Revenue cycle, UR, and access management

A successful revenue cycle begins with a robust access management program. The admissions/registration team typically handles patient eligibility determinations, accurate capture of all demographics, and copay collection. The admissions/registration team is also integral to the utilization review (UR) process, because the UR process itself is often determined by the demographics collected and recorded in the registration process. If the informa­tion is not accurate or complete when it is collected initially, it will affect the rest of the process. Unfortu­nately, this problem is common. Based on the informal and unscientific surveys we’ve done at hospitals over the past 20 years, we estimate that 40% of face sheet information generated through the admissions office is incorrect. Most of the time, the UR specialist or case manager must stop what they are doing to correct the information, which unfortunately does not remedy the problem going forward. We recommend printing every example of incorrect demographic information on a regular basis and then sitting down with the director of admissions/registrations to review the work that had to be done to correct errors or complete missing information. Without that feedback, we have found that admission/registration leaders will report a high accuracy rate, because the UR specialists and case managers are correcting the data. Demographic inaccuracy is particularly problematic when it occurs in insurance information, patient’s full name, or fam­ily contact information. Incorrect insurance information heavily affects the UR specialist’s work because there is no way of knowing what the patient’s insurer expects in terms of UR requirements. It also affects the work of case management as they plan transitions of care, which can lead to delays in discharge or transfer.

The UR process for a patient with original Medicare is generally quite different than that for a patient with Medicare Advantage (MA) or another commercial insurer. The regular Medicare UR process is typically quite stable, whereas every other insurer may have its own distinct process outlined in its provider manual. For example, regular Medicare patients must have medical necessity for hospital care documented in the medical record and reviewed by the UR staff, but payer notification isn’t required. For MA plans, the noti­fication requirements vary, with some requiring notification only for inpatient admission, some requiring notification for inpatient admission and outpatient (observation) stays of more than 24 hours, and some requiring notification for any hospital care.

Hospitals do not always do a good job of ensuring that every employee knows his or her role in the organi­zation’s revenue cycle. Even if a formal revenue cycle team does not exist in your hospital, every worker—especially the members of the UR/CDI team—should know the effect of his or her job on the revenue cycle. A consistent UR workflow is critical for a successful revenue cycle. Creating such a workflow means train­ing everyone on the UR team on a standard workflow that includes all tasks necessary to confirm eligibility for admission and continuing stay. Too often, workflow depends on the individual’s preferences and past experiences rather than on the program’s goals and those of the hospital it represents. If steps are missed or tasks are forgotten, the revenue cycle may be compromised and reimbursement may be delayed.

Editor’s note: This article is an excerpt from “The Hospital Guide to Contemporary Utilization Review, Third Edition” by Stefani Daniels, RN, MSNA, CMAC, and Ronald L. Hirsch, MD, FACP, CHCQM, CHRI.