CONDUCTING AN OPERATIONS ASSESSMENT

1. MISSISSIPPI PRIMARY HEALTH CARE ASSOCIATION CONDUCTING AN OPERATIONS ASSESSMENT Presented by: Michael R. Taylor, Precision Resources, Inc. MRTPRI@aol.com

2. SESSION GOAL Share tactics that equip attendees to evaluate the effectiveness of their health center’s operations and develop resulting plans for improvement

3. SESSION OVERVIEW • Hypothesize Assessment Objective(s) • Analyze Relevant Information/Data • Refine Assessment Objectives • Observations - What to Look for • Document Outcomes • Develop Implementation Plan

4. HYPOTHESIZE ASSESSMENT OBJECTIVES(SCHEDULING)

5. HYPOTHESIZE ASSESSMENT OBJECTIVES(REGISTRATION/DISCHARGE)

6. HYPOTHESIZE ASSESSMENT OBJECTIVES(PROVIDER VISIT)

7. HYPOTHESIZE ASSESSMENT OBJECTIVES(CHARGE CAPTURING)

8. HYPOTHESIZE ASSESSMENT OBJECTIVES(BILLING/COLLECTIONS)

9. NOW IT’S YOUR TURN • Take about 15 minutes • Think about your health center’s operations • Identify two functional areas where you’re 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

10. HYPOTHESIZE ASSESSMENT OBJECTIVES( )

11. HYPOTHESIZE ASSESSMENT OBJECTIVES( )

12. NOW IT’S YOUR TURN SHARE!

13. 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 • Don’t necessarily represent root causes • BUT serve as a foundation to define initial assessment objectives and areas of focus

14. 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

15. 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? • Who’s 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

16. 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

17. 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

18. 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

19. 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

20. 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)

21. OBSERVATIONS - WHAT TO LOOK FOR(BEHIND THE FRONT DESK) • Payment requests • Are requests made routinely • When is payment requested • How are requests made • Are patient accounts checked for previous balances • Do staff know when co-payments and deductibles apply and the amount to request • Patient reactions to payment requests • Do requests seem expected • Are patients prepared to pay

22. 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 patient’s account • Are notations made when coverage is verified

23. 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

24. 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 Do most Out Guides indicate that charts were pulled fairly recently Are records organized reasonably to locate key documents (e.g., most recent H&P, progress notes, medications list, etc) HEALTH RECORDSARE THEY AVAILABLE AND COMPLETE FOR APPOINTED PATIENTS

25. 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

26. 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

27. 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

28. 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

29. OBSERVATIONS - WHAT TO LOOK FOR(SCHEDULING) • Communications Content • Are schedulers equipped with a current list of health plans that the center accepts including co-pays, 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

30. 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

31. OBSERVATIONS - WHAT TO LOOK FOR(PATIENT VISITS) • Patient Visits • Do provider productivity levels meet acceptable norms (If not, why) • Are provider productivity standards communicated/reflected in employment agreements • 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 timely manner

32. 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

33. 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

34. 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 payer’s claims submission deadline • Is there an adequate, ongoing effort to clear any backlog(s)

35. 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

36. 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

37. 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

38. IT’S 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?

39. 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

40. 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

41. 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

42. 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

43. SUMMARY • A well conceived and executed operations assessment should yield the intelligence you’ll need to: • Improve patient satisfaction • Increase patient throughput • Enhance staff productivity • Increase quality of care • Improve collections and overall financial performance

44. SUMMARY • To achieve results, however, you’ll likely have to: • Revise policies and procedures • Update staff job descriptions • Re-train staff • Modify information systems • Educate patients • Monitor performance • Measure impact

45. QUESTIONS