Process Flow - VSM - Example
- 1. Detox Services Revenue Cycle – Code 5200 Bed Days PatientAccessandRegistrationMedicalandCounselingServicesBilling,Reimbursement&MedicalRecords Pre-Assessment: Pre-assess and Schedule Assessor reviews patient’s current medical situation (non-Dx) Substance Abuse Detoxification Unit: Admission Medical Screening ICD-10 Form (DAMS) Key Restraints: · Must perform codes 3604, 3605, 3606, 4011, 5200 · Must have valid Diagnosis Times Check-in: n/a Waiting, Check-in to Assessment: 10-120 min Pre-assessment: 15 min Waiting, Pre-assessment to Financial: 12-20 min Financial: 20 min Waiting, Financial to Vitals: 3-5 min Review of Systems: 60 min Waiting, Review of Systems to Physical: 5 min Physical: 30 min Waiting, Physical to Admission: 2 min Admission: 10 min Counselor Session: 15-60 min Dispense Meds: 5 min Vitals: 5 min Total Beds Total $ Full Capacity 28 5,040$ Census 6 Mo. Average 27 4,860$ Difference / night -1 (180)$ Total @ 6 mo average -180 (32,580)$ Front Desk: Gather demographic information and consent Patient Enters Restoration Reception Area, requests Detox Services Schedule patient Detox Admission Financial Assessment Determine appropriate funding source based on patient demographics Patient verifies status on appropriate form Physical: Prescribe detox services Provider performs physical assessment Performs physical Signs off on Dx Protocol and medications MH Plan from non-Physician (Medications): BILL CODE 3605 Patient Education, non-Physician (individual, per session): BILL CODE 3606 MH Assessment from non-Physician (Medications): BILL CODE 3604 Psychosocial Rehabilitation Services: BILL CODE: 4011 Review of Systems: Vitals and history Alcohol and/or drug abuse services, not specified (room and board): BILL CODE: 5200 Audit and resolve claims Document Scanning Nurse dispenses Medications Update CMBHS Nurse observes physical and behavioral symptoms Update CMBHS Follow and notate in MAR Update Nurse Flow Chart Nurse takes vitals, asks about and observes withdrawal symptoms Update CMBHS Enter in OOWS/ CIWS Counselor meets with patient Discuss treatment Plan with patient Update CMBHS Completes Review of Systems questionnaire (family history, drug use, etc) Urinalysis, BP, BG, TB test, Breathalyzer Generates MAR (bill 3605) Generates OOWS / CIWA (bill 3604) Nurse performs RoS and vitals Detox Reimbursement Specialist enters code Verify patient satisfied other 4 codes for prior day, add 5200 Update Anasazi Central Reimbursement Specialist Audit suspense and denial reports to resolution Update Anasazi Medical Records Specialist Reviews documents to scan into patient record Scans document into Anasazi Salaries Provider: 60.00 RN: 30.00 LVN: 19.75 CNA: 12.50 LCDC: 16.50 Reimbursement Spec: 13.00 Medical Records: 12.50 Front Desk: 12.50, 14.00, 14.00 1. 5200 code being added manually 1. Could these documents be created and stored in Anasaai?1. Suspense reports take precedence over denial reports. Can systems help enter correct information the first time? 1. Can these be entered electronically? Would free up this person 1. We are dedicating MANY resources before we are able to provide billable services 1. Is scheduling necessary? 2. Could pre-assessment and financial assessment be combined? 3. OR, pre-assessment and RoS combined? Page 1 Registration and Financial Assessment (HIPAA & AOB) Demographics, Insurance & Financial Information Sheet Substance Abuse Services Consent General Consent to Assessment, Treatment and Services
- 2. Detox Services Code 5200 - Bed DaysPatientAccessandRegistration=$94.85(perprocess) MedicalandCounselingServices=$29.25(per process) Billing,Reimbursement&Medical Records=$2.91(perprocess) Billable Services: Per-Process Cost = $29.25 Per-Day Staff Cost = $1440 Non-Billable Services: Per-Process Cost = $97.76 Per-Day Staff Cost = $2289.92 40% of patients are re-scheduled 60% of patients are screened and NOT admitted Clinical - Assessment (LCDC INTERN): $4.20 per process Financial Assessment: $6.25 per process Medical - Physical (RN): $60.00 per process Automate CMBHSMH Plan from non-Physician (LVN): $8.25 per process Automate CMBHS Patient Education, non-Physician (LVN): $1.65 per process Automate CMBHS MH Assessment from non-Physician (LVN): $8.40 per process Psychosocial Rehabilitation Services: (Counselor): $9.30 Medical - Review of Systems (LVN): $19.80 per process Automate Anasazi update Alcohol and/or drug abuse services, not specified: $1.65 per process Automate Anasazi updateClaim Processing: $2.70 per process Don’t print out document = no scanning Document Scanning: $0.21 per process Legend Patient Enters Restoration Reception Area, requests Detox Services Check-in $4.60 Pre-Admission $4.20 Financial evaluation $6.25 Review of Systems $19.80 Physical $60.00 Dispense Meds $8.25 Nursing Flow Chart $1.65 Vitals $8.40 Counseling Service $9.30 Finalize Billing Strip $1.65 Submit Claim, reconcile Anasazi $2.70 Assessor reviews patient’s current medical situation (non-Dx) Substance Abuse Detoxification Unit: Admission Medical Screening ICD-10 Form (DAMS) Eliminate document data- entry tasks Front Desk: $4.60 per process Patient Enters Restoration Reception Area, requests Detox Services Schedule patient Detox Admission Determine appropriate funding source based on patient demographics Patient verifies status on appropriate form Provider performs physical assessment Performs physical Signs off on Dx Protocol and medications Nurse dispenses Medications Update CMBHS Nurse observes physical and behavioral symptoms Update CMBHS Follow and notate in MAR Update Nurse Flow Chart Nurse takes vitals, asks about and observes withdrawal symptoms Update CMBHS Enter in OOWS/ CIWS Counselor meets with patient Discuss treatment Plan with patient Update CMBHS Completes Review of Systems questionnaire (family history, drug use, etc) Urinalysis, BP, BG, TB test, Breathalyzer Generates MAR (bill 3605) Generates OOWS / CIWA (bill 3604) Nurse performs RoS and vitals Detox Reimbursement Specialist enters code Verify patient satisfied other 4 codes for prior day, add 5200 Update Anasazi Accountant Submit claim Reconcile Anasazi Medical Records Specialist Reviews documents to scan into patient record Scans document into Anasazi Gather demographic and insurance information, consent form Registration and Financial Assessment (HIPAA & AOB) Demographics, Insurance & Financial Information Sheet General Consent to Assessment, Treatment and Services Provider reviews all information from nurse, advocates for Detox recovery Central scanning QCs each document Document Scanning $.21 $60.00 $19.80 $9.30 $8.40 $8.25 $6.25 $4.60 $10.41 47.2% 62.8% 70.2% 76.8% 83.3% 88.2% 91.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% $- $20.00 $40.00 $60.00 $80.00 $100.00 $120.00 Dollars Process ProcessCost $960.00 $950.40 $446.40 $331.20 $278.40 $259.20 $201.60 $201.60 $101.12 25.7% 51.2% 63.2% 72.1% 79.5% 86.5% 91.9% 97.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% $- $500.00 $1,000.00 $1,500.00 $2,000.00 $2,500.00 $3,000.00 $3,500.00 Dollars Staff Title Detox- PerDayStaffCost Document Opportunity Process 1 2 3 4 5 7 6 8 9 Detox - Per Process Cost Detox - Per Day Staff Cost Required for admission, but not directly bill-able Diagram Page 1 Diagram Page 2
- 3. Systems Personnel Paper Anasazi CMBHS Excel CSR (front desk) LCDC LVN Provider CNA Reimbur sement Spec Medical Records Mental Health Assessment, non- physician (3604) Mental Health Plan, non physician (3605) Mental Health education, non- physician (3606) Psychosocial Rehabilitation (4011) Other Services, room and board (5200) Medical and Counseling Services Billing, Reimbursement and Medical Records Audit Claims Resolve Claims Document Scanning Patient Access and Registration Check-in Pre-assessment Financial Review of Systems Provider Assessment Admission Page 2
- 4. Staff IDEA: Considering scheduling conflicts and no- shows, why schedule?. Purpose: Maximize available beds Wasted movement Patient Enters Restoration as a Walk In Patient Enters Restoration Through Sobering Patient Enters Restoration as an Appointment Checks-in at front desk Returns to front desk with demographic sheet filled out Staff updates Anasazi and creates paper file Front desk staff notifies Medical pre-assessor of potential Detox client Pre-assessor walks to front desk, brings patient and paperwork to pre- assessment office Assessor reviews patient’s current medical situation (non-Dx) This sheet is printed on colored paper, difficult for MR to scan Substance Abuse Detoxification Unit: Admission Medical Screening ICD-10 Form (DAMS) Assessor consults with Provider to Dx Is patient viable for Detox services? No Financial person called, walks from different building Kanban Patient moves to financial approval office Does patient have insurance we accept OR no insurance? No Can patient prove Bexar County residence? Yes TAP/Carelink Process Yes No Kanban Patient moves to nurse for Review of Systems Does drug screen come back positive? Refer to IHRP No Kanban Patient moves to Provider Yes Auto-fill form? DSHS will fund, pays ~100% of claims submitted Registration and Financial Assessment (HIPAA & AOB) Demographics, Insurance & Financial Information Sheet Have patient sign “No insurance, no proof of ID” form Does patient pass physical? Patient sent to hospital No Patient personal property inventoried and locked up Yes Is patient capable of speaking with Counselor? Counselor will have brief ‘introductory’ session with patient Yes Patient goes to sleep, watch TV, courtyard No CODE 3605: Take meds every 4 hours CODE 4011: Meet with Counselor CODE 3604: Vitals checked once daily and CIWS/ OOWS filled out Patient discharged Dx may require LCDC signature before moving forward. Counselor Process Return patient property Key Restraints: · Must perform codes 3604, 3605, 3606, 4011, 5200 · Must have valid Diagnosis Look up patient in CMBHS to review notes, bring to office from waiting room Discuss treatment plan, Notate in CMBHS; BIRP note Close-out file in CMBHs, return patient to day-room Audit daily census print-out to make sure patient is available Provider leaves paper file for IN- HOUSE reimbursement specialist Is billing strip correct? Save billing strip in Anasazi for billing Yes Investigate cause for discrepancy No Reconcile Census report (excel) with CMBHS Send email to LCDC to update status in CMBHS OR Provider to mark as discharge AMA LCDC Update CMBHS Auto-fill form? Patient to apply for TAP/Carelink Is patient homeless? Patient cannot apply for TAP, apply for DSHS No Is patient resident of Bexar County? Yes Patient cannot apply for TAP, apply for DSHS No Front desk supplies copy of demographics and credentials (ID & SS) Yes Finance person fill out TAP application online Print out application, patient signs Generate Letter of Good Faith using template on shared drive Print out, walk to other building for LCDC to sign Return to desk, scan in signed documents Forward scanned documents via email to UHS Once UHS responds, enter Dates of authorized service(s) into Anasazi Fill-out Carelink (UHS) form with applicant information Fax information to Carelink authorization dept Log into IDX and look up patient’s authorization Email authorization document to Central Print out hardcopy for records · Our total time for TAP processing approximately 35 minutes (assumes all resources are received and available) · UHS drives need for this process Paperwork filed with patient Record Refer out or to IHRP Refer to contracted provider Central Reimbursement Process Patient claim sits for 1 week in suspense report for retro- revisions Does billing strip have all required information? Send back to clinic reimbursement contact for resolution No Post ClaimYes Is claim denied? No action required No Reimbursement File for appeal Yes Kanban Census report is printed out and becomes a static document. Times Check-in: n/a Waiting, Check-in to Assessment: 10-120 min Pre-assessment: 15 min Waiting, Pre-assessment to Financial: 12-20 min Financial: 20 min Waiting, Financial to Vitals: 3-5 min Review of Systems: 60 min Waiting, Review of Systems to Physical: 5 min Physical: 30 min Waiting, Physical to Admission: 2 min Admission: 10 min Counselor Session: 15-60 min Dispense Meds: 5 min Vitals: 5 min Enter patient information in CMBHS Verify pt does/not have Medicaid Medicaid patients accepted only as scheduled on Wednesday and Thursday – NO Walk-ins Nurse asks patient questions, fills out Review of Systems form in Anasazi RoS form (electronic): family history, drug use, etc. Nurse generates Chart Cardex (general patient overview and protocol) Print/Copy, adds: Documentation related to patient history and test results to chart: Nurse performs tests Urinalysis, TB test, Breathalyzer, Glucose, BP Personal Property Inventory Substance Abuse Services Consent General Acknowledgement General Consent to Assessment, Treatment and Services Substance Abuse Consumer Bill of Rights Substance Abuse Services Consent General Consent to Assessment, Treatment and Services These two forms were signed at check-in!!! TAP/Carelink begins working on Retro- Medicaid coverage for patient Is TAP/Carelink successful in acquiring coverage? No TAP/Carelink requests reimbursement of funds from CHCS Yes CHCS Reimbursement verifies Retro- Medicaid Coverage CHCS Reimbursement acquires authorization from Medicaid Reimbursement files Retro-claim with Medicaid Is claim approved? Funded Yes Funded Adds printed labels to each document Follow Appeals process No Is appeal successful? Yes Write-offNo Update census report with either admission or scheduling information Yes Why print these at all? Patient vitals taken, medicated Patient vitals are taken every hour for the first 4 hours Medication dispense process MAR (Medication Administration Record) OOWS and/or CIWA depending on substance detoxing from Add to Chart Vitals process Bring patient into nurses station Gather BP, Temp, HR & RR data Return patient to day-room This data is entered into CMBHS Staff IDEA: Need a better way for counselors, staff and patients to communicate. Purpose: Set expectations CODE 3606: Nursing notes filled out once per shift, based on observation Where do these go? Patient fills out exit survey File is reviewed by CENTRAL Reimbursement Specialist Automate audit? Is patient ready for discharge? Automate adding code? CODE 5200: Update Anasazi with code for patients still in detox Automate audit?Reimbursement Specialist audits each file in CMBHS vs Anasazi for accuracy Enter observed symptoms on OOWS/CIWS score sheet Nursing flow chart filled out Medical Records Process Divide patient documents into medical and non- medical, scan Medical first Is patient Medicaid? Verify policy is active in TMHP Yes Look up patient profile in Anasazi No Is document appropriately stamped with Medicaid ID? Stamp front and back of each document in the patient chart with Medicaid ID No Yes Assign date, document type, document title & source in Anasazi Scan document Did document scan successfully? No Spot-check document Save documentYes Route hard-copy document to Central Scanning for QC No Physician’s Discharge Orders Yes Sign off on Personal Property Inventory Central Scanning Process Courier service delivers documents to Central Review physical document for completeness and accuracy Review Attachment in detail in Anasazi Is document properly scanned? Shred Yes No Does inaccuracy require licensed revew? Fix document, scan in No Route back to Medical Records to rectify Yes Yes Reviews Review of Systems that nurse performed, confirms information notated in Anasazi Questions patient about outcomes from participating in program Review patient chart, update Anasazi with descriptive notes of Nurse’s Review of Systems Performs physical Provider walks patient back to locker-area Provider updates hard-copy patient chart to submit to Nurses’ Station Provider approves patient Protocol in Anasazi Patient Chart is routed to Medical Records Total Beds Total $ Full Capacity 28 5,040$ Census 6 Mo. Average 27 4,860$ Difference / night -1 (180)$ Total @ 6 mo average -180 (32,580)$ Impact of missing one bed per day Central Reimbursement Process If payer is TAP/Carelink Manually Entered by Customer Specialist Manually Entered by Reimbursement Specialist Page 3 Page 4 Page 5 Page 6 Unit nurse cross checks MAR with medication supply in med cart. The Med Tech, CNA, Unit Nurse call patients to the med window at the nurses station. If patients are not in the common area, a team member finds patient. Patients line up at the medication window, one by one. MAR cross checked with pt detox protocol, medication privided to the pt. Medication administered is recorded in the MAR Nurse documents symptoms, side- effects or refusal Assessor enters patient info into CMBHS Finance has to walk over!
- 5. Reference Census Update ‘nurses’ census Update vitals sheet with any new information Take vitals Enter vitals information in vitals spreadsheet Enter vitals in patient chart (OOWS) Enter data into CMBHS Reimbursement enters into Anasazi Bill for services from Anasazi