University of Michigan Hospital

Inpatient Business Office

Analysis of Financial Clearance Workload at the Inpatient Business Office

Final Report

Prepared For:

Pamela A. Chapelle, Director of Business Services

Cherie Dumas, Manager of Business Services

Peter Li, Fellow, Program and Operations Analysis

Mark Van Oyen Ph. D., Associate Professor – Industrial and Operations Engineering 481

Prepared By:

Industrial and Operations 481 Group 9, Program and Operations Analysis

Chris Becker, Senior IOE Student

Jared Gruber, Senior IOE Student

Jordan Dank, Senior IOE Student

Sethapatch Pongpasuth, Senior IOE Student

April 22, 2010

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TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................ IV

Background ........................................................................................................................................... IV

Current Situation ................................................................................................................................... V

Methodology, Key Findings and Conclusions ..................................................................................... V

Recommendation ................................................................................................................................... VI

INTRODUCTION ........................................................................................................................ 1

Background ............................................................................................................................................. 1

CURRENT SITUATION ............................................................................................................. 2

Office Structure ....................................................................................................................................... 3

General Office Tasks .............................................................................................................................. 3

Specialty Staff Tasks ............................................................................................................................... 3

METHODOLOGY ....................................................................................................................... 4

Data Collection ........................................................................................................................................ 4

Data Analysis ........................................................................................................................................... 6

FINDINGS AND CONCLUSIONS ............................................................................................. 7

Flowchart of Current Financial Clearance System ............................................................................. 7

Historical Data of Number of Cases ...................................................................................................... 9

Distribution of Tasks Performed by the Business Office .................................................................... 9

Distribution of Tasks Performed by UH and Mott Departments ..................................................... 10

Average Time a Staff Member Spends Working on Each Task ....................................................... 11

Breakdown of Insurance Verification ................................................................................................. 12

Breakdown of Consent Form Completion .......................................................................................... 13

Classification of Office Tasks ............................................................................................................... 14

Calculated Time per Case .................................................................................................................... 14

Full Time Equivalent (FTE) Required to Remain On-Site ............................................................... 15

Data Validation ..................................................................................................................................... 16

ALTERNATIVES CONSIDERED ........................................................................................... 16

One Staff On-Site .................................................................................................................................. 17

Two Staff On-Site .................................................................................................................................. 17

Three Staff On-Site ............................................................................................................................... 17

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Zero Staff On-Site ................................................................................................................................. 18

RECOMMENDATION .............................................................................................................. 18

ACTION PLAN ........................................................................................................................... 18

APPENDIX ..................................................................................................................................... i

Appendix A: Pictorial Representation of Staff Breakdown ................................................................. i

Appendix B: Task List Reference .......................................................................................................... ii

Appendix C: Workload Analysis Data Collection Form for General Staff ...................................... iii

Appendix D: Workload Analysis Data Collection Form for Team Lead Staff ................................ iv

Appendix E: Workload Analysis Data Collection Form for IMN Staff ............................................. v

Appendix F: Workload Analysis Data Collection Form for Transplant Staff ................................. vi

Appendix G: Percentage of Time Spent on Tasks (Entire Office) .................................................... vii

Appendix H: Percentage of Time Spent on Tasks (UH / Mott Department) .................................. viii

Appendix I: Frequency Study Instruction Sheet ................................................................................ ix

Appendix J: Frequency Study Data Collection Form ......................................................................... x

Appendix K: Classification of Office Tasks ......................................................................................... xi

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LIST OF FIGURES

Figure 1: Flowchart of Financial Clearance Process Performed by the Business Office .......8 Figure 2: Distribution of Tasks Performed by the Business Office ........................................10 Figure 3: Distribution of Tasks Performed by UH and Mott Departments ...........................11 Figure 4: Breakdown of Insurance Verification Cases ...........................................................13 Figure 5: Breakdown of Consent Form Completion Cases .....................................................14

LIST OF TABLES Table 1: Historical Data of Number of Cases per Week ............................................................9 Table 2: Average Time per Week a Staff Member Spends Working on Each Task .............12 Table 3: Calculated Time Per Case for Type of Insurance Verification ................................15 Table 4: Full Time Equivalent (FTE) Required On-Site ........................................................15 Table 5: Weekly Hours of Patient Visits for a Given Amount of FTE On-Site .....................16 Table 6: Calculated and Observed Time per Case for Insurance Verification Tasks ..........16 Table 7: Expected Advantages and Disadvantages for On-site and Off-site Staff ................19

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EXECUTIVE SUMMARY The Inpatient Business Office of University Of Michigan Health Services (UMHS) handles insurance verification for inpatients at the University Hospital (UH) and Mott Children’s and Women’s Hospital (Mott). Tentatively by 2011, a hospital-wide project called the Patient Access Financial Clearance (PAFC) will be implemented to consolidate financial clearance departments under the banner of Patient Business Services (PBS).

In preparation for the PAFC initiative, the manager of the Inpatient Business Office asked a team of Industrial Engineering students from the University of Michigan to perform a workload analysis of business office tasks and to recommend ways to reallocate its staff between two locations: the current inpatient business office and the off-site KMS building.

Background Financial clearance involves the hospital’s ability to receive payment for patients’ medical needs. Patients admitted to the hospital must be cleared for procedures and practices performed by hospital staff. Financial consultants in the Inpatient Business Office perform this task for inpatients at the hospital. Two major changes looming for the Inpatient Business Office include: the PAFC initiative and the implementation of RevRunner software. Both are driving the project scope and goals.

Patient Access Financial Clearance (PAFC) Initiative The PAFC will consolidate financial clearance operations across the hospital under the name of Patient Business Services (PBS). Goals of the PAFC include:

• Standardization of financial clearance tasks

• Immediate identification of patient’s insurance policies upon admission

• Reduction of financial clearance redundancy for intra-hospital transfer patients

• Increase in cash collections The main office for the PBS will be located in the KMS building on State Street, south of University of Michigan central campus.

RevRunner Software Implementation RevRunner software will consolidate numerous insurance provider websites into one master system that business office staff may consult for each case. Also, it will provide a better platform for adding notes that will limit redundancy that currently occurs. The team expects that the result of implementing RevRunner will make business office tasks more efficient.

Project Scope

In scope:

• Financial clearance tasks for UH and Mott o Begins when patient is scheduled for admission o Ends when insurance is verified and case is closed in Mainframe

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• Referrals to IMN or other charity support programs • Referrals for heart and bone marrow transplants • Referrals for Children’s Special Healthcare Services (CSHCS)

Out of scope:

• Insurance verification for patients other than inpatients handled by other departments in the hospital

• Direct billing of patients or insurance providers • Tasks associated with actual care of patients • IMN or other charity support program tasks

Goals and Objectives

Two primary goals are driving the need for this project:

• Understand and analyze the staffs workload • Determine appropriate staffing allocations to satisfy current throughput while minimizing

on-site staff

Current Situation Currently, the Inpatient Business Office is divided into two departments that complete financial clearance for different sections of UH: main UH and Mott. Both departments perform similar financial clearance duties on inpatients of each hospital section.

Office Structure The business office contains general and specialty staff, subdivided into two main departments: the UH department and the Mott Women and Children’s (Mott) department:

General Office Tasks The staff performs financial clearance by two main steps: insurance verification and consent form completion.

Methodology, Key Findings and Conclusions The team conducted four phases of data collection: interviews and observations, a workload analysis, a frequency study, and data validation.

Interviews and Observations The team conducted interviews and observations on all staff members in the UH and Mott departments for three weeks. From the interviews and observations, the team created a process flowchart of office duties and task lists used for the workload and frequency studies. The team concluded that only patient visits require staff to remain on-site in the UH office.

Workload Analysis The team conducted a workload analysis in the form of a random beeper study on 18 members of the business office. Each staff member participated in the study for two weeks and generated a

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total of 4,502 data points. The team collected data and entered it into excel formatted for pivot table analysis to record relevant statistics.

From the generated task distributions, the staff spends 51% of its time on three laborious tasks: working in MCCM, working in the Mainframe, and adding notes and closing accounts. Although patient visits were only 3.7% of the total workload, the team observed that every staff member encounters cases that require patient visits.

Frequency Study The team conducted a frequency study based on the process flowchart and generated percentages for each type of insurance verification. Eighteen staff members participated in the study for one week. The study generated a total of 2,355 data points.

Regarding insurance verification, 79% of insurance cases are verified online and 21% of cases require a phone call or cannot be verified. Regarding consent forms, 79% of consent forms were validated online, and 21% of cases required patient visits.

Data Validation Following the two quantitative studies, the team observed select staff members and directly timed financial clearance tasks. The team compared data collected from validation to the time per task metric calculated from combining the workload analysis and frequency study. The team found no significant difference between the times.

Recommendation The team concluded that 0.75 full time equivalent (FTE) are required on-site to maintain patient visit. Although 0.75 FTE is the total workload needed for patient visits and could be satisfied by one staff, the team recommends that two staff remain on-site to perform patient visit duties.

Two staff on-site will provide security against absences. Additionally, four other specialty staff members will be on-site to complete patient visits should the case arise that both general on-site staff are absent.

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INTRODUCTION The Inpatient Business Office of the University Of Michigan Health Services (UMHS) currently performs financial clearance tasks for inpatient admissions of the University Hospital (UH) and the Mott Children’s and Women’s Hospital (Mott). Financial clearance is completed by two main tasks: insurance verification and consent form completion. Tentatively by 2011, a hospital-wide project called Patient Access Financial Clearance (PAFC) will be implemented to consolidate financial clearance tasks under the title of Patient Business Services (PBS).

In conjunction with the PAFC project, the manager of the Inpatient Business Office requested a workload analysis of daily tasks and a recommendation for restructuring staff between on-site and off-site hospital locations. A team of Industrial Engineers from the University of Michigan has collected data by workload analysis and a frequency study of office tasks. The team then analyzed data obtained from these studies to determine office workload distribution and to develop staffing recommendations. Project goals, scope, data collection, analysis methods, findings, conclusions and recommendations are detailed in this report.

Background Financial clearance involves the hospital’s ability to receive payment for patient’s medical needs. Patients admitted to the hospital must be cleared for procedures and practices performed by hospital staff. Financial consultants determine the hospital’s ability to receive payment for necessary procedures.

The Inpatient Business Office, currently located on-site on the University Hospital campus, performs financial clearance for inpatients (Persons admitted to a hospital treatment that requires at least an overnight stay or observation) admitted to UH or Mott. The PAFC institutional initiative will create a headquarters for all hospital financial clearance departments, including the Inpatient Business Office, located at the KMS building on State Street, south of University of Michigan central campus. The Inpatient Business Office is divided into two departments: one on floor six of the Med-Inn Building, and the other on the main floor of the Mott Woman’s and Children’s Hospital (Mott). The majority of staff in both departments will be relocated to the PBS headquarters in the KMS building. The team will recommend the optimal staffing allocation for the Inpatient Business Office.

Patient Access Financial Clearance (PAFC) Project The PAFC will consolidate financial clearance operations across the hospital under the name of PBS. Goals of the PAFC include:

• Standardization of financial clearance tasks • Immediate identification of patient’s insurance policies upon admission • Reduction of financial clearance redundancy for intra-hospital transfer patients • Increase in cash collections

The PAFC project is expected to alter the workload of the business office. Thus, an analysis on the work distribution and capability of the current staff is required.

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RevRunner Software Both departments of the Inpatient Business Office perform financial clearance tasks using a combination of hospital and insurance software, phone calls and patient visits. Currently, separate websites exist for each insurance provider. Also, notes for all financial clearance cases must be recorded redundantly in numerous hospital systems. RevRunner software will consolidate numerous insurance provider websites into one master system that business office staff may consult for each case. Also, it will provide a better platform for adding notes that will limit redundancy that currently occurs. The team expects that the result of implementing RevRunner will make business office tasks more efficient.

Project Scope

In scope:

• Financial clearance tasks for inpatient admits to UH and Mott o Begins when patient is scheduled for admission o Ends when insurance is verified and case is closed in Mainframe

• Referrals to Independent Medical Network (IMN) or other charity support program • Referrals for heart and bone marrow transplant • Referrals for Children’s Special Healthcare Services (CSHCS)

Out of scope:

• Insurance verification for patients other than inpatients handled by other departments in the hospital

• Direct billing of patients or insurance providers • Tasks associated with actual care of patients • IMN or other charity support program tasks

Goals and Objectives Two primary goals are driving the need for this project:

• Understanding and analyzing staff workload • Recommending appropriate staffing allocations to satisfy current throughput while

minimizing on-site staff

CURRENT SITUATION Based on the team’s initial interviews and observations, the Business Office is divided into two departments to complete all financial clearance for inpatients at UH. To complete financial clearance and close a patient’s case, staff must perform both insurance verification and consent form completion.

Outside of general office tasks, five specialty staff handles cases that are not part of regular financial clearance tasks. In UH some cases require Medicaid or other charity insurance approval. In Mott, some patients require special health services. Although, staff of the Inpatient

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Business Office is not directly responsible for approval of the various special cases, they play an integral role in applying for such services.

Office Structure The Inpatient Business Office consists of 19 employees, under management of 1 office manager. These 19 employees are divided into 2 departments: UH and Mott. The UH department handles admissions from the main hospital, and the Mott department handles admissions from Mott Children’s and Women’s Hospital (Mott).

The UH department consists of 12 staff, and the Mott department consists of 7 staff. Staff members from both departments perform general office tasks, except for a small number of specialty staff in each department who have slightly different job descriptions. Complete job descriptions for general and specialty staff are presented in the Current Situation section of this report. A pictorial representation of the staff breakdown is presented in Appendix A.

General Office Tasks Eighteen of the nineteen staff performs the general office tasks that were observed and participated in studies for this project. General tasks consist of insurance verification and consent form completion. Specialty staff also perform additional tasks. A complete task list can be found in Appendix B.

Insurance Verification Insurance verification can be achieved either on-line through insurance provider websites or by phone call to insurance payer companies. Cases that cannot be verified by these methods require phone calls directly to patients or their families. If a patient’s insurance cannot be verified by any of these means, cases are referred to IMN for Medicaid approval. One specialty staff is responsible for completing IMN referrals. After IMN has reviewed a patient’s Medicaid eligibility, the case is returned to the Inpatient Business Office for completion of insurance verification and consent form completion.

If a patient reviewed by IMN is ineligible for Medicaid, then the same IMN support staff, in the UH department, refers patients for “M-Support,” which is a Michigan charity program. M-Support provides financial assistance for patients in special need.

Consent Form Completion For a case to be completed and closed in the hospital’s system, all consent forms must be completed. Consent forms consist of HIPAA forms and other patient information documents. Patients often sign consent forms upon admission to the hospital. For cases where forms are initially completed upon admission, consent form information is present in the hospital’s system. Notes about each case are added to the necessary input mechanisms by the staff and cases are closed. For cases where forms are not initially completed, staff must make patient visits to complete relevant information. Patients may sign the forms, refuse to sign the forms, or are unable to sign the forms because of medical condition.

Specialty Staff Tasks Five staff members are defined as specialty staff: one IMN/ M-Support staff member works in the UH department and two transplant staff members, one Children’s Special health Care

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Services (CSHCS) staff member, and one transfer patient staff who all work in the Mott department.

Independent Medical Network (IMN) / M-Support Staff IMN/ M-Support staff performs all general staff duties. In addition, this staff handles referrals to IMN and M-Support.

Transplant Staff Transplant staff performs all general staff duties. In addition, these staff handle referrals and donor list operations for two types of transplant cases: heart and bone marrow transplants. Duties involve handling applications and donor lists.

Children’s Special Health Care Services (CSHCS) Staff Children’s special health care services staff do not perform general staff duties. This staff member did not perform the workload analysis or the frequency study. CSHCS duties include financial consulting for state sponsored children’s health care coverage programs specific to chronic conditions.

Transfer Specialist Staff Transfer specialist staff performs all general staff duties. In addition, this staff handles cases that are transferred from other hospitals. These cases require that insurance is re-verified even when patients’ insurances are presented upon their admission to UH.

METHODOLOGY A work measurement study on the Inpatient Business Office at the University Hospital was accomplished in two steps: data collection and data analysis.

Data Collection The data collection phase was conducted in five parts: a literature search, interviews and observations, workload analysis, frequency study, data validation, and historical data.

Literature Search All team members conducted a literature search for one week to identify and study relevant data collection and analysis methods, procedural obligations and historical information.

Data Collection and Analysis Methods

• Flowcharting • Work measurement studied • Frequency studies • Excel pivot table functions • Capacity analyses

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Procedural obligations

• M-Learning modules • HIPAA regulations

Historical information

• University Hospital (UH) Operating Room (OR) staffing data

Interviews and observations The team interviewed and observed on all 19 staff of the Inpatient Business Office for 12 hours per team member over a three week period from January 25 to February 12, 2010.

Historical Data The team collected historical office data provided by the office manager on an as needed basis. Data was collected in two types:

Weekly Data

The first set of historical data contains weekly productivity for the business office during the weeks that the team conducted the workload analysis and frequency study. Weekly historical data was collected for the week of 15 February, 2010 to the week of 22 March, 2010.

Long-term Average The second set of historical data contains the monthly productivity for the business office. Monthly historical data was collected from January, February, and March 2010.

Workload Analysis The team conducted a workload analysis, also known as a random observation time-beeper study, on both departments of the business office. The team educated the office staff about random beeper study theory and procedures on February 9, 2010. All business office staff (Except for CSHCS staff) conducted the random beeper study from February 15 to March 24, 2010. The study was completed in two phases with each participating staff collecting data for two business weeks. The eighteen staff were equally divided for each phase over the four week period of data collection. The study yielded 4,502 data points for the entire office.

Frequency Study The team conducted a frequency study on both departments of the business office. All business office staff (Except for CSHCS staff) conducted the frequency study from March 17 to March 31, 2010. The study was completed in two phases with each participating staff collecting data for one business week. The eighteen staff were equally divided for each phase over the two week period of data collection. The study yielded a total of 2.354 data points for the entire office.

Appendix for frequency study

Data Validation The team conducted time studies on selected staff for one day per team member between March 30 and April 2, 2010. The team recorded a sample size of 13 cases.

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Data Analysis The team performed data analysis on all methods of data collection to develop key findings and conclusions.

Interviews and Observations From interviews and observations, the team created a list of the most commonly performed tasks for general staff, which is presented in Appendix X of this report. The business office manager and team coordinator both reviewed and verified these tasks. The team developed a flowchart of office tasks that details the workflow for financial clearance. The flowchart is presented in Figure 1 of this report.

Historical Data From historical data provided by the business office manager, the team calculated average weekly and monthly throughput for financial clearance cases.

Weekly Data The team used weekly data to calculate time per case for each type of insurance verification used in the ‘Data Validation’ and ‘Calculated Time per Case’ subsections of Findings and Conclusions.

Monthly Data The team converted monthly data to weekly case throughput for the business office by assuming there are four weeks per month and five working days per week. The team calculated long-term average weekly throughput and used this number to calculate required full time equivalent (FTE) necessary to complete all patient visits.

Workload Analysis The team used task lists created from interviews and observations to collect data for the workload analysis. Task list and data collection forms are presented in Appendices B through F. The team entered the data collected into excel, formatted for pivot table analysis. Relevant pivot tables were created to draw findings and conclusions. Tables, charts, and graphs displaying task distribution are displayed in the Findings and Conclusions section and Appendices G and H of this report.

Frequency Study Staff were required to record the number of times each individual task was performed on a given day. Based on the collected data, the team determined distribution of type of insurance verification and consent form completion. Specifically, the percentage of cases verified online, verified by phone or not verified, and percentages of online and patient visit consent form completion were calculated. An instructional sheet and data collection form for the frequency study are presented in Appendices I and J of this report.

The team entered the data collected into excel, formatted for pivot table analysis. Relevant pivot tables were created to draw findings and conclusions. Tables and charts displaying type of insurance verification and consent form completion distribution are displayed in the Findings and Conclusions section of this report.

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Data Validation Tasks were timed, recorded and compared to time per case presented in the Findings and Conclusions section of this report. The team used the workload analysis and frequency study to calculate the time per case for each type of insurance verification. From observations, the team concluded that insurance verification for every case requires three tasks (from the workload analysis): ‘Working in the Mainframe / Insurance Websites’, ‘Working in MCCM’, and ‘Adding Notes and Closing Cases’. Cases verified online consist of only the aforementioned three tasks. Cases verified by phone include the task ‘On the Phone with Insurance Companies’ in addition to the base three tasks. Cases that are ‘Not Verified / No Insurance’ cases include the tasks ‘Contacting Patient for Insurance’ and ‘Working with IMN/ M-Support’ in addition to the base three tasks.

From data collected by the time studies, the team calculated the observed average time per case for each type of insurance verification. The team then compared the observed values to the expected time per case calculated from the workload analysis and frequency study data.

FINDINGS AND CONCLUSIONS After collecting and analyzing data as described in the methodology section, the team identified the findings and conclusions on the following: flow of tasks in current financial clearance process performed by the business office, distribution of tasks performed, average time spent working on each task, breakdown of insurance verification and consent form cases, and number of FTE required to remain on-site.

All 18 staff participated in the workload analysis and frequency studies. After reviewing the data collected, the team determined that the method used by one staff member to fill out the forms was significantly different from the rest of the staff. Therefore, this staff member’s data has been omitted from the findings and conclusions.

Flowchart of Current Financial Clearance System After observing the Inpatient Business Office and its processes, the team created a flow chart of the current financial clearance process performed by the business office. The flowchart is shown in Figure 1.

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(Based on observations between January 25, 2010 and February 12, 2010)

Figure 1: Flowchart of Financial Clearance Process Performed by the Business Office

Note: Percentages shown in the flow chart were determined from the frequency study. The flow chart shows the flow of patient cases that need to be reviewed by the Inpatient Business Office. After a patient is admitted into the hospital or observed by a doctor, the patient’s financial case is transferred to the Inpatient Business Office. The cases are first received by either one of the two team leads, and the team leads divide the work list for each of their staff. The staff receives cases on their work list and selects a case to review. First, the staff reviews the patient’s insurance status in the Mainframe system. If insurance can be verified online, the staff moves on to next step to review consent form. If insurance cannot be verified online and the patient has commercial insurance, the staff calls the insurance provider to verify insurance. If insurance cannot be verified online and the patient does not have insurance, the staff submits the case to IMN for review. If IMN accepts, the staff moves on to next step; otherwise, patients apply for M-Support with the assistance of IMN/ M-Support specialty staff. After moving

Patient Admit/

Observation

Leads Divide Work List (8 am, 11 am, 3 pm)

Review Insurance Status in Mainframe

Insurance Verified Online

Verify Consent Form & Patient Info

(All Staff)

Add System Notes and Close Case

Form Completed

Call Patient About Medicaid

Apply/Submit to IMN for Review (1 Specialty Staff)

Accepted

Apply for M-Support (1 Specialty Staff)

NotAccpeted

Visit Patient to Complete Forms

Form NotCompleted

Call Patient Insurance Provider

Insurance Not Verified Online /No Insurane

Insurance Not Verified Onine /Commercial Insurance

Review Work List & Select Case (All Staff)

79.2%

16.6%4.2%

79.1%20.9%

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through one of the three branches described, staff verifies the consent form and patient information. If the consent form is complete, the staff adds system notes and closes the case. Otherwise, the staff visits the patient to complete the consent form prior to closing the case. The staff then reviews his/her work list, selects a new case to review, and repeats this process.

Historical Data of Number of Cases The team collected two sets historical data from the business office manager, which contains the number of cases the business office worked on during a specified period of time. These sets include weekly throughput of cases from two sources: weekly and long-term average data. Table 1 shows the comparison of the two sets of historical data the team compiled.

Table 1: Historical Data of Number of Cases per Week

Cases Per Week Value During data collection period 1202 Long-term average 1160

Table 1 shows that the number of cases during the week of data collection period is slightly higher than the long-term average number of cases. Therefore, the calculation for FTE necessary to maintain patient visit throughput is adjusted for long-term average.

Distribution of Tasks Performed by the Business Office From workload analysis, the team determined the average percentage of time required to perform each of the tasks for the business office. Figure 2 shows the distribution of tasks sorted according to percentage of time required; the bars show the percentage of time required to perform tasks and the line shows the cumulative percentage of time spent on tasks starting from the left hand side.

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(Based on a sample of 4,502 data points from workload analysis performed between February 15 and March 24, 2010)

Figure 2: Distribution of Tasks Performed by the Business Office

Note: For table with corresponding values, refer to Appendix G Figure 2 shows that the percentage of time spent ‘Working in Mainframe / Insurance Websites’, ‘Working in MCCM’, and ‘Adding Notes and Closing Accounts’ were the three highest at 22.1%, 18.1%, and 10.4%, respectively. Together, these three tasks constitute 50.6% of a staff’s working time. In addition to these three tasks, the staff spend 8.1% of their work time ‘On the Phone with Insurance Companies’, 7.4% ‘Reviewing Problem Accounts’, and 7.2% ‘Checking E-mail and Voicemail’. These six tasks together require up to 73.2% of working time.

Distribution of Tasks Performed by UH and Mott Departments From the workload analysis, the team compared the distribution of tasks performed by the UH department to the Mott department. The comparison of the distributions is shown in Figure 3.

0%10%20%30%40%50%60%70%80%90%100%

0%

5%

10%

15%

20%

25%

Cum

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(Based on a sample of 4,502 data points from workload analysis performed between February 15 and March 24, 2010)

Figure 3: Distribution of Tasks Performed by UH and Mott Departments

Note: Table with corresponding values in Appendix H

As shown in Figure 3, the distributions of tasks performed by the UH and Mott departments are similar, with only slight differences. In the UH office, staff spent most of the time working in Mainframe or insurance websites, followed by working in MCCM; whereas in the Mott office, staff spent most of the time working in MCCM, followed by working in Mainframe or insurance websites. The rest of the tasks have identical distributions, and only minor differences in rank of percentage of time spent. The team concluded that no significant differences exist between the percentages of time spent on tasks between the two offices.

Average Time a Staff Member Spends Working on Each Task Based on the percentages of time required to perform each task used in Figure 2, the team was able to determine the average time per week a staff member spends working on each task. The team assumed that a staff member works 8 hours per day, 5 days per week. The values are shown in Table 2.

0%

5%

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25%

30%

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Mott

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Table 2: Average Time per Week a Staff Member Spends Working on Each Task

Task Time/Week/Staff Member (Hrs)

Time/Week/Staff Member (Mins)

Working in Mainframe/Insurance Websites 8.82 529.4 Working in MCCM 7.23 433.9 Adding Notes and Closing Accounts 4.18 250.6 On Phone with Insurance Companies 3.24 194.6 Reviewing Problem Accounts 2.95 177.0 Checking E-Mail & Voicemail 2.86 171.7 Lunch/Break 1.88 113.0 Attending Meetings/Administrative Duties 1.68 100.8 Patients Visits: Consent Form Verification 1.32 79.4 Contacting Patient for Insurance 1.31 78.4 Work Related to Transplant Patients 1.19 71.4 Miscellaneous 1.18 70.9 Team Lead Duties 0.93 56.0 Viewing Patient Medical Records/Care Web 0.34 20.3 Printing Face Sheets 0.22 13.3 Utilization Management 0.20 12.3 Patients Visits: Insurance Issues 0.16 9.6 Working with IMN / M-Support 0.13 8.0 Reviewing Unbilled Account Reports 0.12 6.9 Cash Collections 0.04 2.7

As Table 2 shows, on the upper end, each week a staff member spends 8.82 hours working in Mainframe or insurance websites, 7.23 hours working in MCCM, and 4.18 hours adding notes and closing accounts. On the lower end, each week a staff member spends 8.0 minutes working with IMN or M-Support, 6.9 minutes reviewing unbilled account reports, and only 2.7 minutes on cash collections.

Breakdown of Insurance Verification From the frequency study, the team determined the breakdown of insurance verification cases according to the following categories: already verified by utilization management, verified online payer, verified on the phone, and not verified and no insurance. The breakdown is shown in Figure 4.

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(Based on a sample of 1,375 data points from frequency study performed between March 17and March 31, 2010)

Figure 4: Breakdown of Insurance Verification Cases

Figure 4 shows that 50% of insurance cases were verified online. In addition, 29% of cases were already verified and can also be checked online. Only 21% of insurance cases must be verified by other means.

Breakdown of Consent Form Completion From the frequency study, the team determined the breakdown of consent form verification cases. Consent forms could either be completed online, which does not require patient visits, or not completed online and a patient visit is required. If a patient visit is required, the patient could either sign, decline to sign, or is unable to sign. The breakdown of consent form verification cases is shown in Figure 5.

Already Verified by Utl Mgmt.

29.24%

Not Verified / No Insurance

4.22%

Verified on the Phone 16.58%

Verified Online Payer

49.96%

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(Based on a sample of 979 data points from frequency study performed between March 17 and March 31, 2010)

Figure 5: Breakdown of Consent Form Completion Cases

Figure 5 shows that 79.06% of consent forms were already signed, and therefore completed online. The other 20.94% of consent forms were not completed online and therefore patient visits are required. Out of the all the patient visits, approximately half were successful in getting the patient sign. For the remaining visits, most patients were unable to sign, and only a few declined to sign.

Classification of Office Tasks The team divided the tasks from the workload analysis into two categories: tasks performed for every financial clearance case and tasks not performed for every case. Tasks performed for every financial clearance case include those tasks that are presented on the flowchart. Tasks not performed for every financial clearance case include tasks that arise rarely and tasks that are performed ad hoc. Specific task classification is presented in Appendix K. Tasks performed for every financial clearance case consists of 68% of office workload. Tasks not performed for every financial clearance case consists of 32% of office workload. Furthermore, of the 32% of tasks not performed for every financial clearance case, 50% is related to tasks that are performed ad hoc. Ad hoc tasks (16.06% of total office workload) were included to calculate total FTE required on-site to maintain patient visit throughput.

Calculated Time per Case The three types of insurance verification include: insurance verification online, insurance verification by phone and not verified or no insurance cases. The team calculated the time per case for each type of insurance verification, presented in Table 4, from a combination of the workload analysis, frequency study and weekly historical data.

Patient Unable to Sign45.66%

Patient Signs53.18%

Patient Declines1.16%

Completed / Checked Online

79.06%

Not Completed / Patient

Visits20.94%

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Table 3: Calculated Time per Case for Type of Insurance Verification

Task Calculated Time/Case (Minutes) Insurance Verification Online 1.275 Insurance Verification By Phone 7.059 Not Verified / No Insurance 25.76 Consent Form Verification Online -- Patient Visits 6.36

The data analysis section details how these values were calculated and that most of the tasks are clerical in nature. The team expects that the implementation of RevRunner software should reduce the average time per case for all types of insurance verification.

Full Time Equivalent (FTE) Required to Remain On-Site From the workload analysis and frequency study, the team determined the FTE required on-site maintaining the office throughput of patient visits. The team calculated the FTE required on-site as outlined in Table 4.

Table 4: Full Time Equivalent (FTE) Required On-Site ID Statistic Value Method A Patient visits time/week/staff

member (hours) 1.484 = From Table 2

B Patient visits time/week for all staff during data collection period (hours)

26.71 = A × 18 staff

C Patient visits time/case (hours) 0.106 = B / 251 patient visits per week during data collection period

D Patient visits time/week for all staff long-term

25.77 = C × 242 patient visits per week long-term

E FTE Required 0.644 = D / 40 hours per week

F FTE Required (Adjusted) 0.748 Value in E adjusted for unavoidable tasks (eating lunch, attending meetings, and checking e-mail) = E + (E x 16.06%)

Table 4 shows that only 0.748 FTE is required to remain on-site. However, if only 0.748 FTE remain on-site to complete patient visits, unforeseen circumstances (e.g. sickness) to the on-site staff will result in an expected accumulation of patient visits. The team developed a strategy to control the weekly time required for patient visits per on-site staff member presented in Table 5.

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Table 5: Weekly Hours of Patient Visits for a Given Amount of FTE On-Site

Full Time Equivalent

(FTE)

Percent of Time Required for Patient Visits

Weekly Time Required for Patient Visits

(Hours) 1 74.8% 30 2 37.4% 15 3 24.9% 10 4 18.7% 7.5

Table 5 shows, for a given number of FTE, the percentage and expected amount of time per week spent on patient visits.

Data Validation To validate the data, the team determined the average time per case a staff member spends performing insurance verification. From the workload analysis and frequency study, the team calculated expected time per case for each type of insurance, shown in Table 3. To validate the values in Table 3, the team calculated the observed time per case for each type of insurance verification, shown in Table 6.

Table 6: Calculated and Observed Time per Case for Insurance Verification Tasks

Task Time per Case (min) Calculated Observed

Insurance Verification Online 1.275 1.962 Based on the values from Table 6, the team determined that the calculated time per case for insurance verification online, which consists of 79.2% of all financial clearance cases, is not significantly different than the observed time per case for insurance verification online.

The team could not validate calculated values for ‘Verified by phone’ or ‘Not Verified / No Insurance’ cases. From interviews and observations, the team learned that the variability for these cases is large, resulting in a difficult to measure average time per case. Also, from interviews and observations the team learned that these cases, which only consist of 20.8% of all insurance verifications, take significantly longer than insurance verification online. Thus, the team concluded that the calculated time per case for these scenarios is reasonable.

ALTERNATIVES CONSIDERED Based on the findings and conclusions, the team considered varying the number of staff on-site to complete the weekly throughput of patient visits. Based on the frequency study and historical weekly data, the team calculated that the throughput is 252 patient visits per week.

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The team derived staffing alternatives from Table 4 presented in the Findings and Conclusions section of this report. Table 5 details the expected percentage and time per week required to complete patient visit tasks for varying number of FTE. Furthermore, Table 5 and the alternatives considered do not include the four specialty staff (Two transplant, one transfer, and one CSHCS staff) who are to remain on-site as requested by the business office manager.

All alternatives considered regarding staffing refer to full time equivalent (Staff working 40 hours). The workload could be accomplished by other means, such as multiple part-time employees as long as a total of 40 hours per week is considered by business office management.

One Staff On-Site One staff would remain on-site and perform all patient visits in addition to other general tasks. According to Table 4 above, the one staff should allocate approximately 75% of time working (about 30 hours per week) to complete patient visits. Additionally, 25% of workload will be allocated to general financial clearance tasks. Based on the long-term weekly average, the team expects that approximately 16 (= 1 staff × 1160 cases/week ÷ 18 staff × 0.25) cases per week should be allocated to this staff member.

However, when the staff is absent from work, the business office would need to find other means of completing patient visits during the time of absence. Therefore, keeping only one general staff member on-site will create potential problems if that staff member is absent.

Two Staff On-Site Two staff would remain on-site and perform all patient visits in addition to other general tasks. According to Table 4 above, the two staff should each allocate approximately 37% of time working (about 15 hours per week) to complete patient visits. Additionally, 63% of workload will be allocated to general financial clearance tasks. Based on the long-term weekly average, the team expects that approximately 81 (=2 staff × 1160 cases/week ÷ 18 staff × 0.63) cases per week should be allocated to these staff members.

With two staff on-site, the probability of all staff being absent on the same day is lowered. For the event that one staff is absent, the other staff can complete all patient visits. For the rare event that both staff are absent, the four specialty staff can potentially complete patient visits.

Three Staff On-Site Three staff would remain on-site and perform all patient visits in addition to other general tasks. According to Table 4 above, the three staff should each allocate approximately 25% of time working (about 10 hours per week) to complete patient visits. Additionally, 75% of workload will be allocated to general financial clearance tasks. Based on the long-term weekly average, the team expects that approximately 145 (=3 staff × 1160 cases/week ÷ 18 staff × 0.75) cases per week should be allocated to these staff members.

With three staff on-site, the probability of all staff being absent on the same day is extremely low. For the event that one staff is absent, the other two staff can comfortably complete all patient visits. However, three staff remaining on-site contradicts the office manager’s request to minimize on-site staff.

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Zero Staff On-Site No staff would remain on-site to complete patient visits. Patient visits would be outsourced to another hospital department, such as admissions or emergency department. As a result, the entire business office could be relocated at the off-site location, with the exception of the four staff the business manager requested to stay on-site. With this alternative, the entire staff would have a total of 25.8 more hours per week to perform other tasks.

From interviews, the team found that historically, on weeks that demand to the business office has increased, outsourcing has been used as a means for completing patient visits. However, this alternative may not be feasible. Other departments in the hospital may not be able to add to their workload, and the business office must therefore keep performing patient visits.

RECOMMENDATION The team recommends that two staff, in addition to four specialty staff, remain on-site to complete patient visits. The team’s recommendation is based on the project goal to minimize on-site staff to complete patient visits. With only one staff, absences would cause a bottleneck of patient visits. Two staff minimizes business office staff on-site and provides security against bottlenecks.

Table 4 shows 30 hours of work per week are required to complete all patient visits. The two general staff remaining on-site will perform all the patient visits and will perform other general tasks. The team estimates the staff will evenly split patient visits and each spend approximately 15 hours per week completing patient visit tasks in addition to performing financial clearance. From the calculation described in the Alternatives Considered section, these staff should be given approximately 81 financial clearance cases per week outside of their patient visit duties.

With six total staff remaining on-site, no issues will exist regarding absences. Additionally, a general staff moved off-site may fill in for an on-site staff if that on-site staff member happens to be absent for a period of time.

The staff moved off-site will continue to perform financial clearance, but will not perform any patient visits. The off-site staff will transfer cases requiring patient visits to on-site staff. The mechanism for transferring financial clearance cases already exists, and transfers are completed internally within the business office systems. Off-site staff who encounter cases requiring patient visits will transfer these cases to on-site staff’s work list via MCCM. The on-site staff will then perform the patient visit and transfer the case back to its originally assigned off-site staff’s work list. Off-site staff will record notes and close the case.

ACTION PLAN The business office should take the following steps to implement the recommendation:

• Decide or inform staff about on-site and off-site locations and advantages/disadvantages of each:

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Table 7: Expected Advantages and Disadvantages for On-site and Off-site Staff

Advantages Disadvantages

On-site staff - No relocation - No adjustment to new office

- Redistribution of workload to include more time for patient visits

Off-site staff - No annual parking fees - More time available to perform financial clearance tasks other than patient visits

-Adjustment to new office space

• Allocate off-site KMS building space and supplies for business office staff • Allocate on-site UH space for staff remaining at UH • Re-distribute workload between on-site and off-site offices • Re-run workload analysis after off-site relocation and RevRunner software

implementation to quantify changes made

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APPENDIX

Appendix A: Pictorial Representation of Staff Breakdown

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Appendix B: Task List Reference

General Staff Tasks • Team Lead Duties: Team leads divide work lists to office staff • Working in MCCM: Any time staff is reviewing MCCM work list and choosing a case to

review • Working in Mainframe/Insurance Websites: Any time staff is on software such as Web Denis,

CHAMPS, or other online verification server to check if a patient’s insurance is active and applicable to a given case. This also includes working in Health Quest

• On Phone with Insurance Companies: If the staff must make a phone call to an insurance company. Either a commercial insurance provider or an insurance verification provider that has not been verifiable online

• Contacting patient for insurance: Directly contacting patient via phone call or mail for insurance or relevant information

• Checking E-Mail & Voicemail: Checking or sending e-mail, personal or business related • Adding Notes and Closing Accounts: Typing case notes into Health Quest or MCCM and

closing out accounts. This includes accounts that are being suspended but are not specifically being closed

• Reviewing Problem Accounts: This is reviewing accounts that have been suspended or have been unable to verify insurance

• Attending Meetings/Administrative Duties: Present at a meeting or other administrative functions

• Cash Collections: Any actions regarding collection of payment from a patient • Patient Visits

o Consent form verification: Patient visit regarding consent forms o Insurance Issues: Patient visit regarding insurance options for patients who have no

insurance or whose insurance has become inactive • Lunch/Break: Any break, includes getting coffee • Viewing Patient Medical Records/Care Web • Reviewing Unbilled Account Reports • Utilization Management • Printing Face sheets • Miscellaneous: Any action that has not been covered by this list. Please provide some description

in the space provided Specialty Staff Tasks

• Working Related to IMN/ M-Support • Work Related to Transplant Patients • Work Related to Children’s Special Health Care Services (CSHCS) • Work Related to Transfer Patients

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Appendix C: Workload Analysis Data Collection Form for General Staff

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Appendix D: Workload Analysis Data Collection Form for Team Lead Staff

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Appendix E: Workload Analysis Data Collection Form for IMN Staff

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Appendix F: Workload Analysis Data Collection Form for Transplant Staff

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Appendix G: Percentage of Time Spent on Tasks (Entire Office)

Task Percent of Time

Working in Mainframe/Insurance Websites 22.06% Working in MCCM 18.08% Adding Notes and Closing Accounts 10.44% On Phone with Insurance Companies 8.11% Reviewing Problem Accounts 7.37% Checking E-Mail & Voicemail 7.15% Lunch/Break 4.71% Attending Meetings/Administrative Duties 4.20% Patients Visits: Consent Form Verification 3.31% Contacting Patient for Insurance 3.27% Work Related to Transplant Patients 2.98% Miscellaneous 2.95% Team Lead Duties 2.33% Viewing Patient Medical Records/Care Web 0.84% Printing Face Sheets 0.56% Utilization Management 0.51% Patients Visits: Insurance Issues 0.40% Working with IMN/ M-Support 0.33% Reviewing Unbilled Account Reports 0.29% Cash Collections 0.11%

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Appendix H: Percentage of Time Spent on Tasks (UH / Mott Department)

Task Percent of Time (UH)

Percent of Time (Mott)

Working in Mainframe/Insurance Websites 27.42% 14.25% Working in MCCM 13.33% 25.00% Adding Notes and Closing Accounts 11.65% 8.68% On Phone with Insurance Companies 11.31% 3.44% Reviewing Problem Accounts 6.33% 8.90% Checking E-Mail & Voicemail 6.03% 8.79% Lunch/Break 4.68% 4.75% Attending Meetings/Administrative Duties 3.26% 5.57% Patients Visits: Consent Form Verification 5.02% 0.82% Contacting Patient for Insurance 4.68% 1.20% Work Related to Transplant Patients 0.00% 7.31% Miscellaneous 2.10% 4.20% Team Lead Duties 1.69% 3.28% Viewing Patient Medical Records/Care Web 0.37% 1.53% Printing Face Sheets 0.04% 1.31% Utilization Management 0.79% 0.11% Patients Visits: Insurance Issues 0.56% 0.16% Working with IMN/ M-Support 0.56% 0.00% Reviewing Unbilled Account Reports 0.00% 0.71% Cash Collections 0.19% 0.00%

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Appendix I: Frequency Study Instruction Sheet

Insurance Verification: This is a group heading and should not have tick marks in it. For each case worked, please mark the final step taken to verify insurance in one of the four options: already verified by Utilization Management (UM), verified online payer, verified on the phone, not verified/no insurance.

Already verified by UM: if the case has already been verified and no further verification is need, please tick here

Verified online payer: if you need to go online to verify the payer, please tick here

Verified on the phone: if you make a call to an insurance company, please tick here

Not verified/no insurance: if you are unable to verify the insurance or the patient has no insurance, please tick here

**Remember what is important is the final result. If you had to perform all of these tasks until you finally verified a patient’s insurance by phone call, please tick “Verified on the phone.” Similarly, if all of these tasks must be performed until you find that a patient has no insurance, please tick “Not verified/ no insurance”.

Consent Form Signatures: This is a group heading and should not have tick marks in it. For each case regarding consent forms, please mark whether the consent forms have been completed and checked online or if a patient visit is needed. If a patient visit is needed, please mark whether the patient signs, declines, or is unable to sign. Please do not mark in the Not Completed/Patient Visit row as this is another group heading.

Patient Signs: If the patient signs the consent forms, please tick here.

Patient Declines: If the patient declines to sign the consent forms, please tick here.

Patient Unable to Sign: If the patient is unable to sign the consent forms, please tick here.

Cash Collections: Whenever you make a cash collection, whether made by cash, check, credit card, or other means please tick here.

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Appendix J: Frequency Study Data Collection Form

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Appendix K: Classification of Office Tasks

Tasks Performed for Every Financial Clearance Case

Task Percentage of Time

Adding Notes and Closing Accounts 10.44% Contacting Patient for Insurance 3.27% On Phone with Insurance Companies 8.11% Patients Visits: Consent Form Verification 3.31% Patients Visits: Insurance Issues 0.40% Team Lead Duties 2.33% Working in Mainframe/Insurance Websites 22.06% Working in MCCM 18.08% Working with IMN/ M-Support 0.33% Total 68.33%

Tasks Not Performed for Every Financial Clearance Case

Task Percentage of Time

Attending Meetings/Administrative Duties* 4.20% Cash Collections 0.11% Checking E-Mail & Voicemail* 7.15% Lunch/Break* 4.71% Miscellaneous 2.95% Printing Face Sheets 0.56% Reviewing Problem Accounts 7.37% Reviewing Unbilled Account Reports 0.29% Utilization Management 0.51% Work Related to Transplant Patients 2.98% Viewing Patient Medical Records/Care Web 0.84% Total 31.67%

* ‘Ad hoc’ tasks referred to in Findings and Conclusions subsection: Classification of Office Tasks.