Navigating the value transformation journey: The role of patient access and medical necessity

In a previous blog post, I introduced my view of what organizations on the path toward accountable care need to do to progress on their journey. Today, and over my next few posts, I’ll share an in-depth look at how some organizations are strengthening current capabilities and developing new capabilities to help them navigate the journey from providing care to managing health.Miles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealth

Two critical areas of improvement are patient access and medical necessity; advancements here can improve patient satisfaction, accepted claims, and cash flow. Ideally, medical necessity is a simple check during registration. In reality, comprehensive medical necessity management requires compliance in multiple other workflows, including point-of-care, health information management, and patient financial services.

Improving patient access and medical necessity involves both technology and process improvement

Physicians and hospitals have spent a considerable amount of resources installing systems that automate these key functions. Many of these organizations have seen that automation in these areas isn’t enough, on its own, to accomplish needed improvements.

Process improvement has a long history in health care, especially in clinical care. More recently, contemporary process improvement models—most notably, Lean and Six Sigma—have been applied to revenue cycle management.

  • One Florida health system applied Lean/Sigma principles to decrease the time it took to process fax-based appointments by 80 percent; by eliminating redundant systems, they were able to decrease the total scheduling time by 20 percent. This same system has also installed collection practices that have increased cash receipts at registration by more than 120 percent.
  • A Virginia system decreased the amount of time it took to register inpatients by 44 percent, and increased preregistrations on the outpatient side by 11 percent.
  • A Connecticut hospital employed medical necessity process improvements to reduce write-offs by 32 percent, decrease bad debt by 29 percent, and increase receipts by $18 million in one fiscal year.

A Georgia-based hospital system engaged its entire team in workflow redesign, team goal development, and work prioritization to ensure accountability, transparency and visibility within the revenue cycle.  In doing so, the system transformed the organization’s revenue cycle by aligning people, process and technology and by implementing a culture of accountability and shared success.

Using a combination of process and technology is helping many to increase efficiency in patient access and medical necessity reviews by streamlining workflows and automating various tasks. I will address the next step in the process, improving clinical technology, in an upcoming post.

9 thoughts on “Navigating the value transformation journey: The role of patient access and medical necessity

  1. Pingback: Navigating the value transformation journey: Putting clinical technology to work | Healthcare Exchange

  2. Great post. I think you may be missing the opportunity for further efficiencies by introducing patient/caregiver self service tools. Other industries have seen costs drop in the neighborhood of 10:1 when self service tools are introduced while satisfaction rises.

    • Great comment. I could not agree more. I will be covering that very topic in future blogs. It’s always difficult to cover everything important in short blogs. Thanks for your interest and your comment! Miles Snowden.

  3. Pingback: Navigating the value transformation journey: improving financial performance through coding and documentation improvement | Healthcare Exchange

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