PFS New Direction – An Update

CMC

September 15, 2011

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History

• Original work done in 2001

• Vision The patient is ready to be seen at the time of the appointment; no delays caused

by the PFS Process

The patient will give demographic and insurance information one time

The PFS process is clear and consistent with minimal hand-offs

The PFS process is supported by:

o Motivated, well-trained, empowered staff

o Effective use of electronic system(s)

o Common tools

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The Past Pre-Visit

Time of Visit

Post-Visit

Scheduling

Insurance Verification

RegistrationObtain ReferralsAuthorizations

Limited CounselingPOS Collections

Fee Ticket Collection and Completion

Registration and Insurance Corrections

Coding & Charge Entry / Claim Edits Post-Billing

Collection Follow-up and Claim Denials / Appeals

Insurance Re-verification and FSC Re-assignment

Claim Write-off and/or Bad Debt Losses

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PFS New Directions

Pre-Visit

Time of Visit

Post-Visit

Scheduling / Registration / FSC Assignment & Insurance Verification / Obtain Referrals & Pre-Authorizations / Financial Risk Identification/

Financial Counseling

Customer Service Verification / Document Imaging

POS Collections More Customer Service

Charge EntryCharge Edit CorrectionsExceptions ProcessingCompliancePayment Posting

Post-Billing Appeals

QA

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2011 Work Group

Department Participants

•Marsha Cannon (OB/GYN)

•Cindy Flynn (Pediatrics)

•Cindy Gewinner (Surgery)

•Dianne Griffith (Orthopaedic Surgery)

•Kathy Hoertel (Surgery)

•Christy Picard (Medicine)

•Dana Sterbenz (Surgery)

•Jeanne Thoma (Anesthesiology)

FPP Participants

•Charles Albach

•Connie Belcher

•Laura Ingersoll

•Andrew Johnson

•Karen LaClear

•Kelley Mullen

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2011 Updates

• PFS standards, guidelines, and recommendations – review, edits, additions, and final draft complete

• Required registration fields – update complete

• PFS policies and procedures – scheduling a 6 hour session to update templates for distribution to departments

• Management reports – scheduling a 2 hour session to redesign reports

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PFS standards, guidelines, & recommendations

• Added: Definitions for FSC and Plan

Process areas for each statement, i.e., compliance, insurance assignment, scheduling, pre-arrival, point-of-service, charge entry, and AR follow-up

Column for which PFS policy and procedure the statement ties to

• Pulled insurance assignment out of other areas of the PFS process

• Split statements to stand on their own, rather than grouping statements

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PFS standards, guidelines, & recommendations

• Compliance CMC responsible for an on-going quality assurance plan to define performance

measures and accountability

Annual review process

Financial information should only be scanned into GE, not Allscripts

• Insurance Assignment Certified plan assigners are required to attend annual refresher education

Insurance additions, changes, or deletions should be done a the visit level, not the FSC level

All G-plans should be moved to P-Plans within 1 business day

Electronic eligibility responses should be worked within 24 hours

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PFS standards, guidelines, & recommendations

• Scheduling All departments move to Scheduling Hubs over time (guideline)

Patients will be given an explanation of their financial responsibility

• Pre-Arrival Missing insurance information will be obtained a minimum of 7 business days

prior to the appointment date

Referral information is entered on the scheduling appointment data form or AVM visit shell

Patients receive information regarding their appointment prior to arrival (recommendation)

Appointment reminders are done using HIPAA compliant communication methods

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PFS standards, guidelines, & recommendations

• Point of Service GE/Allscripts used to manage work flow and house information

Appointments statused within one business day

Front desk staff work any remaining alerts

New or changes registration/insurance information immediately entered into GE

No other forms used for the collection of registration information

P-plan assignor available at all times to practice sites

If plan assigned at point of service is not verified, eligibility verification should be done within 2 business days

Use of patient responsibility forms and Medicare advanced beneficiary notice

Insurance card scanned when patient is new to GE, insurance has changed, or annually

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PFS standards, guidelines, & recommendations

• Point of Service AOB, patient responsibility forms, ABN’s, paper referrals, and arbitration

agreements are scanned into GE

Patients asked for co-payments and outstanding departmental balances

Patients asked to make payment on school-wide balances (recommendation)

• Charge Entry Charges should be entered within 48 hours

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PFS standards, guidelines, & recommendations

• AR Follow-up Default to secondary payor or self-pay when an eligibility rejection is received is

discontinued

AR groups will contact the payor or patient before changing the account FSC to self-pay

Rejections for eligibility will be worked at least weekly

FSC change report will be worked daily, if possible, and at least weekly

Self-pay patients who call to report new insurance are referred to PBS

All charges must flow through TES

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Required Registration Fields

• Defined fields that are required versus important to obtain

• Added fields users are branched to for completion

• Identified which steps in the PFS process fields are required, scheduling, pre-arrival, or point of service

• Added fields required for aMPI, Meaningful Use, and Patient Portal

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Next Steps

• Consolidate patient responsibility forms into one, school-wide

• PFS policies and procedures – scheduling a 6 hour session to update templates for distribution to departments

• Management reports – scheduling a 2 hour session to redesign reports