Academic Medical Center captures more payments, increases capacity
UC Health, a large Cincinnati hospital affiliated with the University of Cincinnati College of Medicine, sought help improving in three discrete areas of operation. Their objective was to improve the rate of collection of the monies owed to them, and increase capacity in their Women’s Center.
Performance improvement consultants from Healthcare Performance Partners (HPP) offered an assessment to examine:
- The rate of cash collections in the Emergency Department (ED);
- Adjustments and denials of payment in infusion and oncology; and
- Patient flow in the women’s center, to provide better service to the community.
The approach to these seemingly unrelated problems was the same: look at the connections or handoffs between people; and look at how many steps it takes to get things done.
Cash collections in the ED
Staff members did not have a standard way to collect co-pays and other forms of payment in the ED. Patients in various states arrived by various modes—by emergency transport, as a transfer, or as a walk-in. Where in the flow of work would it be appropriate to ask for payment?
The target was $150,000 in collections annually, yet during the prior 12 months, the ED had taken in just $13,800. The staff felt overwhelmed by the large target, until they realized that, to meet it, they only had to collect $35 every other hour. Breaking down the target this way made the staff realize it was a target they could meet.
With guidance, the staff members created a standard work flow for the various types of patients, and a script for a respectful way to ask for payment. Instead of asking whether a person could pay, they asked how they would choose to pay. This subtle difference in messaging, and its consistent delivery, improved collections immediately.
In the seven weeks after their improvement event, ED staff collected more cash than it had in the prior year. Patients complied without complaint. Within 6 months, the department was on track to collect $142,000 the first year. Currently, the staff is devising strategies for recouping additional payments over the course of the next four years.
Adjustments and denials of payment in infusion and oncology
Patients receiving chemotherapy or infusion treatment after a hospitalization come to the Infusion Center. Usually the patient would return for six to 12 outpatient visits to complete treatment.
Before the improvement project began, the Center was sustaining over $450,000 in annual controllable adjustments and denials of payment by the insurers. The team looked into the reasons for the denials and discovered, for example, that inpatients released from other hospitals who were to have their follow-up treatments at UC Health were often not being pre-authorized. Treatment would begin before the patient was cleared, and payment was not forthcoming.
Direct results of the work
The team discovered that only one person was handling all of the authorizing work for the unit. When she was on vacation or was sick herself, or if she had too many patients to process, she did not have time to do pre-authorizations. They fell through the cracks in her too-busy schedule.
When the burden of work falls unduly on one person, the temptation is to say, “We need more people.” The team offered a way to look more broadly and creatively at the allocation of resources. Five other people in another part of the hospital system also do this work of pre-authorizing. All agreed to a trial the very next week, integrating the lone staff member from the infusion unit with the others. When the load goes up, others can pitch in. This concept, called “load leveling,” worked well in this case.
Within three weeks, the annual rate of denial plummeted to $70,000. Further work in the infusion unit created standard work, clearly defined activities, and a pre-authorization trigger. The pathway for each patient is defined. Once these refinements were made, the rate dropped to less than $40,000 per year.
Women’s Center patient flow
The Women’s Center had become constrained for appointments. This meant that women were waiting longer for appointments, and the demand coming from new patients could not be met. The team conducted a one-week assessment to determine where the bottlenecks existed in the process, and then a two-week event to implement.
The group developed a flow pattern by provider, showing each patient’s itinerary. Understanding the flow in greater detail allowed the team to schedule appointments more rationally. The effect was to increase access by 28% without additional providers, staff members, or exam rooms.
Staff members expressed great satisfaction at meeting long-sought goals: collecting fees in the ED, obtaining timely payment from insurers, and exceeding performance goals in the Women’s Center.
“We feel like we can provide great patient care. We have control of our professional goals and objectives. Managers feel like they have control,” said a clinical outpatient director. “We do daily rounding now, and we update our scoreboard hourly. This is liberating.”
One nurse stated that receiving reimbursement for their service feels like a form of recognition. He noted that appropriate reimbursement coming in allows them to provide more access and furthers their healthcare mission.