Registration, Simplified

Gienna Shaw, for HealthLeaders Media , May 13, 2011
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It’s often the first point of patient contact—and it can also be the most chaotic. At patient check-in and registration, harried staff collect data as simple as name and daytime phone number, as critical to care as medical and family history, and as thorny as copays, coinsurance, and deductibles. Patients hate the waiting room, too—with its germy inhabitants, old magazines, and reams of paperwork to fill out. And with the growing number of high-deductible insurance plans and rising copays, an inefficient front desk can also mean missed revenue opportunities.

That’s why organizations are investing in technologies to make registration and check-in more efficient—and more profitable.

Breaking the logjam

No matter how many employees you have at the front desk, there are times when they’re organizing pens and rubber bands and times when they’re so busy they can’t keep up.

Juliet Breeze, MD, CEO of the Richmond Bone & Joint Clinic, with three locations in the Houston area, says she might not have addressed front desk inefficiencies if it weren’t for comments on patient satisfaction surveys specifically requesting express check-in. “Because invariably they would be the ones who ended up behind the person who seemed to be taking a long time filling out their forms or talking to
the check-in ladies about a question or a problem.”

But bottlenecks weren’t Breeze’s only concern.

“The other thing that became clear to us, as we were simultaneously working on some projects having to do with patient collections, was that we were missing a big opportunity at our check-in desk to address balances in advance of the patient’s visit. So we would check the patient in and because the check-in people were so busy, they would sometimes forget to talk to the patient about the balance that we already knew was due,” she says. “And we were not only missing the opportunity to collect their balance at check-in, but also the balance of their children or their spouse or someone for whom they were a guarantor in the past.”

The 20-physician practice installed an NCR-brand kiosk check-in system that’s integrated with its payment management system. The kiosks alert patients to current and past balances—they can pay with the swipe of a credit or debit card. Patients can’t complete the check-in process without paying the balance or speaking to a financial counselor.

Breeze has calculated the financial benefits of the program down to the penny. “We saw exactly $206,817.63 in additional money collected at check-in in 2010, which was our first year, compared to 2009,” she says—a 5% increase. She’s also cut down the cost of sending out paper bills and is saving on salaries, going from three front-desk staffers to one.

The cost of an outpatient clinic setup with one to five kiosks ranges from $25,000 to $100,000 in up-front costs, plus typical maintenance fees, according to NCR; Breeze says the system has more than paid for itself.

Breeze wasn’t sure patients would like the kiosks—and because it was having such a positive impact on collections, it didn’t really matter. “I specifically did not put a question on our patient satisfaction survey about the check-in process because I didn’t want to hear complaints,” she says. But after the kiosks were installed, patients started adding write-in comments to their satisfaction surveys, praising the check-in process.

“It was very surprising to me. I had no idea people would enjoy the benefits of express check-in so much,” she says.

Preventing denials

Orlando Health has been testing another technology that monitors the registration process—alerting employees in real time when they enter data in the wrong format or skip any of the hundreds of fields they must populate to register a patient. “It gives us the ability to verify and make sure our registration process is happening the way we think it’s happening,” says Thomas Yoesle, chief operating officer of patient financial services for the 10-hospital system. Developed in partnership with QuadraMed, Access Quality Manager is fully integrated with the system’s EHR.

Like other organizations, Orlando Health trains (and retrains) employees to correctly capture registration information. “We’re investing a lot of money in our people and our team members to register the patient appropriately. But then it’s always been a struggle to go back and see how they’re doing.”

In the past, a quality assurance group of about 10 FTEs would audit registrations and meet with registrars to give them feedback. By that time the information would be about eight months old—and they reviewed less than 1% of all registrations. Now the department has one or two FTEs to manage the system and build the rules. And the technology monitors every single registration in real time.

The organization has reduced the number of claims edits from about 1,000 a day to about nine a day—at seven cents an edit, that’s a savings of about a quarter million dollars. Claims accuracy used to hover around 80%; now it’s 95%—and jumps to nearly 100% after 24 hours, when registrars have had a chance to correct or complete missing data; the system reminds them what’s missing.

Currently, the program only works with the Affinity EHR, but QuadraMed says it plans to expand it to work with other systems.

Making it easier for patients to pay

Adventist Health System, a 43-hospital system based in Winter Park, FL, has also installed check-in kiosks at seven of its sites that patients can use to register, update their demographic information, and pay their bills. But it adds one more layer to the strategy: an online
portal to register as many patients as possible before they even get to check-in. That’s especially important with the growth of high-deductible insurance plans and rising copays—patient payments account for about 25% of revenue, with online patient payments contributing 10% to revenue, says Tim Reiner, VP of revenue management at Adventist.

“We need to be collecting that money and not writing it off to bad debt,” he says. “Part of it is proactive, part of it is also we want to get out in front of them and prepare them to know what their financial obligation’s going to be. We want to have that conversation before you come to the hospital, because we want you to have good service when you’re there.”

And while organizations are increasingly offering online payments, Adventist has begun offering online payment arrangements—where a certain amount of the patient’s balance is automatically charged to their credit card each month.

“It really takes a lot of the work out of that utility of sending a paper statement, sending another one for a payment arrangement, even putting them in a workflow around a dialer [or] call center,” Reiner says.

Recurring payment arrangements average $250,000 at any given time. The organization doesn’t have to pay an account management vendor for those patients—at 8% to 10% of a patient’s balance, that’s a savings of as much as $50,000 a year. Plus they save about 50 cents for every paper statement they don’t have to send out.

“In today’s market, the interest rates are not that high, so the money you get in the bank earlier is not that significant now,” he says. “But our CFOs still like to have that money secured.”

Improving clinical
data collection

Aunt Martha’s Healthcare Network, based in Olympia Fields, IL, uses a handheld tablet for check-in and registration at its 17 clinics. The PhreesiaPad verifies insurance coverage, presents patients with their balance due and lets them pay with a credit card swipe, and gathers medical history and other data.

Other administrative tools, including the ability to track patient flow and review reports for monthly revenue, payer mix, and patient chief complaints are particularly useful, says Armando Silva, Aunt Martha’s director of medical records.

The pad provides patients with a level of privacy that encourages them to be more open when filling out histories, says CAO Bob Richardson, which in turn improves clinical care.

And the patients like it, he adds, which will help improve patient satisfaction and make the organization more competitive.

“It really does make a difference for patients’ perceptions and quality of care,” he says. “Going forward, especially with health reform, all clinics, all medical service organizations are going to have to be more efficient or patient-focused.”


Gienna Shaw is senior technology editor for HealthLeaders Media. She may be contacted at

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