TriCore Reference LaboratoriesUsing Clinical Analytics to Optimize Lab Operations in Real Time

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Today’s Discussion

• TriCore Overview• Rhodes Group Overview• Case Study

• Lab Operations Staffing• Financial Staffing

TriCore Reference Laboratories

Facts:

• Located throughout New Mexico

• Regional medical laboratory providing diagnostic testing for patients and providers

• Merged in 1998 with the hospital laboratories of University of NM Health Sciences and Presbyterian Healthcare to form TriCore Reference Laboratories.

• >8.5 Million Test Per Year

• 99% Volume Performed On‐site

• 75% of Clinical Data

Las CrucesCarlsbad

Clovisx2

Silver City

Las Vegas

Socorro

Tucumcari

Espanola

Ruidoso

Santa Fe

El Paso, TX

Greater ABQ

Los Alamos

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Rhodes Group• Serving the Clinical Laboratory Market Space for 15 years

• Specializing in Large scale Hybrid Commercial Laboratories.

• Outreach, Clinical and Financial concentration areas in Consulting Services and Software.

• Large scale front to back integration vendor

• Merged with TriCore in 2015

• Billions Lab Tests Stored and Communicated

• Billions of dollars worth of financial/claims services to clients

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Overview of

Rhodes Products

Fast Platform Front End Integration Engine

Rhodes Report Engine

Fusion Claims and Revenue Engine

Scholar Metrics and Analytics Engine

Consulting Products

Patient & Order Management eMPI and MDM and Eligibility EMR, HIS, LIS, Path, FIN, 

Fusion, and Report Engine  system integration

Clinical Repository Information Base, for Lab and Path data and Images

Advanced Report Templates and PDF rendering

Exception Control/Client Services Distribution Engine for Reports 

(HL7, eMail, Download, Print, Fax)

Billing workflow Claim Check eligibility engine AR and Rejection management Client and Patient statements

Clinical Metrics Revenue Metrics Expense Metrics

Revenue Optimization Claims consulting System Implementation Consulting Front End Optimization Consulting Report Product Optimization 

Consulting Analytics Consulting

eMPILarge DataIntegration

Information Base

Rhodes Scope Of Information Integration

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Rhodes Information Base Data Layer

eMPI Data

Order Data

Result Data

SpecimenTransport

ReportData

Claims Data

RevenueData

HRData

Scholar ClinicalBI Tools

Scholar RevenueBI Tools

Scholar ExpenseBI Tools

Scholar Pop HealthBI Tools

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Lab Operations 

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Real time Lab Status

• Objective• Staffing is our largest expense• How to schedule our lab staff in a flex situation to maximize efficiency?• Specimen processing versus technical lab needs• Adjust in real‐time to volume and arrival times with couriers.

• Measurements:• 90th Percentile TAT• Overtime Percentage

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How to get there?

• Rhodes Repository• Fed from multiple lab systems (powerpath and Sunquest)

Knows how much lab work and where in the timeframe it is at in real‐time.• Fed from Kronos timekeeper:Knows what employees are currently clocked in, where, when.

• Rhodes Scholar integrates this data and compiles alerts every 30 minutes.

As of 2pm:There are 7,000 tests in the labThere are 12,000 tests awaiting collection or courier

This shows by department…Blue is those “Completed”Red is those “Not Received/Collected”Yellow is those “WIP”

This shows the tests that are coming in by location.

The colors show what department the tests will go to.

This detail shows the individual tests that are “oldest” in the lab.Allows management to intervene if there are particular items that need attention.

Here we can see how many employees are clocked in at the current time in various job categories.

We can drill down to the employee details … to see which employees that has been there longest for whom to send home or redirect to other tasks.

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Here as of 2pm… we see there is about 20k tests still awaitingWe know how to staff for the evening

Then by 6pm… we see there are still 17k tests still needing work.We know if staffing is still adequate or should be adjusted

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Turnaround Time By HourThe white bars indicate the 10th percentile to the 90th percentile of TAT.The yellow line shows the Average TAT.It’s important to monitor all of the results, not just the average.

Here we can see a spike in volume in the afternoon and a tremendous increase in the 90th percentile of TAT

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Outcomes

• Still a work in process to get the staff and supervisors adjusted to the concept of real time flex staffing

• The historical data itself has been very informative for regular staffing schedules

• TAT allowed them to monitor the lab outputs throughout and ensure no levels of quality dropped

• Still a work in process…

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Financial Operations

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Patient Eligibility Denials

• Objective• Reduce the number of patient eligibility denials• Reduce the manual effort and FTE’s required to perform patient eligibility checks.• Maximize the utilization of information provided by 270/271 eligibility checks

• Measurements:• Patient eligibility denial rates• FTE requirements

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Issue – Manual Eligibility Checking

• A large number of lab claims were being denied because of incorrect patient insurance information

• In most cases the laboratory did not see the patient and needed to rely on others to provide patient insurance information either through an EMR or patient portal interface or on paper requisitions. 

• Eligibility checking was done manually, either at Patient Service Center (when patient presented), specimen processing, or at the billing office. Because this was a manual process in some cases the eligibility check was done multiple times (once at each site) or some times not done at all.

• Manual eligibility checks provided only pass/fail response

• Manual eligibility checks were costly to perform based on a per click charge for each manual check

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Manual Eligibility Checking• Prior to process changes staff were doing  an average of over 63,000 manual eligibility checks per month.

• Many individual staff members conducted eligibility checks over the course of a month with a max number just over 4000 for one individual. 

• Average cost of $.10 per check

• Calculated number of 5 FTE’s performing manual eligibility checks 

• Rejection rates for patient not eligible denials were running at 5% prior to  process change

Row Labels

• Rejected• Grand Total

Apr 2015

• 4.7%

Mar 2015

• 4.8%

Feb 2015

• 5.2%

Jan 2015

• 5.4%

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Solution• Implemented a batch eligibility on April 1 2015

• Automated checks done for the following payers• Medicare • Medicaid• Aetna• Cigna• Humana• Pres Health• Molina• United Health Care

• These payer accounted for approximately 90% of third party billing volume

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Solution

• Batch HIPAA Eligibility Checking• Completely Automated• Uses HIPAA 270/271 format• No Transaction (Per Click) Cost• Automatically fix claims using returned information• Automatically fix patient record in MPI system

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Auto‐Fixes Performed• Correcting patient names

• First • Last • Middle Initial (very important for Medicare)

• Correcting Patient Address

• Correcting Date of Birth

• Correcting Subscriber Number 

• Changing Subscriber Name

• Correcting Relationship Code

• Other payer primary (COB) 

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Results

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Eligibility checking 

MonthClaim Check Transactions

% Change

Aug, 2015 86,806 15.3%

Jul, 2015 75,275 27.0%

Jun, 2015 59,260 41.4%

May, 2015 41,914 53.6%

Apr, 2015 27,283 19.5%

Volume of 270/271 transactions per month revamped up over the first two months and by June matched pre‐implementation levels of manual checks.

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Eligibility checking Auto‐Fixes

Operations Autofix

Row LabelsAuto Update Change from Claimcheck % Change

Sep 2015 5,726 26.8%

Aug 2015 4,189 7.8%

Jul 2015 3,861 3.5%

Jun 2015 3,725 5.0%

May 2015 3,538 7.2%

Volume of 270/271 transactions per month ramped up over the first two months and by June matched pre‐implementation levels of manual checks.

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Rejection Rate 

Row Labels  Sep,2015

Aug, 2015

Jul, 2015

Jun, 2015

May, 2015

Rejected 2.6% 3.9% 4.4% 4.2% 4.3%

Grand Total

Rejection rate for patient eligible rejection in the 5 months following has fallen to an average of 4.1% but the September rejection is below 3%

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Rejection Rate by Payer 

Payer  Sep, 2015

Aug, 2015

Jul, 2015

Jun, 2015

May, 2015

Apr, 2015

Mar, 2015

Feb, 2015

Jan, 2015

Total

Cigna 1.3% 1.5% 1.7% 1.2% 1.4% 1.6% 2.3% 2.8% 2.1% 1.8%

Medicaid 1.4% 1.6% 3.4% 4.1% 5.4% 5.9% 5.9% 5.4% 4.9% 4.8%

Medicare 4.8% 5.8% 7.2% 7.6% 8.0% 9.5% 9.2% 9.6% 9.6% 8.5%

Other 6.2% 8.2% 8.1% 5.4% 7.0% 7.4% 7.9% 9.0% 9.2% 7.7%

Pres 0.8% 0.8% 1.2% 1.8% 2.7% 2.8% 3.1% 3.6% 4.5% 2.8%United Health Care 2.3% 2.9% 2.7% 2.7% 3.1% 4.3% 4.4% 5.2% 4.5% 3.9%

Total 2.6% 3.9% 4.4% 3.9% 4.3% 4.8% 5.0% 5.5% 5.4% 4.7%

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• 5.0 FTE’s reduction from reduction in manual patient eligibility.

• FTE savings have been redirected to other value‐added tasks in billing

FTE savings

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Summary

• Achieved an reduction of 5 FTE’s

• Decreased eligibility checking costs by $6,000 to $7,000 per month

• Decrease patient not eligible rejection rate by over 20%

• Reduced re work  and manual processes up front and post‐billing

• Improved quality of billing information

Lessons Learned

• It was difficult to stop existing manual processes…

• Staff was not necessarily trusting an electronic process or data

• Staff was concerned about job security… why are they watching me?

Next Time

• Involve staff earlier in the process

• Report back the outcomes throughout the process

• Make staff aware of long term plans and job security

TriCore Reference LaboratoriesUsing Clinical Analytics to Optimize Lab Operations in Real Time