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Increased Revenue OpportunitiesIV Infusion Charge Capture Austin SmithRadiology Pre-Authorization Project Vanessa Calderon

Process Improvement (Clinical Quality), IH-DMIV Infusion Charge CaptureTeam: Executive Sponsor: Maureen Adams Executive Director Med/Surg NursingPatty Armstrong Director of ComplianceSusan Barrett HIM ManagerAngie Boord Pharmacy ManagerCrystal Estabrook Director of Revenue CycleLacy Little Y7 Adaptive DesignCorey Martin Central Supply ManagerRoxy Menke Clinical Informatics SpecialistMary Parks P5 Nursing ManagerAmber Sandquist Coding CoordinatorAustin Smith Process Improvement CoordinatorJan Stipe Director of Case ManagementChris Wood N5 Nursing Manager

Revenue Cycle Recovery IV InfusionI. Business Case

II. Current Condition

IV. Target Condition (Proposal)

VI. Metrics/Follow-up

Author: Austin SmithDate: 1/10/11 V. Action PlanWhatWhoWhenIII. Problem Statement

BackgroundIdentified by: Revenue Cycle team during auditsProposed/Selected for Process Improvement ProjectStarted: 1/3/2011

1. $500,000 additional revenue2. Accurate Medical Records3. Reduce Denials Associated with Documentation

Business CaseCurrent ConditionIV Push: Reimbursement Requirement: Chart, Document Start Time Current Practice: Consistently charted, start time documented Coding: Charges for all IV Pushes

IV Piggyback: Reimbursement Requirement: Chart, Document Start/Stop Time Current Practice: Consistently charted, start time documented, no stop time Coding: No Charges for IV Piggybacks

IV Hydration: Reimbursement Requirement: Chart, Document Start/Stop Time of each bag Current Practice: Seldom Charted, no start/stop time Coding: No Charges for IV Hydration

Problem StatementPatients with Observation status are not currently billed for IV Piggyback or IV Hydration because stop times are not documented.

Target Condition Short TermDecided to narrow the focus to only IV PiggybacksCoding charges IV Push for IV Piggyback without Stop TimesJustification: Push only requires a start time, this would be under charging

January 1st September 6th Charges: $1,379,815Estimated Collections:$434,642Problem Solving Target ConditionHow do we document all ACTUAL stop times?

Options:Nurses remember start time and know when to go back for stop timeNot accurate, no reminder, hard to ID observation patients Get the actual stop time from the event log in the IV PumpNo reminder, hard to ID observation patients, time away from patientsIV Pump interface with CareCast or EPICNo Capability YETIV Pump Alarm when switching from IV Piggyback to HydrationNo Capability

Only physically possible solution: Nurses manually chart stop times.

We Were at a Stand Still untilAsked Lacy Little - Younker 7 UBE to help determine feasibility of options and brainstorm additional solutions.

Found Done Time in the charting area of CareCast Investigated to see functionalityIs a calculated time acceptable?Does this field appear where a coder could see it?

Problem Solving Target ConditionTarget Condition Long TermUse Done Time Field in CareCast to automatically calculate the Stop Time of IV Piggybacks based on:Administered Time Nurse Entered Volume Pharmacy Entered Rate Pharmacy Entered Done Time will show up on DMAP for coding

July 24th September 6th Charges: $65,531Estimated Collections :$19,659

10Financial Results2011 Annualized

Charges: $2,400,000Estimated Collections $776,000

Total Increased Revenue (1/1/11 3/2/12)

Charges: $2,800,000Estimated Collections:$905,000

11Questions?

Austin J. Smith Employee Safety ManagerIowa Health Des Moines515-241-6647Smithaj3@ihs.org

Radiology Pre-Auth ProjectTeam: Sponsors: Todd Kranpitz Executive Director Radiology Services Crystal Estabrook, Director of Revenue CycleAmber Sandquist, Denials CoordinatorMatt Helgeson, Manager Radiology, IH-DMYvonne Grant Supervisor Radiology, ILH Curtis Waddingham Supervisor Radiology, MWHMcKenzie Cooper (CT Tech), Lisa Sandin (MRI Tech)Jane Beeman, Manager Pt. Access SchedulingGlenda Seemiller, Director Pt. AccessAmber Aschan, Michelle Engle (Specialized Schedulers, Audit Team)Vanessa Calderon, Process Improvement Coordinator

AgendaProject Background A3Building the TeamCreating a Manageable ScopeProcess Mapping to Identify IssuesBuilding SolutionsSustaining the Gains

A3: Radiology Pre-Certification ProjectI. Business CaseRadiology was selected at IH-DM as an area of focus given the potential for loss.The benefit of this project is to increase revenue through decreasing the number of denials for missed pre-certifications/uncertain medical necessity.The need for this project is driven by revenue improvement initiatives.

III. Current Condition

2010: Losses due to missing Pre-Auth and Medical necessity - $146,573.80Baseline: Oct. 2010 March 2011 $55770.17By Payor:

By Procedure: Top MRI, Top CT Write-Offs

V. Target Condition

Reduce denials dollars by 50% per month by August 2011 focusing on procedures with highest financial impact. This amounts to a maximum denial level of $27000 (Based on 50% of a 6 month average between Oct. 2010 and March 2010) per month for 2 months of review (through September 2011).

VII. Metrics/Follow-up (Current Avg: $14.166.60 for 5 months post-project) or 74.59% reduction

Author: Vanessa Calderon(Updated 9/6/11)VI. Action PlanWhatWhoWhenMap Value Stream and Prioritize IssuesFocus on Quality at the Source by creating and improving existing tools for scheduling to aid in information gathering; mistake proofing.Close information loop between scheduling and Radiology and use time saving measures to facilitate earlier exchanges of information (DCR Tracker, Communication with Audit Team)Refine Process Define Standard Process and create implementation plan for training. May require time study for determining workload.Continue Tracking/Reporting Changed Orders. Continue Tracking Monthly Write-off amounts.TeamJane/Audit Team/ SchedulersAudit Team/ Rad. Techs

Vanessa (w/ Team)

TeamMarch 2011April June 2011

April June 2011

June 2011 July 2011

August 2011-FutureIV. Problem Statement

80% of denials are due to missing pre-authorization and medical necessity. Missing means altogether not present or incorrect (correct one is missing). $150,000 in write-offs for 2010 were attributed to these causes.

II. ScopeThe scope of the project is from the time the procedure is ordered to the time of the first denial for payment. All 3 campuses (IMMC, ILH, MWH) radiology departments are within the scope of this project with a focus on CT and MRI procedures. Outpatients, including observation patients, will be addressed by this project. Only denials relating to Missing pre-auths and medical necessity are within scope.

Apr 2011$11,748.54May 2011$11,853.09Jun 2011$8,697.33Jul 2011$20,459.37Aug 2011$18,074.66T19T19MEDIPASBCALLSELEC$50,973.81$63,495.51$91,563.14CT PELVIS W CONTRAST MRI BRAIN W WO CONTRAST/MRI ORBIT FACE NECK W WO CONTR27602.0829606.88Project BackgroundPre-authorizations often necessary for proceduresIf procedure changes, new pre-auth must be obtainedGathering pre-auths can be time consuming and time by radiology staff should be spent serving patients

Step 1: Gather DataUse Pareto Analysis and Graphs to Narrow Scope

Step 1: Gather DataDetermine mix of cases being denied (Two-Factors)

*Focus on CT, MRI (upper left purple area) first, then on specific insurance to capture additional denials (lower pink area)Step 2: Develop TeamExplore the AreaLook for key players in the processIn addition to Managers, Find Area Leaders:Radiology StaffMcKenzie Cooper (CT Tech), Lisa Sandin (MRI Tech)Scheduling StaffAmber Aschan, Michelle Engle (Specialized Schedulers, Audit Team)Step 3: Define ScopeBasic Scope and Problem Statement DefinedPresent Data to Team to Refine ScopePinpoint Areas where Low Effort = High ImpactSet Attainable yet Aggressive Goals based on Facts

Step 4: Map the ProcessObservation and Group-Work to Map Process (Visio)

Step 5: Log IssuesYellow Kaizen bursts on map indicate areas where errors can occur that lead to missing authorizationsTop Issues placed in an Issue Log / Action Item List

Step 6: Build CountermeasuresDevelop Tools to help brainstorm Countermeasures

Step 7: Construct/Conduct TrialsDocument Steps involved in TrialDetermine timeframe, scope, and players involvedCommunicate TrialCheck Intermittently and capture Results

Trial: One CT Tech will review all Abdomen/Pelvis orders 3 days before cases to determine if orders need to be changed. Contact Audit Team who will obtain New/Changed Authorization before scheduled case.Step 8: Expand TrialBased on ResultsFrom one CT tech at one campus to all CT techs at 3 campuses (IMMC, ILH, MWH)Expanded further to includeAll MRI All CasesStep 8: Expand TrialUse of DCR Tracker to Aid in Automation of Process

Step 9: Sustain ProcessOngoing: Finance Tracks denials Monthly, and CT and MRI cases are sorted out as a separate metricOngoing: Control Chart based on tracked write-offs6 Months: Audit Team tracked each case that traveled through new process to determine viability of processChallenges: EPIC changes to all processesAddressing months outside of control limitsFinal Results

Questions?

Vanessa L. CalderonProcess Improvement CoordinatorIowa Health Des Moines515-241-6887caldervl@ihs.org