This Conversation May Be Recorded for Quality Purposes

Fundamentals of a Call Observe Quality Assurance Program

Jasmine ThomasQuality Assurance SpecialistWellSpan Access Call Center

What should you be listening for?

Establish the specific behaviors employees must practice based on departmental goals and expectations.

Wildly Important Goals

Did the agent ask the caller for their preferred name and address the caller by that name throughout the call?

Did the agent pull the caller/patient up in the scheduling system?

Did the agent remind the caller to review their preparation instructions?

• Authenticates Two Identifiers• Verifies Diagnosis/Symptoms/Dx Code(s)• Encourages Caller to Register for

Labs/Schedule Imaging Studies• Clearly Identifies Arrival Instructions

What should you

be listening

for? Listens Actively

Avoids long, unexplained, Silent Pauses

Uses Courteous Words & Statements

Enunciates Clearly & Speaks Slowly for Ease of Understanding

Establish behaviors that are specific to a call center and/or customer service work environment.

Create an Evaluation Form!! Does Not Meets

Partially Meets Meets Exceeds Not Applicable

Determine how you are going to rate each behavior.

Define Each Behavior

Checks Scheduling System for Additional Appointments to be Registered

o Does Not Meet- Agent fails to pull the caller up in the scheduling system. Agent pulls the caller up in the scheduling system but does not complete the registration for any future visits occurring within the next 30 days.

o Partially Meets- NAo Meets- Agent pulls each and every caller up in the scheduling

system, identifies any future visits occurring within the next 30 days and completes the registration for said visit(s).

Define Each Behavior

Listens Actively

o Does Not Meet- While completing the registration, the agent does not give the caller their full attention, continuously interrupts the caller while they are speaking and continuously asks the caller to repeat themselves.

o Partially Meets- Agent only gives the caller their undivided attention during parts of the registration. During other parts of the registration, the agent is, noticeably, distracted and/or asks the caller to repeat themselves.

o Meet- Agent gives the caller their undivided attention, is able to pull cues from the caller/conversation to assist in the registration and listens without interrupting the caller.

First Impression/Great Greeting

Telephone Skills

Identifying Information

Customer Experience

Handoffs

Closing

Bonus (how to achieve an Exceeds)

Categorize the

Behaviors

Develop a Scoring System/Scoring Key

Does Not Meet: 75% <

Partially Meets: 75 – 84.99%

Meets: 85 – 100%

Exceeds: 100% >

Does Not Meet: 0 – 43

Partially Meets: 44 – 49

Meets: 50 – 55

Exceeds: 56+

Create a Summary

Make sure your team understands the behaviors and how they are being evaluated

Keep your team privy to any changes/updates

Provide timely feedback

Schedule routine Coaching

Calibrate!!!

QA Specialist

Best Practices

Questions???

Sample Calls…

Well THAT Didn’t Go Well …Well THAT Didn’t Go Well …

Lessons Learned from a Project Failure

Virginia RobbinsDirector, Patient Access

Penn State Hershey Medical Center

The ProjectThe Project

Implement automated eligibility checking for: Ambulatory pre-registration ED registration

Let’s call it product “Auto Elig” from Vendor X

Some Key FactsSome Key Facts

Fully employed physician model One Patient/One Chart, OP and IP Ambulatory Pre-Registration

5000 visits per day Team Manager: 6 months in position and new to leadership

ED Registration 200 visits per day Manager: 1 year in position, 4 years in Access leadership

Team MembersTeam Members IT Analysts

Role is to understand software Meet system requirements

Access Team Manager/Manager Running complex teams and meeting

operational business needs Director

Simultaneously responsible for Access evaluation of new Revenue Cycle software

Project GoalsProject Goals

1. Ambulatory: Eliminate manual eligibility verification of 5000 visits/day Automate process Work exceptions only Increase accuracy, reduce time, reduce staff

2. ED: Replace multi site verification with single site Increase accuracy, reduce time, not staffing impact

Ambulatory Pre-Registration ProcessAmbulatory Pre-Registration Process

1. Create encounter in billing system to initiate billing process

2. Set “Precert” to Y if service could potentially need pre-certification

3. Has patient been seen within 6 months? Yes: verify insurance eligibility No: Call patient, perform full registration, verify insurance

eligibility

Pre-Registration Process – Con’tPre-Registration Process – Con’t

4. Copy co-pay information from insurance eligibility source to billing software for practice site staff at patient arrival

5. Set “Referral” to Y if patient’s insurance requires a referral for specialist care

Downstream Processes – Patient AccessDownstream Processes – Patient Access

Centralized Pre-Certification team pulls all “Pre-Cert = Y” encounters, review benefits, initiates pre-certification process if needed.

Centralized Referral team writes PSHMC referrals and calls non-PSHMC PCPs to obtain referrals.

Downstream Processes - Practice SitesDownstream Processes - Practice Sites

Patient arrives for care, checks-in Pre-Registration complete; reduces registration

time Pre-Cert and/or referral, if needed, are in place Co-pay displayed in billing system for easy

collection

Project ProgressionProject Progression

Director unable to be present due to competing project requirements with Revenue Cycle software evaluation (Red Flag #1)

Vendor X spent 6 hours with Pre-Registration and Pre-Certification managers to review current procedures in detail

IT not present (Red Flag #2)

Project ProgressionProject Progression

Vendor X returns with project plan based upon their standard processes and without reference to our current processes (Red Flag #3)

Step 1: implement new tool without automation. i.e., replace today’s multiple web sites with vendor’s one web site

Project ProgressionProject Progression

Interfaces built and mapping done to send billing data to Vendor X’s Auto Elig website

Pre-Registration Associates trained in Auto Elig Ready for Go Live!

GO LIVE ResultsGO LIVE Results

Vendor’s automatic “push” of encounter to Auto Elig website is up to 7 days prior to date of service

We validate at 25 days prior to date of service to … Allow time to obtain Pre-Certification Allow time to write Referral

We had to do manual push of data, encounter by encounter

GO LIVE ResultsGO LIVE Results

Manual push takes 30-40 seconds longer to process than previous websites

30 sec * 5000 lookups daily = 41.6 extra hours/day = 5.7 FTEs worth of additional processing time

This is progress?!?

It Gets Worse …It Gets Worse …

Even if Auto Elig could check at 25 days (which it cannot) it also cannot return the co-pay to the billing system in the same place and format that the Practice Site Check-in Staff expects to see (500 people)

Stakeholder base just exploded beyond Patient Access … and they weren’t included in the project.

Time for DiscussionTime for Discussion

Vendor: PSHMC is validating at 25 days instead of 7 days as all

other clients do 7 days is best practice PSHMC must change

PSHMC: Very willing to change processes but … How do other clients do pre-certification?

Discussion continues …Discussion continues …

Vendor: Ummm…..

Answer: Ordering physicians’ offices obtains Pre-Certification No other clients with centralized Pre-Certification team

because … No other clients with fully employed physician model

Ambulatory Lessons LearnedAmbulatory Lessons Learned Vendor:

Did not identify what is unique to PSHMC despite six hours review of current processes

Lessons: Vendor assumptions may be invalid Assume you know more than the vendor Question everything Put the breaks on if not satisfied with

information provided

Ambulatory Lessons Learned (Con’t)Ambulatory Lessons Learned (Con’t)

Operations leadership Pre-Registration Team Manager too green to see where

new process was lacking Director was not present; conflicting projects

Lessons: Don’t exceed bandwidth Balance operational needs and new technology

implementation

Ambulatory Lessons Learned (Con’t)Ambulatory Lessons Learned (Con’t)

Operations/IT Intersection IT did not need to understand current processes to

implement new product Operations team did not understand the “techie talk”

Lessons Need project leadership resource No operational duties Manage vendor relationship

Meanwhile, over the in ED …Meanwhile, over the in ED …

All is working well Why? ED visits are for today so encounter flows to Auto

Elig automatically (trigger is 7 days or younger) ED Registration Associates pull ED co-pay,

continue to manually add to billing system

ED BenefitsED Benefits

One source of eligibility verification instead of previous multiple sites

ED co-pay is available at check-out per previous process; no change

Time-savings per registration but volume is too low to impact staffing (ED 200 visits per day over 24 hours v Ambulatory 5000 visits per day over 8 hours)

So Where Do We Go From Here?So Where Do We Go From Here?

Coming soon to a theatre you:

Automated Eligibility, Take II What’s different this time …

Project Manager is assigned Director is leading Operations project team Solved the 7 day/25 day barrier Practice Site leadership on board – staff will learn how to

use Auto Elig

Proposed New Flow For AmbulatoryProposed New Flow For Ambulatory

Create encounter at 25 days prior to date of service (not change)

Manually validate eligibility at 25 days only if Pre-Cert = Y (20%)

Automatic eligibility verification at 7 days for all other services (80%)

Exception worklists for the 80% Practice Site: get co-pays in Auto Elig

QUESTIONS?

Getting it Right Up Front:

Registration Accuracy

TAKING A CLOSER LOOK: REGISTRATION ACCURACY We will take a look at how to ensure

registration accuracy from three different perspectives: Registrar Department Organization Quality Assurance Process

RESEARCH ON ACCURACY

30-40% of denials are caused by registration errors, representing as much as 0.5% in lost revenues

Hospitals in the top quartile have a registration accuracy rate of 97% compared to the national average of 93%

GETTING IT RIGHT UP FRONT: REGISTRAR Use all available resources

Help documents

Follow an established workflow Workflow is set of tasks—grouped chronologically—that

are necessary to accomplish a given goal Goal is to maximize efficiency and accuracy

GETTING IT RIGHT UP FRONT: DEPARTMENT Department specific policies and procedures

Necessary as a resource and to hold staff accountable Have staff review policies and procedures annually

(including clinical staff who perform registration tasks)

Develop workflow Have new staff trained using workflow

Choose training staff wisely

GETTING IT RIGHT UP FRONT: ORGANIZATION QUALITY ASSURANCE Resources

Help documents Email – Distribution lists Hot Tips Monthly Registration Newsletter

Bill Edits System generated Customized based on registration errors

GETTING IT RIGHT UP FRONT: ORGANIZATION QUALITY ASSURANCE Maintain a Quality Assurance (Audit) Process

To monitor and track registration errors to identify necessary improvements to the registration process

To improve the education and enhance the accountability of registrars in order to achieve the highest standards of registration accuracy

GETTING IT RIGHT UP FRONT: ORGANIZATION QUALITY ASSURANCE

INTERNAL AUDITS Monitor and correct accounts on daily reports

System generated reportsCustom reports

EXTERNAL AUDITS Billing and Registration Departments

REGISTRATION ACCURACY STANDARDS

The parameters of the Accuracy Standards policy should be clearly defined and consistent across all registration departments and should include:

Registration Quality Assurance Referral Legend

Accuracy Rates

REGISTRATION ACCURACY STANDARDS

Registration Quality Assurance Referral Legend

Lists errors and the assigned point values

Audits range from 1 to 5 points

Incorrect Location = 1 point

ABN not presented to the patient (Compliance) = 5 points

QUALITY ASSURANCE FEEDBACK Automated email sent directly to registrar

Explains the error

Provides what corrections were made

Reference to a help document (when necessary)

REGISTRATION ACCURACY STANDARDS

QUESTIONS?