1. Building an Automated Financial Clearance Process
Niobis Queiro, MBA
Corporate Vice President, Revenue Cycle
Hartford HealthCare Corporation
Hartford, CT

2. Hartford HealthCare 4 hospital system serving 63 towns in Connecticut
75,711 inpatient visits per year
2 Million outpatient and homecare visits a year
280,000 ED patients per year
60% of all behavioral health visits in the state of CT
$52 million in charity care FY 2011
$14 million invested in research
15,000 Employees
2,100 Physicians
$2.0B Total Revenue

3. Current Issues Facing Healthcare Industry
Losing 7.2% on Medicare Cases, losing 14% on Medicaid*
Medicare Reimbursement rates declining**
Increasing Medicare & Medicaid population
Increasing high deductable plans and bad debt
Hospitals will Never Be Paid as Well as They are Today
Rewards chasing revenue, not margin/quality
Capitation payment encourages less volume
Evidence Based Care Plans are needed
Fee for Service versus Fee for Value
Physicians, hospitals, providers and plans not aligned (incentives)
Coordination lacking inside/outside walls of hospital
EMR Adoption/MU requires new processes**
Data is housed in silos
Care Delivered in Silos
Rapid increase in patients with multiple chronic diseases (CHF, COPD, Diabetes); 133M Americans have a chronic disease***
5% patients = 55% of admissions, care at Medicare rates
Health Plans shift risk to provider. Bundled care, ACO
Chronic Disease Patient Volume Increasing
What we know for sure is that we will never get paid more than we are today and that likely we will get paid less and more like Medicare rates across the board.
This required Hartford Healthcare to identify areas to rapidly remove cost from the delivery mechanism and standardize process and accelerate revenue.
Pick one of the below to speak to and then move on to the next slide:
larger % of patient vol will be medicare/medicaid (due to reform, aging population, recession), and those rates are being reduced. Also with VBP where reimbursement tied to Quality Performance (30-day Readmits, Avoidable Admissions, HACs/HAIs, RAC audits), those that fall short on a broadening list of quality metrics, have more rev at risk.
Fee for Service: Whether or not the nth service would be beneficial to the patient and the payer. Excessive fixed cost structure, abundance of access for competing entities for well insured population of patients
Care Delivered in Silos – EMR/MU are great enablers but require revised processes to take advantage of the powerful information available for decision making on patient care.
Chronic Disease Patient volume increasing – think about segmenting patients. 4 groups – healthy group, relatively healthy with scheduled elective procedures/emergencies. 3rd group is single chronic disease but healthy. 4th group is complex, multi-chronic disease. The 3rd and 4h groups require most care. Frequent flier in-patients. Chronic disease, and Complex Chronic disease wave is coming, where 7 out of 10 deaths are from chronic diseases. Heart disease, cancer and stroke account for 50% of all deaths each year. Require focused care plans that is 24/7, from an integrated care system. Monitoring the patient at home.
Contracted Health Plans shift risk to providers, and pursue bundled care as a 3 yr focus on managing specific beneficiaries. ACO is program to be launched.
*Source:Modern HC , pg 16 MEDPAC . FierceHealthFinance, **ObamaCare Impact this for Primary care Physicians. 1 – Appropriate Tort Reform when practice pattern reflects standard. ***CDC 2005 Chronic Disease Prevention and Health Promotion Report.

4. Traditional Operating Models Will Fail Under The Complexities of Healthcare Reform
Short term:
Increased access to care
New shared reimbursed at government rates
Outcome risk
Reduced operating margins
On the horizon:
ICD-10
Outcomes Performance
Clinical integration
IT interoperability
ACO investments
Next generation gain sharing
Bundled payments
Healthcare change is not new – BUT the difference this time is the rapid implementation of changes.
In a very short time period, providers will be treating more patients and paid less per encounter (the only absolute of healthcare reform)
If you are not working now to optimize patient revenue and aggressively control expense, your long-term viability will be challenged
The demands of healthcare reform will require new investments and result in underinvestment in key operating areas (Patient Access, business office, supply expense)
Providers must focus on and invest in core competencies (managing the health of a population)
Importance of a centralized and organized access area to ensure Hartford’s success in an accountable care model to improve access and patient transitions between/across care providers across the HHC system.
Greater Access – Reduced Reimbursement – Growing Operational Complexity

5. Patient Access: The Root of Much Evil
Percent of data needed for billing originates at registration: 70%
National average registration error rate: 46%
Percent of denials that could be prevented at registration: >50%
Healthcare Informatics Research Series Data
Patient Access Resource Center
NAHAM
Modern Healthcare
HCPro Quarterly benchmarking report 12/10
Sources: Patient Access Resource Center: HCPro Quarterly Benchmarking Report 12/10,
Healthcare Informatics Research Series Data, NAHAM, Modern Healthcare

6. Cash Collection Curve
Cash collection probability and absolute dollar amount declines with passing time. Moral of the story: collect early and often.

7. Hartford HealthCare Project Goals
Create an Optimal Patient Experience that Makes HHC the Provider of Choice
Create and Automate a Data Rich Financial Clearance Process
Produce Patient Liability Estimates for Transparency
Improve POS Cash Collections
Centralize Scheduling
Real-time Quality Assurance to empower the end-user
Enable Field Level Registration Edits
Link patient Access Errors to Denials and A/R Liquidation
Provide structure around E&B and Authorizations
Establish a Partnership with all HHC providers and assets

8. Hartford HealthCare: Flashback 18 months
No patient access standardization
Variable financial clearance process
No centralized scheduling
No patient liability estimates
< $1M/Yr in POS cash collections
No registration quality edits
No link between access & denials
IT patchwork across 4 hospitals

9. Current state: Hartford HealthCare Patient Access
201
Automated Financial Clearance Workflow Platform
Address
Validation
Centralized Scheduling
Eligibility & Benefit Verification
Prior Auth
(pilot)
Patient Funding w/ Via Note
Patient Estimates
Medical Necessity
Reg
Integrity
ADT Feed
ATB Data
Reporting & Metrics
HCIT Integration
Post Go-Live

10. Point of Service Patient Liability Estimates

11. Linking Patient Access Errors to Denials
Improved A/R Liquidation Rates
Reduction in errors at Patient Access
12%
20%

12. Hartford HealthCare KPIs

13. Joys of the Open Road

14. Joys of the Open Road Employee Engagement Team Building Exercises
HHC offers employees access to Local Community College
HHC covers tuition and salary for Wednesday afternoon coursework
Clear career path and education boost employee morale
HHC maintains a 99% employee retention rate
Team Building Exercises
Rewards For Outstanding Performance

15. Lessons From The Road

16. Lessons from the Road Appraise organizational readiness
Finance will likely want to run faster than departments
Provide training to physicians and nursing staff
Communicate early and often with hospital leadership (CEO/CFO)
Appraise Financial Clearance Staff
Some personality types are not suited to ask for payments
Be aware of HR challenges
9 Benefits Packages
4 Compensation Models
Union job descriptions
Employee transfer requires new employee paperwork
HHC full homogenization by 2013

17. John Godfrey Saxe
"The Blind Men and the Elephant" by John Godfrey Saxe (1816–1887).
It was six men of Hindostan To learning much inclined, Who went to see the Elephant (Though all of them were blind), That each by observation Might satisfy his mind
And so these men of Hindustan Disputed loud and long, Each in his own opinion Exceeding stiff and strong, Though each was partly in the right And all were in the wrong.

18. Leadership Behaviors Be In The Moment Be Authentic & Humanistic
Volunteer Discretionary Effort Constantly
Model High Performance-Desired Behaviors that Drive Desired Results
Respect & Leverage Separate Realities
Be Curious vs. Judgmental
Look in the Mirror First – Be Accountable
Have Courageous Conversations
Provide Timely, Clear & Specific Performance Expectations & Feedback
Teach, Coach & Mentor - Spend at Least Half of Your Time Developing Others

19. Questions to Ask Yourself Everyday
What more can I do right now to be a role model for those around me?
What more can I do right now to achieve the outcome we desire?
What more can I do right now to prevent something undesired from occurring?
What expectations or feedback can I deliver right now to make a positive difference?
What more can I do right now to seek or provide the clarity that I think does not exist?
What more can I do right now to make this meeting more productive?
When some outcome has not met my expectations, ask, “How did I contribute to that?” and “What more will I do next time to make it successful?”

20. A journey of a thousand miles begins with a single step.
Lau-Tuz, Chinese philosopher (604 BC BC)