AdCare Hospital is a 114-bed inpatient facility with six outpatient sites. The hospital admits approximately 5,000 inpatients and provides over 85,000 outpatient treatment sessions per year, which represents 100,000 initial claims that must be processed for payment. Collaboration across departments in problem identification and resolution can improve access to information and increase the effectiveness of the revenue cycle.
Over the past several years, with an increase in the number of patients and service locations, AdCare experienced difficulties in revenue collection. A Controllable Events Committee was formed and included stakeholders from various disciplines to identify and address the root causes of these problems. The team has addressed not only ongoing issues-such as the use of mutually understood terminology and standardized communication-but has also assessed our structure and practices for process improvement from a systems perspective. Through this approach, we examined the capture, use of, and access to non-clinical documentation to improve the revenue cycle.
The prior system was to create a manila folder of patient information upon admission of a patient, containing a face sheet for their account, a copy of their insurance card, and insurance verification on that date. This folder was retained in a file room. However, copies of authorization letters, inpatient case management review forms, outpatient case management forms, and appeal letters were retained in files at inpatient, outpatient, or billing office locations. As a result, comprehensive reviews of these documents were time-consuming and inefficient.
Access to non-clinical documentation during the revenue cycle process is essential to ensure accurate and efficient processing of patient accounts and proper reimbursement for services provided. Important non-clinical documentation may include patient identification, insurance card and eligibility verification, and other registration materials, as well as payer authorization correspondence, tracking, and appeal letters.
Document imaging-via scanning-of these patient-specific materials provides a centralized information resource for registration and billing functions. The same resource simplifies document referral and tracking by case management and clinical departments who must communicate with insurance reviewers. Components of the document imaging solution include:
Registration documents. The revenue cycle process begins at pre-registration, which requires retention of verified identification, insurance eligibility and benefits information, and pre-certification or authorization documents. Scanning these materials at initial registration or when updated ensures availability of the most current, applicable documentation as well as a dated record of all previous information in a convenient, centralized location.
Centralized image storage enables corroboration of a patient's identity during the entire span of care, ensures treatment integrity, and protects against the risk of identity theft. Federal and state provisions and provider standards call for a comprehensive approach to mitigating any chance of identity theft or compromised privacy of patients. Proper verification and protection of personal identity information (PII) and personal health information (PHI) are essential elements of this process.
Insurance eligibility and benefit confirmation is crucial in determining a patient's available benefits and making appropriate case management decisions. Administratively, such documentation simplifies coverage reviews and the process of identifying and correcting errors made by registration or billing staff. Post-billing provides a supporting record for eligibility and other, related payer appeals.
While paper copies of these materials could be retained in files, their availability is either limited to that file or, if duplicated, at multiple locations. However, they may not be uniformly updated upon subsequent service dates. The centralized storage of current materials-via imaging-solves the problem of redundant and inaccurate paper records that can result in data-entry errors.
Case management documents. Initial pre-certification materials may consist of an online-generated response from a payer or, if verbal, a form indicating the reviewer, time, authorized level of care, and other essential data. These provide a reference for case management staff and for the central billing office in claims submission and denial management, as well as data for following up with appeals.
Insurance companies have become increasingly inflexible when conducting post-service reviews for authorization, or when the information in their systems regarding pre-certification or pre-admission contact is incorrect. By tracking the date/time, reviewer, level of care discussed, and any comments from the review in a standard format, the case manager has the supporting record to more successfully argue a disputed authorization.
Assisted by centralized electronic storage, case managers at different locations-within the same department or at different inpatient and outpatient locations-can review essential materials, understand the progress and flow of contacts with insurers, and more effectively coordinate care. Similarly, the billing office, when confronted with a denial or question about a billed level of care, can tap the same resource to more effectively perform its role in the revenue cycle process.