Speaker: Amy Repman WellSpan Health: “We will get your Authorization” Learning Objectives Who are we? Vision Insurance Clearance We will get your auth Rewards and Risks Only learning by asking the question, feel free WellSpan Health System Who are we? Integrated health system located in southcentral PA ● Top 100 – Integrated Health Systems ● York Hospital – “Top 100” Hospital with Thomson Reuters – 7 years ● Gettysburg Hospital – “Top 100” Performance Improvement Leader ● WellSpan Health System 3 hospitals (630 beds) 65 sites in 3 counties; 2 states serving a population of 500,000, 60% overall market share 8,000 staff, physicians, volunteers 7 residency programs, 250 students and a research center 6 retail pharmacy sites 510-member multi-specialty medical group 1 home health organization PPO serving 50,000+ covered lives Wellspan Health Statistics ● ● ● 36,000 Inpatient Discharges 1.1 million Outpatient Encounters - 95,000+ ED visits - 74,000 Clinic visits - Lab-specimens and nursing home labs 1.2 annual medical group physician visits Every week, a significant percentage of the AdamsYork population experiences care from WellSpan 14,133 patients visit a physician practice 8,708 patients fill a prescription at an outpatient pharmacy 17,575 patients undergo a test, procedure or treatment 1,918 patients receive a VNA home visit 685 patients are admitted 1,678 patients visit an emergency department Payer Mix Medicare Medicare Advantage Medicaid Blues Other Contracted Commercial/Other 40% 3% 10% 18% 16% 13% Hospital Access Education and training Patient Insurance Procurement Call Centers Corporate Access Department Access call centers – Scheduling and Pre-registration Medical Group Contact Center – First contact for medial group practices, scheduling and pre-reg. Nurse Call Center – patient triage, education and scheduling Insurance Specialty Center – insurance verification, precertification, denials, authorizations Central Registration/Admissions – Both hospitals ED Registration – Both hospitals Total -187 FTE’s and about 217 employees to fill those positions. Mission of insurance department WellSpan Health will initiate a centralized department that focuses on ensuring any test, service, or procedure that is referred by or performed by a WellSpan Provider or facility will have the appropriate authorization and coverage information to ensure adequate reimbursement. Department is Called Insurance Specialty Center In 2007, staff just monitored hospital outpatient schedules – Did you get it yet? Did you get it yet? Moving from did you get it yet? - to I GOT IT! Planning the Roadmap Economies of Scale Standardization Revenue Improvements Quality of Care Teams Medical Group Specialty Practices Scheduling and Authorizations Medical Group Family Medicine Scheduling and Authorizations Non-Medical Group Provider Offices Authorizations Monitoring Authorizations Denials Insurance Verification We will get your Auth Project OIG Ruling Losing market share Insurance requirements growing Provider Office does what? Three things must be completed and faxed to special fax number at hospital by Noon the day before a test: Item 1 • Fax Cover Sheet Item 2 • Order form Item 3 • Office Note Responsibilities of We will get your Authorization Specialists Staff receives notice from Providers office to authorize – electronically (fax server application) Obtains authorization from insurance companies (web or phone call) Notifies office of upcoming test for test tracking Posts authorization information in hospital billing system. Centralized Authorization and Referral Process Risk & Rewards Rewards Physician satisfaction increased because the “administrative” tasks are centralized and not impacting their daily flow. Reduced reschedules of tests/procedures because authorization was not in place. Ensure it is done. Risks & Rewards Risks Insurance companies could deny because we are not the provider. We might not be able to get authorization in time. Provider documentation must be completed. • Addressing Formed risk a team management approach. Provider office education. Our opportunity In 2011 York Hospital – 2011 fiscal year end • ABN write off’s - $126,000 • Pre-authorization write off - $246,000 • Total York Hospital - $372,000 Gettysburg Hospital: • ABN write off’s - $100,000 • Pre-authorization w/o - $ 18,000 • Total GH - $118,000 Total write offs this department could have a positive impact on $524,261 Note: number of insurance requiring insurance intervention has risen 17%. System-wide Support Services Offered Alerts in scheduling system Managed Care Manual on INET Phone queue from 7:30am to 4pm Monday through Friday for provider offices and hospital departments for any questions about authorizations and referrals or assistance in obtaining authorizations Reads and interprets payer contracts/notifications Recruitment to find the right person Phone Interview Personality Testing Computer Testing Interview Shadowing Amy Repman Amy Repman is the Director of Access at WellSpan Health with responsibilities for hospital outpatient registration and admissions, emergency department registration, preregistration department, call center areas, insurance procurement department, and cashiering. She also serves as the business lead for enterprise-wide centralized scheduling initiatives in her organization as well as the business lead for kiosks implementation. She oversees all organization wide registration operations, leads outpatient registration management initiatives and quality call monitoring procedures for the call centers. Prior to joining WellSpan, Amy worked as an administrator in nursing homes. She has had 20 years in leadership roles in the healthcare arena. She has a degree from Pennsylvania State University and holds a license as a nursing home administrator from York College. She can be contacted at: [email protected]pan.org Questions?