filling for absences Installed robust QR process “Working Smarter not Harder”   Electronic Eligibility Verification Restructure Creation of iRAVE (NOT TO BE CONFUSED WITH RAVE!!) 20

iRAVE (NOT TO BE CONFUSED WITH RAVE!!!)

•

What is iRAVE?

 Online resource • • • Insurance reference Available to all staff Documents payer specific requirements 21

iRAVE continued

• What is iRAVE not to be confused with?

 A prize winning pony  A planet  Gorg  RAVE 24

The Next Planned Phases

• Phase 2 – July 2011 (OT/PT, 3 FTE’s) • Phase 3 – August 2011 (Psych/CDU, ST, 4 FTE’s) Why did we stagger these?

Growth

• Expanding RAVE scope Date Jun-11 Jul-11 Sep-11 Oct-11 Dec-11 Dec-11 TBD Clinic MFM- Clinic & Auth Pool Pain Clinic- Clinic & Auth Pool SIE Downs- Clinic & Auth Pool Monthly Volumes 40 460 70 Unsure at this time Neurology Auth Pool Plastics, Urology, ENT, Ped Surg-Auth Pool North Campus-Auth Pool South Campus and CO Springs 675 Unsure at this time 2600 Additional FTE to RAVE No No No Yes- moved 1FTE from Neuro Dept No Yes – Moved 0.8 FTE to RAVE Yes – 1 to be hired 26

Maintaining Communication

• • • Employees bringing issues they otherwise would not have  Now employees have a ‘voice’ Monthly meetings with clinic management Close working relationship with Patient Financial Services  Work to decrease denials 27

Current state (36 FTE)

• • • • • • • Restructure of Radiology authorization workflow  Upgrade of Epic EMR for how workflow viewed • Allows for better reporting Continued work to document process flows  Team and workflow specific Anticipating efficiencies Network of Care site addition to centralization Medicaid PAR’s for Radiology services Promotion of two employees to Rep III status  Multiple duties Modular training 28

Current state RAVE structure

The Jetson’s Era

Future State

• • • • Move from safety net to initiation  For Inpatient, Amb Surg & Obs cases • Benchmark our existing pilot person from Orthopedics Standardizing Psych processes Adding more clinics  Create a RAVE services ‘Application process’ • Service level agreement Creation of Registration Accuracy Task Force 31

Carbon Dating

So How Did We Do?

Secure at Admit Pre RAVE= 90% GOAL= 95% Actual 2011 EOY= 94% Staff Productivity Pre RAVE =50 accts per day Goal= Maintain 45 acct per day Actual 2011 EOY= 68 accts per day Write-offs for No Authorization Goal= Decrease by 50% Actual 2011 EOY= Increase by 235% 33

So How Did We Do? Continued… Increase “Days Out” Pre RAVE=

0-3 days = 81% 4 days = 60% 5 days = 41%.

Goal=

0-3 days = 99% 4 days = 95% 5 days = 90%

Actual 2011 EOY=

0-3 days = 94% 4 days = 75% 5 days = 60% 34

More Data……

• Quality Reviews • Diligent monthly QR Process  Increased Team Average from 2.68 to 2.9 (out of 3) • Dashboard – SAVE RECENT COPY 35

Lessons Learned

• • • Employee Satisfaction  Dynamics of a large department What exactly are we taking on?

 Responsibilities transferred with employees • Some tasks are out of scope of Insurance Verification Rep level  Roles and Responsibilities – Saw a need once RAVE went live.

• Cleaner registrations • Clearly defined roles Work From Home  Re-evaluate current structure to help maintain relationships 36

Contact Information

Tobi Knight – 720-777-5688 [email protected]

Berj Ermoyan – 720-777-5690 [email protected]