# Business Office Quality Process Improvement

Contents

[7.1 Accreditation and Patient Rights, Confidentiality, Privacy,\
and Safety Requirements
7-2](#accreditation-and-patient-rights-confidentiality-privacy-and-safety-requirements)

[7.2 Quality Performance and Improvement
7-3](#quality-performance-and-improvement)

[7.3 Flow Charts for Process Improvement
7-4](#flow-charts-for-process-improvement)

[7.4 Registration Performance Tracking
7-4](#registration-performance-tracking)

[7.4.1 Eliminating Registration Errors
7-5](#eliminating-registration-errors)

[7.4.2 Steps to Improve Registration Quality
7-6](#steps-to-improve-registration-quality)

[7.4.3 Checking Registration Performance for Quality Assurance
7-7](#checking-registration-performance-for-quality-assurance)

[7.5 Benefit Coordinator Performance Tracking
7-8](#benefit-coordinator-performance-tracking)

[7.5.1 Checking Benefit Coordinator Performance\
for Quality Assurance
7-8](#checking-benefit-coordinator-performance-for-quality-assurance)

[7.6 Billing Performance Tracking 7-9](#billing-performance-tracking)

[7.6.1 Chart Auditing 7-9](#chart-auditing)

[7.6.2 Payment Analysis 7-11](#payment-analysis)

[7.6.3 Electronic Billing Systems - Checks and Balances
7-12](#electronic-billing-systems---checks-and-balances)

[7.6.4 Benchmarking the Billing Process
7-13](#benchmarking-the-billing-process)

[7.7 Monitoring Productivity 7-15](#monitoring-productivity)

[7.7.1 Billing Productivity Standards
7-15](#billing-productivity-standards)

[7.7.2 Ways to Divide Billing Workload
7-17](#ways-to-divide-billing-workload)

[7.8 Training and Business Process Improvement
7-18](#training-and-business-process-improvement)

[7.9 Pay-for-Performance Demonstrations
7-20](#pay-for-performance-demonstrations)

[7.10 Quality Improvement Organization
7-21](#quality-improvement-organization)

[7.10.1 Proposed 8th Scope of Work 7-21](#proposed-8th-scope-of-work)

## Accreditation and Patient Rights, Confidentiality, Privacy, and Safety Requirements

The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) and/or other accrediting body will query the staff, especially
Registration, on patient rights, confidentiality, privacy, and life
safety requirements for the facility. The following questions and
positive responses address these key areas.

How do you explain patient rights?

-   Staff provides a booklet that reviews their rights.

-   If patient cannot understand, is developmentally disabled, or deaf,
    staff explains the patient's rights to the family member.

-   Patient rights are posted within the facilities.

How do you maintain confidentiality?

-   Staff uses private booths to accommodate patients.

-   Staff speaks in hushed tones, to include reference to the patient
    name.

-   Confidential information is *never* shared with colleagues or family
    members.

-   The pre-certification desk is located away from mainstream of
    patients, because patients' names are given over the phone for
    insurance purposes.

-   Staff shreds all documents that contain any patient names and keeps
    those discarded documents in a separate container.

How do you maintain privacy?

-   Staff speaks in hushed tones.

-   Information is not requested that is not pertinent to the admission
    or facility visit.

-   Staff accommodates any patient who requests that their room number
    or phone number not be given out.

-   Emergency room staff moves patient into emergency room bay or
    examination room if the triage room is occupied.

-   Staff is aware of the privacy regulation.

How do you maintain life safety?

-   Fire drills

-   Disaster preparation and plans

-   Hazardous spills

-   Infection control

## Quality Performance and Improvement 

After each JCAHO and/or other accrediting body survey is completed, it
is recommended that a Performance Improvement Summary be developed,
updated, and maintained to demonstrate to JCAHO and its surveyors that
improvements have been identified and monitored.

The following table provides examples of activities that would fall
under a quality performance improvement activity. The objective is that
once a deficiency is identified, a plan of action can be put in place to
improve the deficiencies that were noted.

Example of a Performance Improvement Summary

+-----------------------+-----------------------+-----------------------+
| Problems Identified   | Action Taken or       | Evidence of           |
|                       | Recommended           | Improvement           |
+=======================+=======================+=======================+
| Outpatient Bills      | Verify provider order | Payments have         |
|                       | and notes or no       | increased.            |
|                       | payment.              |                       |
+-----------------------+-----------------------+-----------------------+
| Late filing of        | Staff given           | Reports readily       |
| ancillary test in     | in-service on timely  | available.            |
| medical record        | filing.               |                       |
|                       |                       | Reports automatically |
|                       | Electronic health     | posted in EHR once    |
|                       | record enacted.       | test results are      |
|                       |                       | received.             |
+-----------------------+-----------------------+-----------------------+
| Timely Radiology      | Identify inpatient    | Colored dots used.    |
| reports               | versus outpatient.    |                       |
|                       |                       | Radiologist reads     |
|                       |                       | inpatient x-rays      |
|                       |                       | before outpatient     |
|                       |                       | ones.                 |
|                       |                       |                       |
|                       |                       | Reports placed on     |
|                       |                       | chart as soon as      |
|                       |                       | possible.             |
|                       |                       |                       |
|                       |                       | Electronic health     |
|                       |                       | record updates        |
|                       |                       | results immediately.  |
+-----------------------+-----------------------+-----------------------+

Accreditation/certification usually requires annual testing of
competency that includes documentation maintained in personnel files
that substantiates employee competency in their job duties.

## Flow Charts for Process Improvement

A team-oriented approach with tangible department goals can serve as
incentive for process improvement. By creating a series of goals and
rewards for each department, each team is motivated to eliminate any
lags in their particular department and a friendly competitive
atmosphere can be created.

By documenting with charts and graphs the progress of the individual
teams by department, the facility begins to create an overall team
effort and a "continuous quality improvement" environment. This effort
can then be acknowledged by management, which affirms a sense of
appreciation to all departments and enhances the desired behavior.

Charting results can serve as an educational tool for the facility. By
creating a flow chart of the various components and inviting members
from Registration, Coding, Billing, and other appropriate ancillary
departments to meet, there will be discussions regarding possible
problems. This opens the door to create a tighter process improvement
effort. Using this lag analysis process, delays can be discussed without
blame and everyone can examine the results and work together to create
improved workflow solutions.

## Registration Performance Tracking

Incomplete or inaccurate registration information leads to billing and
payment delays. Payment delays eventually impact the quality of care.
The best way to improve the registration process is to track
registration accuracy by implementing a performance improvement plan.

Tracking registration accuracy can be done in several ways. Registration
can conduct a registration effectiveness audit. Billing and Collections
can track the reasons for claim rejections, highlighting and documenting
those caused by registration inaccuracies and deficiencies.

Tracking should reflect both an individual's performance and the
department's overall performance. It is good information which the
department can use to develop a teamwork approach to resolving and
preventing the errors causing the denials.

By understanding the accuracy level and rejections due to poor
registration information, the department can create a plan of action to
improve and standardize the registration process.

For those facilities accepting non-beneficiaries, the department should

-   Track its up-front collections success.

-   Identify the number of patients who owe deductibles or coinsurance
    at the time of service.

It is also important to track how non-beneficiary patients pay; such as,
by cash, check, or credit card.

### Eliminating Registration Errors

A detailed-oriented Registration staff is a valuable asset to the
facility. They are responsible not only for gathering complete and
accurate information, but also for entering that information into RPMS.

It is extremely important to review and update the Insurer File so that
your Registration Staff can appropriately identify the correct the
insurer information in your system.

Some of the most common registration errors are not obvious and at
times, an insurer will use even the slightest error to their advantage.

Examples of insurer-related errors and solutions

  ----------- -------------------------------------------------------------
  Error:      Calculating ages when using the birthday rule for
              coordination of benefits (determining primary insurer)

  Solution:   Determine primary insurer based on who birth date falls first
              in the calendar year, not who is older. The birth year does
              not matter.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Enter Medicare HIC number as they appear on the card,
              substituting slashes for hyphens and including numbers only

  Solution:   Check with the fiscal intermediary to learn their
              requirements for filing claims. Some require that hyphens and
              any other punctuation be omitted. In all cases, do not forget
              the suffix.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Entering insured's identification number a group number

  Solution:   Double-check to make certain group numbers that are entered
              on the registration form matches the number listed under the
              group number heading on the card, not the patient
              identification number.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Using abbreviations that are misinterpreted (e.g., "pat"
              means "patient" to some, "preadmission testing" to others

  Solution:   Created a list of common abbreviations for all staff members
              to use. The list should be consulted when writing or reading
              abbreviations.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Failing to note useful information in the comments section of
              RPMS.

  Solution:   Any relevant information from either the registration staff
              or the benefit coordinator needs to be entered into the "free
              text" section of the registration application. Any
              information is important in deciding whether to proceed with
              collections or wait for additional information from the
              patient or insurer.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Failing to include insurer address

  Solution:   Be sure to copy the back of the insurance card. If the
              address is not entered at the time of registration, it can be
              tracked down by checking the card copy. In the case of
              regional carriers, be sure to note the address on the back of
              the insured's card. Claims most often must be sent where the
              patient is insured, not where the patient is treated.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Transposing first and last names

  Solution:   Insurers rarely look for coincidences on claims (such as
              patient's first name matches the last name of the beneficiary
              and last name matches the beneficiary's first name). Insurers
              routinely reject flawed claims. Check on the card to see how
              names are labeled. Some put the first name last, and some do
              not. Be sure to record it accurately.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Using existing information in the system from a previous
              visit

  Solution:   Update patient information at each visit. Insurances,
              addresses, and employment are all subject to change.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Failing to get provider's signature and proper date of
              service

  Solution:   Clinics are more likely to fall prey to this problem.
              Providers may sign or stamp a batch of forms at once and
              sometimes blank forms. Expect claim denials if a form is
              signed and dated before the time of service.
  ----------- -------------------------------------------------------------

  ----------- -------------------------------------------------------------
  Error:      Failing to get preauthorization

  Solution:   Know which insurers require preauthorization for treatment.
              If in doubt, call. It is better to make the extra effort to
              avoid claim denials.
  ----------- -------------------------------------------------------------

### Steps to Improve Registration Quality

There are five basic steps to improving the quality of the Registration
staff. Initially review the process for a couple of days with the staff.
Once the accuracy has improved, then scale back to random surveys. The
steps are:

**1. Track errors**.

Most clinical and accounting systems, as well as the RPMS registration
application, include tracking by employee. Use this tool to identify and
correct problems that stem from the front end.

**2. Work with staff as soon as errors are identified.**

Don't wait for an annual performance appraisal to review the number of
errors. The consequences of multiple errors for the year becomes the
burden of the facility

**3. Recognize employees for what they do right.**

Identifying errors is important, but praise is needed when things go
right and the accuracy has improved.

**4. Monitor quality daily.**

Spot checking registration records daily helps keep staff on their toes
and accuracy levels high. Again revert to random reviews once quality
and accuracy have improved.

**5. Provide ongoing training.**

Training includes one-on-one review of problem areas as well as more
formal full staff training sessions. Key is to address problems as they
arise and craft solutions with staff. "With" is the operative word.

### Checking Registration Performance for Quality Assurance

To check for compliance:

1\. Pull a list of scheduled patients from a particular day.

2\. Review the information in the RPMS Patient Registration application
regarding insurance information, demographics, and other information;
and review Page 8 to determine if the insurance information was updated
during that visit and whether it was entered into RPMS.

-   Was only a primary insurance referenced?

-   Was a secondary insurance, pharmacy-only, or dental insurance
    listed?

-   Was the insurance billing address correctly reflected?

-   Was the identification number accurately reflected?

3\. Review the billing information on the patient.

-   Was the same insurance information billed?

-   Was the same address used?

-   Was the account paid?

-   Were errors identified and if so what errors?

4\. Determine a percentage for your facility that meets expectations and
pass the review of the audit back to the staff.

5\. Compute a level of compliance for each registration staff person.

6\. Add the information to the Quality Assurance Statistic form.

7\. Use this data as well as the staff person's improvement as part of
the performance appraisal process

## Benefit Coordinator Performance Tracking

-   On a monthly basis, calculate the percent of patients referred to
    the Benefit Coordinator that qualify for alternate resources versus
    those that did not.

-   Determine the percent increase by month of the number of patients
    that qualify, and perform a trend analysis over several months.

-   Develop a monthly cumulative report listing the number of patients
    that were referred to the Benefit Coordinator for alternate
    resources, and calculate the reimbursement on those patients by
    month.

-   Compare the increased reimbursement by alternate resource payor,
    month-to-month.

### Checking Benefit Coordinator Performance for Quality Assurance

-   Establish and staff a full time Benefit Coordinator position.

-   Train the Benefit Coordinator on all aspects of alternate resources:

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-   Benefits

-   Exclusions

-   Eligibility and qualifications

-   Application process

-   Documents needed to substantiate

-   Types of alternate resources available

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-   Cross train Registration staff regarding which potential patients
    may qualify for alternate resources.

-   Assure there is an established process for referring "all" potential
    patients to the Benefit Coordinator from Registration.

-   Follow up with Medicaid, Medicare, and other alternate resources to
    assure the coverage is approved.

-   Document in the **RPMS Patient Registration** application all
    updates on conversations.

-   Always inform Billing of new insurance coverage.

## Billing Performance Tracking

The RPMS Third Party Billing application's **Pending Claims Status**
report will reveal areas that need attention before the claim can be
approved. Many incorrect components of the claim cannot be detected
until billers attempt to approve the claim. If deficiencies are found
the biller has the option to place the claim into a pending status,
using the 3P Claim Pending Status table in RPMS.

The Pending Claims Status report will show if

-   Claims are rejected due to incomplete or inaccurate information from
    registrations.

-   Information on the patients provided at registration is correct and
    complete.

-   Billing understands the correct format used to bill a particular
    insurer, and/or whether the biller incorrectly billed the account.

Building collaboration and more open lines of communication between
Registration, Coding, and Billing will eliminate any finger-pointing and
will improve the entire business process.

### Chart Auditing

The medical record serves as a tool for patient care, medical research,
and healthcare statistical measurements, and as a supporting tool for
reimbursement. The medical record has been evolving for years to the
development of the electronic medical record.

The patient's medical record, or patient chart, is a legal document that
should not be tampered with, falsified, or altered in any manner that
would cause the loss of or suppression of data. The chart should never
be published or released to anyone without the patient's express
consent.

The documentation in the medical record is required to record pertinent
facts, findings, and observations about an individual's health history,
including past and present illnesses, examination, tests, treatments,
and outcomes. The medical record chronologically documents the care of
the patient.

The medical record often serves in many court cases for medical
malpractice judgments as the final piece of definitive evidence.

In addition, the medical record facilitates:

-   The ability of the physician and other health care professional to
    evaluate and plan patient's immediate treatment and to monitor their
    health care over time

-   Communication and continuity of care between physicians and other
    health care professionals involved in the patient's care

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-   Accurate and timely claims review and payment

-   Appropriate utilization review and quality of care evaluations

-   Collection of data that may be useful for education

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-   Support to the claims processing

The process of chart auditing needs to be outlined by each facility
compliance plan. The questions -- how often, how many charts, when to
audit -- should be addressed in the plan. The Office of the Inspector
General has published a variety of model compliance plans in its
electronic reading room that can be referenced.

Internal auditing is done to verify that the facility is performing in
good compliance. This practice also ensures good fiscal returns for
cleanly coded claims. Chart auditing includes the process of verifying
CPT and ICD-9-CM codes against the document for the encounter.

Evaluation and management services represent the foundation of the
patient encounter and procedural coding. Guidelines and rules associated
with the evaluation and management of coding present some of the most
subjective coding conventions out of all sections in the CPT manual.

In addition to the internal auditing, the government audits records to a
variety of different kinds of fraud and abuse. Therefore, it is
important that each facility audit their records prior to any external
audit review.

Stages and steps in an audit process are:

-   **Criteria**

The first stage is to define "*what should be*" -- basically a baseline
for the audit, a best practice that you would like the facility to
achieve, or what actually should be occurring.

-   **Condition**

The second stage is to define "*what is*" -- Document what is occurring
and whether that meets the criteria

-   **Cause**

When the condition does not meet the criteria, you need to document why
-- "*Why is this process falling short?*"

-   **Effect**

"*What is the financial, resource, quality, or other impact of the
condition?*" -- It might mean, lost revenue; it might mean lost time in
research; it might mean duplication of initiatives. In this stage, you
look at the difference and significance between what is and what should
be.

-   **Recommendations**

This stage of the process is to define and implement a solution with an
achievable action plan and follow-up review process. This stage also
includes the establishment of performance targets and performance due
dates.

### Payment Analysis

One of the most important processes is submitting the bill in a timely
manner to the insurance company. For the current inpatient and
outpatient billing timeframes, see the *Indian Health Manual*, Part 5,
Chapter 1, "Third Party Revenue Accounts Management and Internal
Controls" (5-1.3H), which is available at this website:
<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part5/pt5chpt1/part5chapt1.htm#3h>)

An audit should be periodically conducted to sample the billing
timeframe. For this process, simply review 25-to-50 recently paid
accounts from each of your major payers.

1\. Enter the discharge date or the date of the facility visit and then
the date the bill was actually mailed or billed electronically to the
insurer.

Then count the number of days between those times. This figure should
not be more than ten days for inpatient claim, based on discharge date.

2\. Enter the date paid and the number of days between the date billed
and the date paid.

This figure should not be more than 30 days. If the figure is more than
45 days, there is an internal or system problem that needs to be
reviewed.

The audit enables the facility to identify potential issues, bottlenecks
in the process, system transmission issues, and business process
workflow changes that can improve the day-to-day operations.

### Electronic Billing Systems - Checks and Balances

With electronic submission of claims, you should ensure that a
confirmation of receipt is received and the response reports are
reviewed after each batch submission.

-   Know the number of bills approved and ready for export by printing
    or displaying the Summary of Bills Ready for Submission option in
    RPMS Third Party Billing. Limit the number of bills you include in
    each batch to make the batch more manageable and to meet payer
    requirements.

-   Ensure filename used to create the batch file complies with payer
    requirements.

-   Create batch file using the Create EMC File option in RPMS Third
    Party Billing, and FTP from your RPMS file directory to prepare for
    export.

-   After transmitting your batch file, compare the entries to the
    number of claims received by the payer. If they match, you are
    assured that the transfer mechanism you have in place is working. If
    they do not match, you could be omitting claims from your daily
    batch submission, and you will need to remedy this situation
    immediately.

-   Your insurer or billing vendor (clearing house) should be
    transmitting confirmation reports to you regularly that reflect the
    claims they received from you in your last transmission batch.
    Compare these figures to the number of claims you transmitted. If
    the numbers match, you will know the claims have been routed to the
    insurance companies. If the numbers do not match, you will need to
    contact your insurer or billing vendor to resolve the discrepancies.

It is important to examine your confirmation reports daily upon receipt.
Periodically you may find claims that have failed payer specifications.
It is imperative to correct and resubmit these claims promptly. If
allowed to accumulate, these claims will have an adverse effect on your
receivables, thus defeating one of the major advantages of billing
electronically.

For any attachments requested with electronic billing, it is advisable
to ask your insurer if they prefer a hard-copy of the report, or if the
report can be faxed directly.

### Benchmarking the Billing Process 

As part of an ongoing review process, six-to-eight designated
individuals -- from either the facility, from the Area office, or from a
contracted entity -- should form a review group. This review group would
focus on analyzing and finding solutions to problems in the billing
process, by examining and comparing existing processes to successes of
peers. This is called benchmarking.

If a health care facility wants to be the best, it must know how others
manage to be so good. Benchmarking involves finding best-class examples
of product, service, or operational systems, and adjusting the existing
facility to meet those standards. Benchmarking can be the foundation for
any receivables improvement program.

Benchmarking steps involved in the billing process are:

**1. Identify what is to be benchmarked.**

It could be something tangible such as days, bad debt, or billing time
or it could be something as intangible as patient satisfaction

**2. Identify comparative facilities.**

Expect to spend some time on researching, perhaps visiting, and
definitely comparing, other entity's successes.

**3. Determine data collection method and collect data.**

The team that conducts the studies determines what measurements will be
used.

**4. Determine current performance levels.**

Take the measurements of your own function and compare them with the
measurements from the benchmarked facility. That usually produces a
negative or positive performance gap.

**5. Project future performance levels.**

Use the measurements of the gap to figure out what the new performance
goals should be if that gap is to be closed, and how long it will take.

**6. Establish functional goals.**

Write down your objectives.

**7. Develop action plans.**

These plans tell how you are going to achieve the objectives.

**8. Implement the plans and monitor progress.**

If the goals are not being met, problem-solving teams might be formed to
figure out why.

**9. Recalibrate measurements.**

Keep abreast of industry standards and new best practices.

**10. Communicate benchmarking findings and gain acceptance.**

Present findings and recommendations to staff and to higher management
for endorsement.

## Monitoring Productivity

To just evaluate the productivity of a staff person from manual
activities would be very hard to analyze. One of the ways where
productivity could be tracked would be from a follow-up report that is
generated for each financial category. The supervisor could review
accounts randomly on the report for each follow-up person. Another way
would be to have the follow-up staff turn in a weekly manual report on
the number of accounts they have worked and the number of accounts paid.

Examples:

  -----------------------------------------------------------------------
  For...        Use...
  ------------- ---------------------------------------------------------
  Billing       Bills Listing Report, by approving official

  A/R           Transaction report (TAR), by Accounts Receivable (A/R)
                entry clerk

  Coding        Counts Report (RPMS PCC Application), by individual; also
                provides a summary report
  -----------------------------------------------------------------------

### Billing Productivity Standards

A recent survey demonstrates that billers average 53 bills per day or
6.6 bills per hour. The following guidelines provide an estimate for
billing based on the electronic capabilities of the facility.

-   **Fully Automated Facility**

95-to-100% of edits are done on the computer. For this type of facility,
a typical biller should send out at least 2,500 bills per month or at
least 120 bills per day. Factors that could affect this quantity are
payer mix, quality of bills produced by your system, and size and
location of the facility.

-   **Semi-automated Facility**

Edits are made by hand, and an even number of electronic and paper
claims are submitted. For this type of facility, a typical biller should
send out at least 1,000-to-1,800 bills per month or around 86 claims per
day.

-   **Manual Facility**

All information is keyed into the system by data entry staff and is
mailed manually. For this type of facility, a typical biller should send
out at least 35 bills per day.

Factors that affect the productivity of billers include:

-   **The number of telephone calls received by the billers**

Some billers are interrupted by incoming telephone calls all day. This
can make a big difference in productivity.

**Suggestion**: Establish a separate position within the billing
department to handle incoming phone calls.

-   **The volume associated with follow-up on outstanding accounts**

Many billers have to follow up on their claims with third-party payers.

**Suggestion**: If the volume associated with follow-up is too high,
then have either a separate individual or area do the follow-up, or
reserve a few hours each day for the biller to follow-up. For the
latter, this will enable the biller to concentrate on billing rather
than periodically interrupting their day for follow-up.

-   **Problems with data moving through RPMS in a timely manner**

Late charges are always an issue. The more late charges or orphan tests
a biller gets, the bigger the billing backlog.

-   **Billers also functioning as coders**

Performing the multi-task functions of coding and billing, or checking
the coding of the coder and billing, slows down productivity.

**Suggestion**: Have a separate coding staff in the facility and have
the biller focus only on billing.

-   **Billing office setup**

If the Billing office is setup where billers are assigned by insurer,
some billers may be processing more paper claims while others are
processing more electronic claims.

**Suggestion**: Have your computer specialist or Area office work with
the primary insurers that you are submitting paper claims, to determine
whether these same claims can be submitted electronically.

-   **Payer's requirements**

A percentage of the claims processed require a great deal of manual
work.

**Suggestion**: Meet with the insurance company to discuss payment
problems, requirements, and solutions.

### Ways to Divide Billing Workload

There are several ways to divide the workload in the Billing Department
-- by payer, by alphabet, or by team.

Payer Split

The billing responsibilities are divided into the major payer groups --
Medicare, Medicaid, and private insurance.

+---------+------------------------------------------------------------+
| Be      | -   Billers become specialists by payer types. Billers can |
| nefits: |     keep abreast of the changing requirements and          |
|         |     regulations.                                           |
+---------+------------------------------------------------------------+
| Pi      | -   With the secondary billing, such as Medicare and       |
| tfalls: |     Medicaid or Medicare and private insurance, the same   |
|         |     claim will be handled by two billers and may go back   |
|         |     and forth. In addition, telephone calls with the two   |
|         |     insurers may not consistently be handled between the   |
|         |     two billers.                                           |
|         |                                                            |
|         | -   Patient revenue mix may change, causing uneven         |
|         |     workload among the billers.                            |
+---------+------------------------------------------------------------+

Alphabet Workload Split

The billing responsibilities are divided according to an alphabetical
split, based on the patients' last name.

+---------+------------------------------------------------------------+
| Be      | -   Billers are responsible for billing all payers, and    |
| nefits: |     there is no controversy or back and forth between two  |
|         |     billers with coordination of benefits.                 |
|         |                                                            |
|         | -   Billers become cross-trained with multiple insurers    |
|         |     and can cover for other billers if they are on         |
|         |     vacation or sick.                                      |
+---------+------------------------------------------------------------+
| Pi      | -   With the third-party billing requirements changing     |
| tfalls: |     rapidly, it may be difficult for billers to remain     |
|         |     experts in all payers.                                 |
|         |                                                            |
|         | -   Billers will need to be proficient with manual         |
|         |     billing, as well as billing through the various        |
|         |     insurer terminals.                                     |
+---------+------------------------------------------------------------+

Team Workload Split

A team is a combination of payer and alphabet billing processes. A team
can be divided first by payer, and then further divided alphabetically.

+---------+------------------------------------------------------------+
| Be      | -   The Split promotes teamwork, rather than the "their    |
| nefits: |     job, not my job" mentality.                            |
|         |                                                            |
|         | -   There is more flexibility when staff is on vacation or |
|         |     sick.                                                  |
|         |                                                            |
|         | -   Team size can be shifted depending on work volume.     |
+---------+------------------------------------------------------------+
| Pi      | -   Shifting staff from one team to another can create     |
| tfalls: |     resistance to change or stress.                        |
|         |                                                            |
|         | -   Not everyone from the team can attend a meeting or a   |
|         |     seminar, for no one would be available to work on the  |
|         |     bills.                                                 |
+---------+------------------------------------------------------------+

## Training and Business Process Improvement

Constant change in health care rules, regulations, and guidelines makes
training an imperative. The hazards of not taking the time to train,
initially and at regular updates, can prove to be costly. Without proper
training and leaving it up to the individual about where to go for
information makes it difficult for the person to perform effectively.

For example, the results of improper training in Registration could
result in (1) missing data elements that will slow the claims
processing; (2) inaccurate data results in claim rejections and/or leads
to rebilling; and (3) failure to obtain preauthorization within required
time parameters leading to claims rejections and/or reimbursement denied
in part of full.

The costs of improper training at the front-end show up in reduced
reimbursements and/or increased staff effort as the back-end must
duplicate tasks that should have been performed at the front-end.

Training Basics

  -----------------------------------------------------------------------
  Training Task           Description
  ----------------------- -----------------------------------------------
  Create Processes        This entails identifying job requirements and
                          creating processes to meet those requirements

  Develop Policies and    Processes to meet job requirements need to be
  Procedures              backed up with set policies and procedures that
                          serve as guideline that can be referred to
                          after training.

  Create a Training       This can be combined with developing policies
  Manual                  and procedures. What is important is that staff
                          has a written resource to which they can refer
                          to independently resolve issues as they occur
                          while remaining within established guidelines.
                          Training is just someone conveying what needs
                          to be done; staff needs something to refer back
                          to.

  Train                   Bring staff together in small groups during
                          work hours. Explain job requirements and the
                          processes to meet those requirements. Be
                          specific and use detailed examples. The best
                          trainer tries to demonstrate to staff how their
                          work fits into the bigger picture, and how
                          their work is interrelated.

  Set Goals and           Establish measurable goals in key performance
  Objectives              areas. For registration, these can include
                          registration accuracy, number of registrations
                          to complete in a day, etc.

  Monitor Performance     Quality assurance is required to determine if
                          training is adequate. Among the management
                          tools in monitoring performance are reports
                          from the business office on why claims'
                          processing was delayed or why rejections
                          occurred. These records will show if
                          registration records are coming through
                          incomplete or if information is inaccurate.

  Provide Ongoing         Ongoing training can occur in refresher courses
  Training                or informally one-on-one. Effective monitoring
                          allows supervisors to provide training as
                          needed. For example, if a staff person
                          consistently fails to complete a certain field,
                          the supervisor should speak with the staff
                          person to review the problem and discuss why it
                          is a problem.
  -----------------------------------------------------------------------

## Pay-for-Performance Demonstrations

Medicare has various initiatives to encourage improved quality of care
in all health care settings where Medicare beneficiaries receive health
care services, including physicians' offices and ambulatory care
facilities, hospitals, nursing homes, home health care agencies, and
dialysis facilities.

The foundation of effective pay-for-performance initiatives is
collaboration with providers and other stakeholders to ensure that

-   Valid quality measures are used.

-   Providers are not being pulled in conflicting directions.

-   Providers have support for achieving actual improvement.

Through collaborative initiatives with public agencies and private
organizations, CMS is developing and implementing a set of
pay-for-performance directives to support quality improvement.

There are three physician demonstrations:

**(1) Physician Group Practice Demonstration (BIPA 2000)**

Mandated by the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA), this demonstration is the first
pay-for-performance initiative for physicians under the Medicare
program. The demonstration rewards physicians for improving the quality
and efficiency of health care services delivered to Medicare
fee-for-service beneficiaries. The demonstration seeks to encourage
coordination of Part A and Part B services, promote efficiency through
investment in administrative structure and process, and reward
physicians for improving health outcomes.

**(2) Medicare Care Management Performance Demonstration (MMA section
649)**

Modeled on the "Bridges to Excellence" program, this is a three-year,
pay-for-performance demonstration with physicians to promote the
adoption and use of health information technology to improve the quality
of patient care for chronically ill Medicare patients. Doctors who meet
or exceed performance standards will receive bonus payments for managing
these patients.

**(3) Medicare Health Care Quality Demonstration (MMA section 646)**

This demonstration, which was mandated by section 646 of the MMA, will
be a five-year demonstration program under which projects enhance
quality by improving patient safety; reducing variations in utilization
by appropriate use of evidence-based care and best practice guidelines,
encouraging shared decision making, and using culturally and ethnically
appropriate care.

## Quality Improvement Organization

The Quality Improvement Organization (QIO) consists of local
organizations that, by law, contract with the Centers for Medicare &
Medicaid to provide quality improvement assistance to health care
providers, such as physicians, hospitals, nursing homes, and home health
agencies, and to health plans that contract with Medicare.

The QIO was established to redirect, simplify, and enhance the
cost-effectiveness and efficiency of the medical peer review process.
The three main functions of the QIO are to

-   Improve quality of care for beneficiaries by ensuring that
    beneficiary care meets professionally recognized standards of health
    care.

-   Protect the integrity of the Medicare Trust Fund by ensuring that
    Medicare only pays for services and items that are reasonable and
    medically necessary and that are provided in the most economical
    setting.

-   Protect beneficiaries by expeditiously addressing individual cases,
    such as beneficiary quality of care complaints, contested hospital
    issued notices of noncoverage (HINNs), alleged Emergency Medical
    Treatment and Labor Act (EMTALA) violations (e.g., patient dumping),
    and other statutory responsibilities.

### Proposed 8th Scope of Work

To help the QIOs, CMS is proposing an **8th Scope of Work** - a plan
that would include the following enhancements to the previous QIO
contracts.

-   It recognizes that although the U.S. Healthcare system has been
    leading the way in many improvements in health care, the full
    potential of our health care system to improve health is not being
    achieved. The plan aims to promote dramatic improvements in the
    quality of health care so that every person receives the right care
    every time.

-   It proposes that the QIOs may need to build on their current efforts
    to involve other organizations and entities to provide the best
    possible expert assistance in increasingly specialized areas, and
    invites comments on options for accomplishing this through
    subcontracting and other partnerships.

-   It indicates that the design of the program will be organized to
    better distinguish QIO impact from improvement that may occur
    without QIO assistance, such as increased awareness of clinical
    guidelines by physicians.

The 8^th^ Scope of Work will guide the work of the QIOs for the
three-year cycle beginning in August 2005. This proposal focuses on four
settings:

-   Nursing Homes

-   Home Health Agencies

-   Hospitals

-   Physician Offices

It also includes the continuation of protecting beneficiaries and the
Medicare Trust Fund through work on appeals, beneficiary complaints,
payment error, and other case review activities.

The proposed work in the 8^th^ Scope of Work moves beyond the current
7^th^ Scope of Work in the following ways:

-   QIOs will work to promote dramatic improvement, promoting the
    adoption and effective use of healthcare information technology
    (HIT), performance measurement, process redesign, and organizational
    culture change.

For example, working with partners in a pilot project, QIOs are
assisting small-to-medium sized physician offices in California,
Arkansas, Massachusetts, and Utah, in adopting office-based electronic
health record (EHR) systems and using such systems to improve efficiency
of care delivery, quality of care, and patient safety.

-   When the Medicare prescription drug benefit becomes available in
    2006, QIOs will work with prescription drug plans and providers to
    ensure quality care to people with Medicare on improvement projects,
    such as measures to detect inappropriately prescribed rugs and ways
    to identify patients who may be at risk for harmful interactions.

-   QIOs will work to improve care for disadvantaged populations by
    focusing on physician office-based care to make sure all Medicare
    beneficiaries get the right preventive services and appropriate care
    for chronic diseases, such as diabetes.

-   QIOs are expected to continue offering mediation as a service to
    Medicare beneficiaries. This service involves direct provider
    involvement in responding to beneficiary complaints, which often
    results in improved communication between provider and patient, in
    order to resolve quality of care issues.

This multi-pronged approach includes helping consumers make decisions
using timely and accurate quality of care information, and urging
providers to improve quality using free assistance from QIOs and through
"pay-for-performance" demonstrations.