John Muir Health: Organization Overview and Quality Initiatives
John Muir Health, a nationally recognized not-for-profit institution in the San Francisco Bay Area, is committed to providing exceptional patient care. With a focus on quality reviews, revenue cycle management, and a vision for excellence, John Muir Health aims to offer top-tier services while welcoming partnerships for growth. As a High Reliability Organization, they prioritize safety and performance, applying techniques from hazardous industries to healthcare settings. The evolution of their revenue cycle showcases their continuous improvement and adaptation to industry standards.
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John Muir Health Patient Access Services Quality Review Process Rogel B. Reyes Director, Patient Access Services proprietary and confidential
Agenda John Muir Health Overview Organization Initiatives & Revenue Cycle Background Revination Key Performance Indicators Quality Reviews o Purpose o Process/Expectations o Templates o Frequency o End Result Questions TM proprietary and confidential 2
John Muir Health Nationally recognized, not-for-profit, located in the San Francisco Bay Area 6,000 employees and 1,600 volunteers 1,000 primary care and specialty physicians John Muir Medical Group (Foundation Model) Muir Medical Group 2 hospitals (regional trauma center) Behavioral Health Center (IP and OP) Full-range of medical services Recognized for clinical quality Partnerships include: Stanford Children s Hospital, Tenet (San Ramon Regional MC) UCSF (Bay Health / Canopy Health) proprietary and confidential 3
John Muir Healths Vision 2022 Provide our patients with a top-tier (exceptional) patient experience and quality care at a price they can afford Work as one highly skilled, collaborative team coordinating and managing our patients care across our entire range of services Welcome partnerships and affiliations in order to grow and serve more patients Continue to build a culture of excellence proprietary and confidential 4
High Reliability Organization - HRO Derived from industries that operate under very hazardous conditions Goal of achieving/maintaining superior levels of safety and performance Techniques are transferrable to health care settings Applying these techniques, at John Muir Health, will enable processes that help us do the right thing - each and every time proprietary and confidential 5
Evolution of the JMH Revenue Cycle 2010 2013: Consolidated RCM 8 1, preparation for SBO Model. Integrated teams for 2 Technical, Professional, Trauma Physician Billing/ED Uninsured, Home Health, Behavioral Health and Lab 2010 2014: Implemented vendor partners front to back, including outsourcing where practical (Self Pay, Trauma Billing, Low Dollar Insurance, Workers Compensation, Charge Defense Audit, etc.) 2013 & 2014: Physician and Facility Big Bang Epic Go-Lives 2014 & 2015: Epic Stabilization; Revenue Cycle recovery 2015 What do we do next?: We are performing well, but o How do we become even more cost effective? o How do we best harvest that last 1-2% of net revenue? o Do we consider more outsourcing; engage outside consulting? August 2015: Per Christian Pass, Chief Financial Officer .. o I want to do something very different and innovative proprietary and confidential 6
Revenue Cycle Process Improvement The very different and innovative request: Organization-wide support for implementation of a Revenue Cycle Process Improvement Program (Revination employee engagement TM) to improve net revenue, cost efficiency & proprietary and confidential 7
Revination = Revenue Cycle + Innovation Revination is coordinated across 5 major components Payer Yield / Denials Management Patient Responsibility / Payments Patient Eligibility / Advocacy Vendor Utilization / Management Performance Management / Cost Savings These programs will span various departments of the Revenue Cycle including Patient Access Services, Health Information Management, Single Business Office, Revenue Integrity and well beyond. proprietary and confidential 8
Patient Access Services Key Performance Indicators Days Out Secured Rate Call Answer Rate Call Wait Time Point-of-Service Collections Authorization Rate Registration Complete Rate Quality Reviews proprietary and confidential 9
Quality Review Proposal Summary Purpose o To improve the quality of work and open communication channels between the employee and leadership team Process o Thorough review of a random sampling of employee work to ensure set expectations are being met Frequency o Based on the consistency of scores Reviews will be completed weekly to every other month End Result o Improved quality of work while opening communication channels to ensure a positive and consistent patient experience proprietary and confidential 10
Quality Reviews - Purpose Purpose: Improve the quality of work performed by providing structured feedback to PAS staff Hold PAS staff accountable for adhering to established quality standards Identify barriers to quality performance by conducting a thorough review of the work steps Provide open communication channels for PAS staff to meet with their Supervisor and discuss any concerns Produce documentation regarding PAS staff performance; trends throughout the year proprietary and confidential 11
Quality Reviews - Process Process: Each employee will have five random accounts thoroughly reviewed by the leadership team Each review will be documented on a template designed explicitly for the expectations associated with the specific role Each performance area will be reviewed using a three point scale which will then be averaged to compile the total score for the account. 3 Expectation met fully and/or accurately 2 Missing one element of the performance area 1 Expectation not met and/or missing multiple elements All five accounts will be averaged to produce the review score for the employee proprietary and confidential 12
Ambulatory Front Desk Ambulatory Pre-Registration Facility Admitting Financial Counselor Facility Lead Facility Patient Access Representative Facility Registration Scheduling with Schegistration The Templates proprietary and confidential 13
Registration Quality Review Template Quality Review Detail - Error/Omission Checklist Employee Name Audit Date Time Period Covered Monthly Average Account #1 Account #2 Account #3 Account #4 Account #5 Accounts Audited Demographics and General Information Complete Demographics - Name, Sex, DOB, SS#, Address, Phone, Employer, Employment Status Name/phone #/relationship of emergency contact Needs Interpreter, Language, Marital Status, Religion, Ethnicity, Race PCP Complete #DIV/0! Total for section Guarantor Account and Coverage information Appropriate Guarantor Account Type Guarantor Name Complete Demographics, Relation to Patient, Employer, Employment Status Each template will have role specific data elements to be reviewed including: Member info / Member relationship to subscriber Member info / Insurance ID Insurance Payer / Plan is Appropriate Subscriber ID Subscriber Group # Name on card (if appropriate) #DIV/0! Total for section HIC # for Medicare Managed Plans (when applicable) RTE - OPEN MSP ISSUE MSPQ Completed (applicable ONLY Medicare patients) Complete Demographics - Name, Sex, DOB, SS#, Address, Phone, Employer, Employment Status Insurance verified E-verified, HAR note with call details or supporting documents scanned to system to justify active coverage when eligiblity is verfied by website or fax. Supporting documents scanned to system to justify any Data Mismatch or Inactive Coverage. Demographic/General Information Guarantor Information Coverage Information Encounter Information Documents/Scanning Point-of-Service Collections HAR notes to support account activities Patient has been properly identified as a cash patient (self pay) Self Pay Forms completed - Charity Care/Waiver as applicable Insurance attached to the encounter Coverage is in the appropriate filing order #DIV/0! Total for section Encounter Information, Check List and Claim Information Private Encounter? Accident Related? Occurrence code/date Verify patient, guarantor, coverage(s), encounter #DIV/0! Total for section Documents - Review of Scanned/Received Legal Documents Photo ID / Driver license Insurance card (front/back) HIPAA Notice of Privacy Practice (NOPP)/Conditions of Admissions Financial Agreement Medicare Letter - Important Message Patient Information Form Signed Facesheet #DIV/0! Total for section Particular Situation Documentation and Co-payment/ deposits/ POS collection and documentation HAR Notes Support Account Activity Copays/deposits/POS collected or collection attempt documented #DIV/0! Total for section Totals #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Har. Har. Har. Har. Har. Employee Signature Date Team Lead/Supervisor Signature Date proprietary and confidential 14
Quality Reviews - Major Account Deficiency Major Account Deficiencies (MADs): These MADs have been deemed to cause a fatal error in the registration such as denials, delayed/decreased payment, legal/compliancy issues Any of the 11 MADs will cause an account to automatically fail In the event a MAD is discovered during a review the total account score will be one (Not just for the performance area where the MAD is identified) The full thorough review is still completed even after identifying a MAD to identify any other performance area that may need to be addressed proprietary and confidential 15
Major Account Deficiencies (MAD) Should Be Presumptive Eligibility Failure to document notes/no evidence (HAR) Wrong Insurance Plan POS Collection (2 documented attempts and/or what is due at POS) documented in HAR No ability to contact patient - No telephone number No follow-up on insurance notification - By Discharge/By Inpatient Admission Failure to Add Indicator(s) Lack of communication regarding mismatches/No follow up on Patient Class concerns(s)/mismatch Lack of completed form(s) i.e. COA, FA, Medicare(s), etc. Incorrect patient data/Incorrect forms in actual patient account Not identifying need for Interpreter proprietary and confidential 16
Quality Reviews - Frequency Frequency: Diligently conduct QRs for each employee Utilize PAS performance documents to ensure that adequate time is being spent with staff who have the most opportunity to improve the quality of their work Performance consistently above department goal Performance at department goal Performance below department goal Every Other Month Monthly (Standard) Weekly Bi-weekly Follow up to be conducted as quickly as possible after completion of the review. Same day or within 24 hours. proprietary and confidential 17
Quality Review Employee Engagement Anita Gray Jitender Kaur Office Clerk V Financial Counselor Walnut Creek They are great! We NEED them. They let you know where you are and gives you an opportunity to talk to management. What s not to love? They are complete educational opportunities. I think it s a good feedback for us. They tell us about the accounts and if there are any errors. It s a good learning tool. proprietary and confidential 18
Quality Review Employee Engagement Chelsea Bockover Manager Patient Access Tamara Summers Supervisor Financial Clearance They are extremely useful. It helps to make employees better at their job. It s really not nit-picking but a way to educate staff on the way to properly register a patient. Once they make a mistake once or twice they then know how to complete a perfect registration. QRs are wonderful. I think it s meaningful for the staff to know real- time how they are doing. proprietary and confidential 19
Quality Reviews End Result Patient Access Services Key Performance Indicators Baseline 2/16 1st Quarter 3/16 - 5/16 2nd Quarter 6/16 - 8/16 3rd Quarter 9/16 - 11/16 4th Quarter 12/16 - 2/17 Current Maintenance Sustained Improvement Quality Reviews 87% 93% 93% 94% 95% 96% 9% Concord 87% 92% 94% 94% 94% 91% 4% Financial Clearance 97% 97% 97% 98% 97% 100% 3% Outpatient Center 97% 97% 94% 94% 95% 97% 0% Scheduling 97% 95% 95% 96% 98% 95% -2% Walnut Creek 80% 93% 89% 92% 93% 97% 17% Improved the quality of work while opening communication channels between the employee and leadership team to ensure a positive and consistent patient experience. proprietary and confidential 20
Continuous Improvement What s was next Upon roll-out and initial success optimization was the next goal. In order to optimize we wanted to automate the manual process of account selection. Through collaboration with IT an account randomizer was created. proprietary and confidential 21
Account Randomizer Built in Epic Emergency Department Arrival Randomizer IT Analyst built a randomizer report in Epic Pulls all ED arrivals by end-user Timeframe can be modified Report randomly pulls five accounts for review Includes the data elements to be reviewed Results Time Savings o Automated manual pull of accounts o Compiled the necessary data elements for review Prevents potential to cherry picking proprietary and confidential 22
Emergency Department Arrival Randomizer Emergency Department Arrival Quality Review Template Emergency Department Arrival Quality Review Randomizer Report proprietary and confidential 23
Account Randomizer Dashboard Website Admitting Financial Counselor Randomizer IT Analyst built a randomizer dashboard website Pulls all admitted accounts Timeframe can be modified Report randomly pulls five accounts for review Includes the data elements to be reviewed Results Time Savings o Automated manual pull of accounts o Compiled the necessary data elements for review Prevents potential to cherry picking proprietary and confidential 24
Admitting Financial Counselor Randomizer Admitting Financial Counselor Quality Review Template Admitting Financial Counselor Randomizer Dashboard proprietary and confidential 25
Account Randomizer - Future State Created billing indicator 360 Registration Complete Productivity tracking method Represents account completion Create randomizer report to pull in all BI 360 accounts Pulls in all accounts with BI 360 by end-user Timeframe can be modified Report randomly pulls five accounts for review Includes the data elements to be reviewed proprietary and confidential 26
Registration Randomizer Quality Review Detail - Error/Omission Checklist Employee Name Audit Date Time Period Covered Monthly Average Account #1 Account #2 Account #3 Account #4 Account #5 Accounts Audited Demographics and General Information Complete Demographics - Name, Sex, DOB, SS#, Address, Phone, Employer, Employment Status Name/phone #/relationship of emergency contact Needs Interpreter, Language, Marital Status, Religion, Ethnicity, Race PCP Complete #DIV/0! Total for section Guarantor Account and Coverage information Appropriate Guarantor Account Type Guarantor Name Complete Demographics, Relation to Patient, Employer, Employment Status Report will pull in each data element for review including: Member info / Member relationship to subscriber Member info / Insurance ID Insurance Payer / Plan is Appropriate Subscriber ID Subscriber Group # Name on card (if appropriate) #DIV/0! Total for section HIC # for Medicare Managed Plans (when applicable) RTE - OPEN MSP ISSUE MSPQ Completed (applicable ONLY Medicare patients) Complete Demographics - Name, Sex, DOB, SS#, Address, Phone, Employer, Employment Status Insurance verified E-verified, HAR note with call details or supporting documents scanned to system to justify active coverage when eligiblity is verfied by website or fax. Supporting documents scanned to system to justify any Data Mismatch or Inactive Coverage. Demographic/General Information Guarantor Information Coverage Information Encounter Information Point-of-Service Collections HAR notes to support account activities With a direct link to Documents/Scanning Patient has been properly identified as a cash patient (self pay) Self Pay Forms completed - Charity Care/Waiver as applicable Insurance attached to the encounter Coverage is in the appropriate filing order #DIV/0! Total for section Encounter Information, Check List and Claim Information Private Encounter? Accident Related? Occurrence code/date Verify patient, guarantor, coverage(s), encounter #DIV/0! Total for section Documents - Review of Scanned/Received Legal Documents Photo ID / Driver license Insurance card (front/back) HIPAA Notice of Privacy Practice (NOPP)/Conditions of Admissions Financial Agreement Medicare Letter - Important Message Patient Information Form Signed Facesheet #DIV/0! Total for section Particular Situation Documentation and Co-payment/ deposits/ POS collection and documentation HAR Notes Support Account Activity Copays/deposits/POS collected or collection attempt documented #DIV/0! Total for section Totals #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Har. Har. Har. Har. Har. Employee Signature Date Team Lead/Supervisor Signature Date proprietary and confidential 27
Contact Information John Muir Health Rogel Reyes Director, Patient Access Services rogel.reyes@johnmuirhealth.com proprietary and confidential 29
