Referral, Authorization, Verification, Eligibility

Report
2
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!
3
What is RAVE?
R- Referral
A- Authorization
V-Verification
E-Eligibility
4
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
6
Org Chart Pre RAVE
7
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
8
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….
13
Early Phases
• On-boarding outpatient clinics to Ontrac (20082010)
 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
• 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
18
Our New Home…
Gorg like!
Me too!
19
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
22
iRAVE continued
23
• 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?
25
Growth
• Expanding RAVE scope
Date
Clinic
Jun-11
Jul-11
Sep-11
Oct-11
Dec-11
Dec-11
TBD
MFM- Clinic & Auth Pool
Pain Clinic- Clinic & Auth
Pool
SIE Downs- Clinic & Auth
Pool
Monthly Volumes
Additional FTE
to RAVE
40
No
460
No
70
No
Yes- moved 1FTE from
Neuro Dept
Neurology Auth Pool
Plastics, Urology, ENT, Ped
Surg-Auth Pool
Unsure at this time
North Campus-Auth Pool
South Campus and CO
Springs
Unsure at this time
No
Yes – Moved 0.8 FTE
to RAVE
2600
Yes – 1 to be hired
675
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
29
The Jetson’s Era
30
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
32
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]
Questions?
38

similar documents