MISSISSIPPI PRIMARY HEALTH CARE ASSOCIATION

CONDUCTING AN OPERATIONS ASSESSMENT

Presented by: Michael R. Taylor, Precision Resources, Inc. MRTPRI@aol.com

SESSION GOAL

Share tactics that equip attendees to evaluate the effectiveness of their health centers 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
Individuals demeanor is incompatible with job requirements Individuals 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
Individuals demeanor is incompatible with job requirements Individuals customer service experience is inadequate training/

Increased volume of denied claims because Staff dont verify coverage before each patients are not enrolled occasion of service Staff verifies coverage for current plans but dont update patient information in practice management system Less than acceptable cash collections Patients are noncompliant or unprepared Staff dont request payment routinely Staff dont 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 dont 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 havent been increased in five years The Encounter Form hasnt been updated in three years and, therefore, excludes new, high demand services

HYPOTHESIZE ASSESSMENT OBJECTIVES (BILLING/COLLECTIONS)

EFFECTS
Payment for an unacceptable number of claims is pended/denied because submitted patient information is incorrect inconsistent with payers data bases

POTENTIAL CAUSES
Registration staff dont 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 ITS YOUR TURN Take about 15 minutes

Think about your health centers operations
Identify two functional areas where youre 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 ITS 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 Dont 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? Whos 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 Do staff know when co-payments and deductibles apply and the amount to request

Are patient accounts checked for previous balances

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 patients 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

HEALTH RECORDS

-Do most Out Guides indicate that charts were pulled fairly recently

-Are records organized reasonably to locate key ARE THEY AVAILABLE AND documents (e.g., most recent H&P, progress notes, COMPLETE etc) FOR APPOINTED medications list, 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
Are provider productivity standards communicated/reflected in employment agreements

Do provider productivity levels meet acceptable norms (If not, why

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 payers 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

ITS 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 youll 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, youll likely have to:

Revise policies and procedures Update staff job descriptions

Re-train staff
Modify information systems Educate patients

Monitor performance
Measure impact

QUESTIONS