1. IMPROVING PERFORMANCE
A3 GREEN BELT PROJECT WORKBOOK
COLONOSCOPY CHARGES
(PARTIAL SAMPLE OF WORK COMPLETED)
by Christina Garner
Start Date: 04/23/2014
3. 1.Reason for Action-Charter
Problem/Goal Statement
• Problem Statement: Since a recent merger, patients
have been receiving colonoscopy bills for charges that
were unexpected resulting in patient dissatisfaction.
Many services were previously covered for returning
patients.
• Aim/Goal: Decrease number of unexpected charges and
patient complaints by 80%.
• Scope: Bills for colonoscopies performed by XXXX
physicians at XX locations. Bills are from XXXX
(professional fees) and XX (facility fees).
• Trigger: Physician inputs procedure order
• End: Number of incorrectly coded/billed claims is
decreased.
High Level Plan
Target Completion dates:
Checkpoint Target Date Completed Date
Box 1 6/2/2014 6/2/2014
Box 2-3 6/2/2014 6/2/2014
Box 4-5-6 7/2/2014 7/2/2014
Box 7-8-9 10/3/2014 10/3/2014
4. 1. Reason for Action
Suppliers Inputs Process Outputs Customers
• What are the
outputs/results?
• Colonoscopy
• Bill
• Who supplies
inputs to the
process?
• PPO insurance
• Calpers
• HMO
• Medicare
• Hospital
Coders/Contract
coders
• GI coder
• Billing
Office/Eligibility
Dept
• Hospital Billing
Office
• Mgmt
• MAs
• Physicians
• GI front office
• Endo ctr staff
• Endo ctr mgr
• GI auth dept
• Who benefits
from the
results?
• Patient
• Organization
• Staff
• Insurance
company
PHYSCIAN
INPUTS ORDER
• What are the
inputs?
• Eligibility
verification
(before o/v or
procedure)
• Authorization/
UM Review:
(needed for
HMOs, some
PPOs)
• Procedure
report
• Guidelines
• Coding
MA SCHEDULES
COLONOSCOPY ORDER SENT TO
AUTH DEPT.
PROCEDURE
PERFORMED
AND REPORT
SENT TO
CODING &
BILLING
CLAIM
SUBMITTED
PT RECEIVES BILL
Trigger: Order
Input
Done
5. 2.Current State
• + Front desk verifies eligibility (not benefits)
• + Patients have their procedure
• + Patients are getting billed
• + Patients happy with care
• + Calpers exception form
• + Auth dept more knowledgeable of insurances than before
• + MAs advise patients to call their insurance
• + Bills come in “waves”
• + Physicians educated on how to code screen vs dx
• + GI Auth Dept calls for benefits if pt requests
• + Business office is refraining from calling insurance “Obamacare”
because of stigma
• + Office manager and auth dept handling all complaints in a timely
manner
Metrics Baseline Performance
Colonoscopy bills: screening vs. dx
Colonoscopy bills: out of network
Colonoscopy bills: Calpers capitation
Colonoscopy bills: no preventative or dx coverage
Colonoscopy bills: both coded as dx
***APRIL 2014:
33 patient complaints:
• 19 screening vs. dx coding issues
• 2 out of network
• 2 Blue Cross Calpers capitation issues
• 5 no preventative or dx coverage
• 5 colonoscopy/EGD procedures both coded as dx (one should
be dx, one preventative.)
- Front desk only checks for XXXX network status (not XX)
- Patients think “auth approved/not needed” means it’s covered
- Patients are getting bills they did not expect
- Colonoscopy is billed as diagnostic vs. screening
- Colonoscopy is billed as “follow-up” = diagnostic
- Patients do not call their insurance
- Long-time patients are now getting high bills
- Patients don’t know we are an outpatient hospital
- Auth department does not call for benefits unless requested by pt
- Calpers $1500 capitation
- Professional and facility fees may be in or out of network (one in, one
out)
- Physicians tell patient it’s covered
- Patients coming into office and finding out we don’t take their insurance
or are out of network and getting upset
-“Obamacare” flares tempers
6. 3.Target State
Metrics Baseline Performance
**APRIL 2014 - 33 patient complaints**
Target State
Performance
1) Colonoscopy bills: screening vs. dx 19 6.6
2) Colonoscopy bills: out of network 2 0
3) Colonoscopy bills: Calpers capitation 2 0
4) Colonoscopy bills: no preventative or dx
coverage
5 0
5) Colonoscopy bills: both coded as dx 5 0
7. 4.Gap Analysis
Current State Target State Gap (The
Problem)
Root Cause
Colonoscopy codes
are submitted
incorrectly post-
procedure. Patients
call and complain.
Claim is resubmitted.
Codes are submitted
to billing correctly the
first time. No
customer complaints,
physician queries, or
recodes.
Patient receives an
incorrect bill. What
about all the patients
who get billed and
don’t complain?
Physicians enter
wrong codes and/or
billing submits wrong
codes.
Patients don’t check
their benefits and
they receive bills that
are unexpected
Patients are fully
aware of the charges.
Patient receives a
correct bill, but it is
unexpected.
Bad form; patient
education
9. 4. Gap Analysis - 5 WHYS
PROBLEM: Why are patientsreceivingincorrect or unsuspectedbills?
DIRECT CAUSE #1: because the codes are submitted
incorrectly…
Why are the codes submitted incorrectly?
- because physicians input wrong codes on post-procedure
report
Why do the physicians input the wrong codes?
- because the Coding Clinic guidelines have changed
Why don’t they input the correct codes?
- because they forget their training
Why do they forget their training?
-because they are rushed and have a heavy patient load
ROOT CAUSE: PHYSICIANS ENTER WRONG CODES
DIRECT CAUSE #2: because billing is submitting wrong
codes…
Why is billing submitting wrong codes?
-because they code colonoscopies as dx
Why do they code them both as dx?
- because they are unfamiliar with the guidelines
Why are they unfamiliar with the guidelines?
-because they have not been informed
Why have they not been informed?
ROOT CAUSE: BILLING SUBMITS WRONG CODES
DIRECT CAUSE #3: because patients don’t check their
benefits…
Why don’t patients check their benefits?
-because they don’t know that they should
Why don’t they know to check their benefits?
-because they think we do it for them
Why do they think we do it for them?
-because they think that auth’d = covered
Why do they think that auth’d = covered?
-because they don’t read or understand the form
ROOT CAUSE: BAD FORM/PATIENT EDUCATION
9
10. 4. Gap Analysis - 5 WHYS (cont’d)
PROBLEM: Why are patients receivingincorrect or unsuspectedbills?
DIRECT CAUSE #4: because returning patient’s
colonoscopies were previously paid for…
Why were they previously paid for?
- because insurance policies were different
Why were insurance policies different?
- because of healthcare reform and XXXX/XXXX merger
Why does the merger make a difference?
- because XX now owns endoscopy center
Why does that change things?
- because XX has higher fees and is an outpatient hospital
ROOT CAUSE: XXXX/XXXX MERGER
DIRECT CAUSE #5: because patients are unaware of their
benefits…
Why are patients unaware of their benefits?
- because they don’t call their insurance
Why don’t they call their insurance?
- because they think we call for benefits
Why do they think we call for benefits?
- because other medical offices do
Why do other offices call for benefits?
-because they have the staff and it’s good customer service
ROOT CAUSE: WE DON’T CALL FOR BENEFITS
10
11. 5. Solution Approach
Root Cause Hypothesis
Physicians enter wrong codes If the physicians are educated, claims
will be submitted correctly.
Lack of patient education If patients are aware of their benefits,
complaints will decrease. A new form
and a script for staff will help.
Billing submits wrong codes If we speak to billing, the situation will
be resolved.
12. 6. Rapid Experiments
Hypothesis Experiment Expected
Outcome
Actual
Outcome
Conclusion Completion
Plan Item
If *, Then * Analyze coded
procedure reports:
track codes on the
final endoscopy
reports every day
(between 25-30
patients daily).
I would be able to
tell if physicians
were submitting
wrong codes.
I can see the codes
and XXXX superbills,
but do not have
access to XX
superbills.
Need access to XX billing. Schedule meeting
with XX
If *, Then * Eliminate
Calpers $1500
capitation by
negotiating
contract or
submitting
outpatient
hospital
exception form.
Calpers will only
accept form if
patient has co-
morbidities.
Contract between XX and
Calpers not an option.
4/14. Calpers accepting
all exception forms (e.g.
for continuity of care,
facility changed to outpt
hospital vs. ASC). No
claims denied yet that we
know of. Update 7/10:
Calpers will no longer
accept this form. <10 pts
have cx’ld scheduled
procedures when they are
informed.
Calpers will only eradicate
the $1500 capitation if the pt
has comorbidities that
require a hospital procedure
or live too far away from an
ASC. Exception form (auth)
must be submitted prior to
procedure, however <3% of
Calpers pts may meet this
criteria .
Update 7/10: Front
desk given script for
Calpers patients
when they call
and/or auth dept
catches these on
the back-end and
informs pt of cost.
($2,518 baseline
colo, $1500 paid =
>$1k for colo).
If *, Then * Calling for all
patient’s
benefits
Expected this
would solve the
problem
Did not solve the
problem
Does not fit into the auth
dept workflow
Drop practice: too
time consuming for
too little positive
output
13. 6. Rapid Experiments (continued if necc.)
Hypothesis Experiment Expected
Outcome
Actual
Outcome
Conclusion Completion
Plan Item
If *, Then * Improve
endoscopy form
Form would be
changed
Submitted request on
5/8. Received rough
draft to proof on 7/22.
7/29 final proof
approved and sent
for printing.
New form approved, printed
and distributed.
Form distributed to
staff
If *, Then * Physician
education and
coding
reminders
Coding errors
would be
decreased
Coding errors have
not been decreased..
Physicians continue to
provide unclear
documentation which results
in a query from coding dept.
Christina is liaison
between pt,
physician, and
coding dept.
If *, Then * Meet w/XX
coding on
8/4/14.
There would be a
clear solution to
the problem.
We solidified our
standard work for
recodes. Also, I was
looking at wrong
documentation. Coders
code first off of
“Moderate Sedation
Form” and/or the
procedure report,
and/or progress note if
less than 30 days.
If I get access to Chartmaxx I
can see how procedures
have been coded.
1) Get access to
Chartmaxx. 2) XX
will be hiring a “pt
liason” we can direct
billing questions to.
9/8 Chartmaxx
access granted
14. 6. Rapid Experiments (continued if necc.)
Hypothesis Experiment Expected
Outcome
Actual
Outcome
Conclusion Completion
Plan Item
If *, Then * Analyze patient
calls
Most of the calls
would be
diagnostic vs.
screening-related
billing.
Hypothesis was
correct (see metrics
on Slide 7)
The dominant problem is the
diagnostic vs. screening
problem.
Set focus on this
problem.
If *, Then * Patient
education; MA
script
MAs will do this
75% of the time.
An improved form
will help.
Form distributed.
Hypothesis correct –
staff doing this most
of the time.
MAs have been better
informing patients/giving
them codes or directing them
to auth dept or their
insurance co. for questions.
Patients are called by auth
dept if anything is out of the
ordinary.
Continue practice
If *, Then * Change auto-
reply patient
portal enrollment
email to say
something like
“please check
your benefits”
Doable Not doable – reply
message is
standardized for all of
XXX
Not possible at this time. None
15. 7. Completion Plan
Actions Owner Due Date
Monitor MA’s standard work, including new form use and benefit check
suggestions
Lead
MA/Christina
Ongoing
Monitor auth dept standard work for coding errors and benefit checks Christina Ongoing
Track post-project metrics GI manager Ongoing
Monitor front desk scheduler’s standard work, including Calpers script and
benefit check suggestions
FO
Lead/Christina
Ongoing
Update insurance cheat sheet for front desk schedulers Christina Review every 60
days
16. 8. Confirmed State
Metrics Baseline
Performance
Target
Performance
Post
Project
(September)
30
Day
(October)
60
Day
(November)
Q 1) Colonoscopy bills:
screening vs. dx
2) Colonoscopy bills:
out of network
3) Colonoscopy bills:
Calpers capitation
19
2
2
0
0
0
7
0
0
T
C
HD 4) Colonoscopy bills:
no preventative or dx
coverage
5) Colonoscopy bills:
both coded as dx
5
5
0
0
0
0
Q = Quality T = Timeliness C = Costs HD = Human Development
17. 8. New Current State – Standard work example
Medicare Colonoscopy Coverage
Screening
High risk = covered 100% every 2 years. See CMS
guidelines for high risk status in folder.
Not high risk = covered 100% every 10 years until
age 75
Diagnostic Covered @ 80%
Insurance Coverage Details
Blue Cross of CA Covered
PHCS Covered
Tricare Standard Covered 1 every 10 years
Aetna Covered 1 per 10 years after age 50
Blue Shield Federal Covered 1 per year
Cigna Covered
Blue Shield Covered 1 per 10 years after age 50
Blue Cross of CA - LA County Fire Covered 1 per 10 years after age 50; no MAC
AVMA Covered 1 per year, no deductible
Blue Cross - JQF Covered
usually $300 copay, Tier 1 = US, EKG,
EGD
Tier 2 = MRI, CT, surgeries
Blue Cross of CA - UFCW Covered 1 per every 5 years
Blue Cross of CA - CPR (Calpers) Covered up to $1500 Outpatient hospital capitation
Blue Cross of CA - CFH (CA Ironworkers) Covered up to $1500 Outpatient hospital capitation
Healthnet Covered
GEHA Covered
Blue Cross/Blue Shield Boeing Covered
United Healthcare Covered
Blue Cross/Blue Shield (Out of State) Covered
United Medical Resources (UMR) Covered
Coventry Covered
FMTH Benefit Covered
BCBS American Airlines Not covered Pt may have a secondary
BC Delta Not always covered Pt may have a secondary
Southwestern Teamsters Security Fund
Retiree Plan Not covered
Special Cases
Per PCACA Guidelines: If a colonoscopy is scheduled and performed as a screening procedure, a plan or insurer may not impose cost sharing for the cost of polyp removal during the colonoscopy.
Preventative Colonoscopy: ICD-9 code v76.51; CPT code 45378
20. 9. Insights
What went well? What did not go well? Actions?
• Team’s response to new
standard work with new
visual aids
• New endoscopy form
and new
• Obtaining metrics
• Calling for benefits
• Lack of resources
• Identified the root cause
as a coding issue vs. a
calling-for-benefits issue
What helped? What hindered? Actions?
• Coding meeting
improved communication
for the claim rebill/recode
process
• My lack of control over
metrics-gathering
• Slow form approval process
• Billing cycle time
• No access to or measuring
of corporate metrics (i.e.
patients lost, # or list of
rebilled claims)
• In-office safeguards put
in place while awaiting
high-level approvals
• Track metrics that I touch
