The Big Payback

The tertiary and community hospitals of Halifax Health Medical Center (Halifax Health) is the Daytona, Fla. area’s largest healthcare provider, with 764 licensed beds and more than 500 physicians on its medical staff, representing 46 medical specialties. With more than 4,000 employees, Halifax Medical Center also provides the area’s only Level II Trauma Center, pediatric emergency department, neonatal intensive care unit and pediatric intensive care unit serving Volusia and Flagler counties.

As the systems administrator in the patient business financial services (PBFS) department at Halifax Health, I continually review workflows in an effort to automate manual processes. In the recovery reimbursement and reimbursement areas, we focus on streamlining processes to run more efficiently and profitably. To do so, we evaluate areas where processes are vendor-dependent and/or slowing down workflow, contributing to inaccurate data use, and ultimately, lost or delayed revenue.

Flipping the Scripting Process
 In joining the recovery reimbursement department, I discovered that PBFS has a third-party denial and underpay management system that handles all contract reimbursement calculations as well as denial tracking and managed care contract modeling. The system also tracks Clinical Core Measures in real-time, as documented by the case management staff. In order to keep the denial and underpay management system as current as possible, Halifax requires scripted information from our host hospital information system (HIS).

The scripts run HIS Non-Procedural Representation (NPR) reports, which are system “procedures” or programs that have been developed in a standardized format and are ready for use without programmer assistance. Once downloaded, they are sent through the interface engine every 30 minutes. With the former scripting process, PBFS required a representative to be on-call 24/7 to support the scripts. If paged, they would have to dial into the system, document the error, and attempt to diagnose or restart the script and contact the vendor. Many times the vendor would take days or even weeks to resolve an issue.

By creating the automated process, we have saved the hospital approximately one 8-hour day per week from a posting representative.

Because relying on vendor support can cause delays in issue resolution and ultimately more overtime and call-pay for support, our solution was to internally write and support these scripts using automation through the Boston WorkStation from Boston Software Systems. By replacing the vendor scripts, we were able to significantly decrease our reliance on an outside vendor.

Boston WorkStation is a workflow automation and integration technology tool that allows healthcare organizations to respond to changing business, financial and compliance requirements by automating common tasks throughout the organization. These tasks include revenue cycle projects, interactions with Web sites, integrating new applications, systems and devices, and electronically monitoring and managing user activity.

The first of five scripts took two months to write and has been live for three months, with no call-back time for support. Phase two of the replacement project involved three daily interface scripts that were written and tested over a 2-month period. Those scripts went live in mid-August of this year with the third and final phase of the project going live at the end of September. With the new scripts in place, we’re less vendor-reliant and gain additional functionality such as e-mail capabilities and event logging, which did not previously exist.

Eliminating Home Grown Programs
Another issue at PBFS was the existence of a homegrown Visual Basic program that scripted notes from the legacy denial/underpayment management system back into the HIS billing/accounts receivable patient account. Several years ago when Halifax brought in the denial/underpayment management system, the case management area developed a tracking tool to document concurrent inpatient review information. Through this process, inpatient accounts are put on work lists and separated by a current nursing unit for the case managers to review daily and consult with insurance companies on clinical approvals.

All documentation of discussions, faxes and discharge planning, as well as clinical reviews by the case managers, were stored in the denial/underpayment management system. Previously, a programmer at Halifax developed a Visual Basic program that took the notes from the underpayment management system and scripted them into the host HIS. However, over time, with changes in staff and priorities and no Visual Basic programmers on staff, Halifax Health lost the ability to support the homegrown solution. Again, we looked to Boston WorkStation to help automate this process, as their development environment allows non-technical staff to write and maintain scripts. Since the scripts are executed by Boston WorkStation, source code can’t be lost.

Even with the original Visual Basic program, the previous process was tedious and required manual steps. A user had to run a Crystal report to extract the data from the decision support system, and then export the report to a Microsoft Excel file that the Visual Basic program could read. Once the extraction was complete, the user had to physically go to a special computer that could only run Microsoft OS 98 and the homegrown program.

With the Boston WorkStation script, which took only a few weeks to write, the process is completely automated. The script starts every morning by running the Crystal report and exporting to Excel. The script then posts notes into the HIS, applies an Excel pivot table to the original report, and sends an e-mail to specific users with details of successes or failures. We have even been able to save the files, once complete, to a network location with the specific date associated to the notes.

For PBFS, “cash is King.” Therefore, managing the revenue cycle means that we must manage the processes, policies and workflows to capture revenue and convert it to cash.

We can also now provide data formatting, which we have never been able to do before. With the previous process, when a user input data into the decision support system in lowercase form, that was how the data was posted to the host; however, data on the host system is in uppercase. Now, we can manipulate the data to standardize the format before it gets to the host HIS. Data is cleaner going in and the appearance in the notes section is standardized.

Managing the Revenue Cycle
 For PBFS, “cash is King.” Therefore, managing the revenue cycle means that we must manage the processes, policies and workflows to capture revenue and convert it to cash. In the fourth quarter of 2006, Halifax Health brought on the LSS Physician Billing & Receivables (PBR) module in conjunction with our host HIS. The goal of this application is to bring our physician billing back into PBFS, rather than the previous outsourcing arrangement.

On the PBR side, there are many pieces with copays and procedures that must be considered. Unlike hospital billing, PBR provides a lifetime patient account, which means all activity is transaction-based. Adding to the difficulty of cash posting in this environment is the consideration that contracts for hospitals and insurance companies can change every year. Correct patient copay on the account is critical to patient satisfaction when our statements are distributed. On the management side, timely, yet, appropriate adjustments are crucial to our facility in terms of revenue cycle management and A/R days.

Because we are responsible for posting cash, we are always looking for ways to improve efficiency in terms of time and money. We determined that scripting might be useful for our adjustments in the PBR department. On the other hand, when developing scripts, we must be sure that maintenance will not hinder effectiveness, as contracts change frequently. As a result, we created a script using Boston WorkStation to completely automate the adjustment process and accommodate the changing demand for patient responsibility. The script reads an Excel spreadsheet to determine appropriate copays, which any of our supervisors can modify quarterly or annually, whenever the rates change. Therefore, no programmer or vendor is needed to change the script, resulting in less reliance on programmers and vendors.

Currently, Halifax Health is running eight physician practices or departments through PBR and is scheduled to increase that number to 25 by 2008. By creating the automated process, we have saved the hospital approximately one 8-hour day per week from a posting representative. Without this automated process and the increased business in the next year, those hours could have risen significantly. Our staff now has more time to post actual cash and analyze underpayments, which is more productive.

Thinking Ahead
Since automation is a hot topic in our organization, my team discusses processes that take a long time or that cause undue user repetition. By utilizing Workstation, we can empower people to think critically about processes and evaluate opportunities for enhancements. This helps the hospital organizationally and financially and has assisted us in becoming excellent in execution.

Additionally, our main IT department currently utilizes Boston WorkStation to script NPR reports daily to specific printers throughout the organization, as well as to update various dictionaries such as Chargemaster in our HIS. Another user in a sub-division of Information Systems is currently working on scripting notes received from our billing system back into the host HIS.

At Halifax Health Medical Center, we have developed an environment for continuous, on-demand process innovation and workflow automation. Process development requires technology with capabilities such as branching logic, notification, universal connectivity, exception handling and the ability to remotely and unobtrusively monitor and manage the end user’s interaction with an application.

Intelligent processes yield predictable outcomes with payoffs that have a measurable and meaningful effect on the revenue cycle. Automation allows us to develop processes that manage and support end users. As a result, Halifax Health Medical Center can address not only the technological and tactical needs, but also strategic business requirements.

Kim Scaccia is system administrator, recovery reimbursement at Halifax Health Medical Center. Contact her at [email protected].