Schegistration
A Patient-Focused Approach
Cathy Gragg
Revenue Cycle Manager
Tucson Medical Center
ABOUT US
• One of the 300 largest hospitals in the country and the largest
in Southern Arizona. We are the largest single level facility in
the US with nearly 27 miles of combined hallways
• Licensed for 609 adult and skilled nursing beds, 62 psychiatric
beds (Palo Verde Mental Health Services) and 90 bassinets
• Serve more than 37,765 inpatients and 114,929 outpatients
annually
• Over 1,000 physicians represent 60 specialties, from
anesthesiology to vascular surgery
• TMC HealthCare is Southern Arizona's regional nonprofit
community hospital
• TMC's campus also serves as home to the Tucson Orthopedic
Institute, the Cancer Care Center of Southern Arizona and the
Children's Clinics for Rehabilitative Services
OBJECTIVES
• Review the importance of a centralized model
• Review the issues that we were trying to solve
• Describe the obstacles we encountered that drove
the need to make this change
• Review the process we implemented and how we
automated the patient interview at the point of
scheduling
• Benefits realized
• Lessons learned
WHERE WE STARTED
• May 2006, implemented EPIC’s Cadence
Scheduling system
• September 2006, implemented a centralized
scheduling model (user security changed)
New Teams formed:
CENTRAL SCHEDULING TEAM
• Purpose for Creating the Team
• Issues identified
• Call Wait times and Abandonment rates
• Scheduling needed input from departments in order to
schedule complex procedures
• Schedulers needed resources
• Created new staffing model
• Like processes grouped
• Gain efficiencies with centralization
• Ensure that all service lines were represented
Abandonment Rate
40.00%
35.00%
30.00%
Central Scheduling new staffing
model & Pre-Admit Team created
25.00%
Process improvements
implemented
20.00%
EMR & schegistration
implementation
15.00%
10.00%
Jan…
Oct-…
Jul-11
Apr-…
Jan…
Oct-…
Jul-10
Apr-…
Jan…
Oct-…
Jul-09
Apr-…
Jan…
Oct-…
Jul-08
Apr-…
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Oct-…
Jul-07
Jan…
Apr-…
Oct-…
Jul-06
Apr-…
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Oct-…
Jul-05
Apr-…
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Jul-04
Apr-…
0.00%
Jan…
5.00%
Central Scheduling - New Staffing Model
Phase III (Vas
Lab, CNIS,
Resp Care,
DBS)
Phase IV
(APC, OPC,
Cardiac
Rehab, Rest
Srvcs, Peds
Therapy)
Phase I (PAT,
FSS, Diab Ed,
Nutrition)
Phase II (All
Imaging
Areas)
Dept Advisors
Dept Advisors
Dept Advisors
Dept Advisors
1Advance Level
Scheduler (Rep
III)
1Advance Level
Scheduler (Rep
III)
1Advance Level
Scheduler (Rep
III)
1Advance Level
Scheduler (Rep
III)
1 – Core
Scheduler (Rep
II)
3 - – Core
Scheduler (Rep
II)
2 – Core
Scheduler (Rep
II)
3 – Core
Scheduler (Rep
II)
Right Fax
Team
(Process all
inbound faxed
orders – All
Depts)
4 – Order
Transcriptionists
(Rep I
PRE-ADMIT TEAM
• Purpose for Creating the Team
• Issues identified
• Team members separated physically
• No visibility to workload productivity
• Gain efficiencies with centralization
• Like processes grouped
• Integrating pre-service would fully support the organizations
needs
• Identified an opportunity for physical space
• New building space became available
Pre-Admitting Team – New Staff Model
Inpatient/Surgical – Ins.
Verification/Auth &
Registration/Up front Cash
Collections
4 – Insurance
Verifiers (Rep
II)
5 – Registrars
(Rep II)
Outpatient Diagnostics –
Ins. Verification/Auth &
Registration/Up Front
Cash Collections
5 – Registrars
(Rep I)
PROCESS IMPROVEMENTS STILL NEEDED
• August 2007, kicked off Central Scheduling Process
Improvement Committee
• Objective - Centralized access point with multiple portals
transparent to the customer. One transaction to complete
scheduling an appointment
Potential Causes
Technology/Equipment
Education-office staff
No contact info
Can’t ID requested test
Order not
confirmed with phy.
Pt. unaware test
has been ordered
Wrong test ordered
System
resource sharing
Communication
Prep instructions
Wrong pt tele #
Doesn’t meet SOC, ie;
sedation or anesthesia
New patient
Order does not meet
requirements
Order incomplete
Order element missing
Order incorrect
Order cannot
be located
Unable to reach pt on 1st attempt
CS staffing ability to
respond to all calls
Pt. refuses to schedule
Scheduling request after 4 PM
Registration not available
after scheduling completed
Pt. wants to clarify
w/ physician
Order needs
clarification
Confirm appt w/ pt
No prior auth.
Pt. will not schedule
due to no prior auth.
Appointment time
not soon enough
Specialty procs. Bx, etc
Pt. not ready to schedule
Compliance
requirements
Scheduling
Coordination
Registration not available
when needed by departments
Revenue
Why does Central
Scheduling need more
than one contact with
physician’s offices and
patients to complete the
OP scheduling process ?
Process Improvements Implemented
Improve customer
experience
Procedure/arrival time
matches OP Depts
and patient
expectations
Establish hand-off
with Pre-Admit area
for registration
• Collaborate with referring offices to improve their knowledge of TMC’s scheduling requirements.
• Expectation – reduce the number of calls to the customer
• Develop standard process that all OP responsible parties can easily review and update patient
prep information
• Expectation – Information provided by scheduling would be consistent with dept procedures,
eliminating any rescheduling/cancellations due to patients not being prepared for the exam
• After scheduling the patient, transfer call to pre-admit team for registration to complete preclearance within one call with the patient
• Expectation – Optimize process flow for patients arriving for outpatient exams with no stops at
registration required
Process Improvements Recommendations
IN SCOPE
•
•
•
•
•
•
•
•
•
•
Walk-ins with Rx in hand
Same Day/Next Day cases
Targeted Physicians
Patient requests to schedule with
department
Reschedule cancellations, no-shows
All dissatisfied patients /MD’s with CS
process
Call to stay with initial location of call (CS
or VL)
MD offices who’s patient has not been
scheduled > one week
Patient’s with Rx who were incorrectly
scheduled 24 hours in advance
“Series” patients
OUT OF SCOPE
•
•
Routine cases not meeting In Scope
criteria
All In Scope criteria beginning in Central
Scheduling
PROBLEMS WE STILL NEEDED TO RESOLVE
MISSING PATIENT INFORMATION;
• AFS staff not always the first point of contact
• Missing patient information or inaccurate information
• Unable to reach the patient prior to their appointment
• Late add ons
• Duplication of efforts
• Entry into two systems
PROBLEMS WE STILL NEEDED TO RESOLVE cont…
VERIFICATION COVERAGE/BENEFITS;
• Decreased time from time appt scheduled to appt
time
• Data in EPIC different than what was in legacy
system
• Ineligible for coverage listed
• Not a covered benefit – requires financial clearance
• High deductibles / co-insurance identified – requires
financial clearance
PROBLEMS WE STILL NEEDED TO RESOLVE cont…
AUTHORIZATIONS;
• Inability to obtain auth early enough
• Customer dissatisfaction
• Numerous calls to physician offices for patient info
• Patients delays and financial clearance issues
PROBLEMS WE STILL NEEDED TO RESOLVE cont…
DUPLICATION OF EFFORTS;
• Schedulers would ask similar information that
registration needed
• Registration would call the patient
• Patient perceived this as a duplicate call
SPECIAL CONSIDERATIONS FOR SCHEGISTRATION
• Central schedulers needed to be trained to collect
guarantor, and coverage information.
• Department schedulers need to be trained to collect
demographic information.
• This may increase the length of calls for all
schedulers, thus impacting bandwidth for the Central
Scheduling department. Scheduling time will be
impacted but will be balanced by a more streamlined
registration process
HOW WE GOT THERE
• May 2010, Implemented EMR
• New Security for staff added
• Realocation of personnel
• Automated schegistration for Central Scheduling
Schegistration Model – Security changes
• User
• Role
•
•
•
•
Central Scheduler
*Registration representative
•
* Cannot schedule into all OP areas
Order transcription
Referral Management
(authorization)
Schedules for all OP areas
including completing
registration to include:
• Demographics
• HAR creation (if appt w/in
48 hours)
• Create / edit guarantor
• Add / edit coverage
PROGRAMMING CHANGES - SCHEGISTRATION
• Added new programming point to jump the scheduler
into registration before appointment entry when the
patient has unverified registration info;
• Demographics / guarantor - new or elapsed
• Created new programming point to fire after
appointment is made to jump the scheduler into
registration if the appointment is scheduled within 48
hours.
• Scheduler creates the account
PRIOR STATE
•
•
•
Central scheduled into outpatients
departments.
After the scheduling, registration
contacts patients to collect
demographic, guarantor, and coverage
information. Some of this information
may be verified at the time of this preregistration phone call, although it is
possible that not all of this information
is verified during this call.
If there are eligibility or co-pay
issues/information that needs to be
communicated, the patient may be
contacted again.
CURRENT STATE
•
•
•
Collection of demographic, guarantor, and
coverage information is moved up to the
time of scheduling. Afterwards, this process
will result in two distinct workflows:
Appointments within 48 hours (one-call):
• Scheduler collects demographic,
coverage, guarantor information and
create the account. The scheduler
checks eligibility via real-time eligibility.
Appointments scheduled past 48 hours:
• At the time of scheduling, the scheduler
will collect demographic information.
After scheduling, registration staff will
collect, review and verify coverage and
guarantor information as well as create
the account. The registrar
communicates co-pay information to
the patient and collects via the phone if
possible. If unable to collect the copay
over the phone, the patient is
instruction to pay the copay at the sign
in desk.
% of Pre-registration
50%
45%
43%
40%
35%
30%
25%
21%
20%
15%
11%
10%
7%
7%
2007
2008
8%
6%
5%
0%
2006
2009
2010
2011
2012
BENEFITS REALIZED
• Enterprise system allowed for schedulers and
registration staff to work within the same system
• All users had access to same information, including
where the authorization would be entered
• Implemented hard stops for missing financial clearance
• No Auth
• ABNs
• Financial Waivers
BENEFITS REALIZED cont.
Pre-schegistration
• Call times
• Avg talk time = 2:56 min
• Percentage of preregistration at point of
scheduling = 7%
Post-schegistration
• Call times
• Avg talk time = 3:26 min
• Percentage of preregistration at point of
scheduling = 21%
LESSONS LEARNED
• Need to broaden scheduling access for all registration
staff
• Department schedulers do not collect demographics
• RTE (real-time elig) needs to be complete for ALL high
volume payors
• Documentation overlaps proved to be problematic –
i.e., schedulers document in referrals while registration
documents in FYI and Acct Notes
• Only works well when scheduling with the patient
• Still issues with obtaining Auth from physician offices
for appts made inside 48hrs of DOS
QUESTIONS
CONTACT INFORMATION
Cathy Gragg – cathy.gragg@tmcaz.com
Revenue Cycle Manager, Enterprise Wide Scheduling