Managing Receivables Through Patient Access Ingenuity

About the Organization Cedars-Sinai Medical Center: 886 Licensed Beds in Beverly Hills, California (purchased Marina Del Rey Hospital in 2015) 243,040 Annual Patient Days (665 per day) 697,539 Annual Outpatient Visits (1,911 per day) 47,320 Annual Admissions 88,422 Emergency Department Visits 11,625 Full Time Employees $659,947,000 FY16 Community Benefit ($21,785,000 in direct charity care) 3

Registration Department Management Organization Registration Department Management Organization One Director and Eight Managers. Imagining and Breast Center AHSP and Mark Goodson Building Samuel Oschin Cancer Center Emergency Department Registration Organization Training and Quality Assurance Main Admissions and Lab Pre-Admissions Financial Clearance and Steven Spielberg Building Cancer Center Auths Eligibility 4

Where We Started The Challenges Immediate and Long-term Inexperienced, untrained staff with very low morale who felt they were in dead end jobs Days in Receivable at 120 No standards or goals relative to Patient Access responsibility concerning production of a clean bill First Pass Yield (the percentage of bills that clear all edits and produce a clean bill) at 20% Declining Monthly Cash Upfront Cash Collections of $4,000.00 per month ($48,000 per year) Customer Service Waits and Delays Decentralized Registration Poor Organization Structure Misalignment of Staff and Volumes Decentralized Authorizations Decentralized Outpatient Scheduling No Solid, Applicable Training Duplicate Medical Records at 15% Paying an Outside Vendor for Eligibility Services Challenging Technology Operating on a DOS System AND a Looming Computer System Conversion Space 5

Poor Organization Structure Centralized registration staff within buildings whenever possible rather than trying to staff every clinic Built a solid leadership model of leads, supervisors, and managers who were subject matter experts in each of their areas Completed an in-depth study of how long each registration took, determined how many registrars it took to staff each area and staffed accordingly, which had an immediate positive impact on customer service and waits and delays Eliminated overage of staff in some areas and were able to augment staff in others without losing staff Completely redesigned the Financial Counseling Department and eventually eliminated that department and replaced it with the Patient Financial Advocate Department Emphasis was now more focused on obtaining authorizations in a central effort and the PFA Unit became the safety net for data integrity prior to the bill dropping The PFA Unit also provides financial clearance assistance house wide 6

Solid Applicable Training The problem: Training was virtually non-existent at the beginning of the project Very few staff level employees were proficient in PC usage and navigation because the DOS System had only recently been moved to a PC based system True Story: When asking a staff member to right click, she moved the mouse to the right side of her computer!!! Data integrity was deplorable Bills had to have human intervention prior to going to the carriers/patients because they couldn t pass the edits electronically No upfront cash was being collected Employees were feeling unappreciated and moral was low because the only feed back they ever received was bad 7

Solid Applicable Training (continued) The fix: Develop a training department within the Patient Access Department (This will pay for itself!) Create an attainable career ladder with monetary reward for perfecting competency Develop a specific training criteria targeting practical application within the department and relative to every day operations. Establish acceptable, achievable standards and monitoring system. Current modules include: Customer Service Registration Fundamentals RQI/What is it/how to use it Government Insurance Advanced Insurance Cash Collections Respect in the Workplace 13 Modules Total Train, Track, Trend, Revise Study Skills/Testing Strategies Forms and Consents Non-government Insurance MSPQ Insurance Verification - ABNs Medical Terminology 8

Solid Applicable Training (continued) Staffed with trainers who were subject matter experts and possessed excellent verbal, written and presentation skills and had up-to-date technological skills Develop a grading scale for each learning module Each module has an associated test at the end of training for that module The tests are done on the computer and the grades show on the computer at the end of the test. Each participant may retake each test one time only and only up to three modules. All staff are made aware that failure to pass the training will mean the employee may not continue in the Patient Access Department Seek input from the participants and continually improve and update the curriculum 9

Career Ladders

Career Ladder Qualifications for Each Level 15

Career Ladder 2016 Eligibility Criteria Hire date prior to June 1, 2016 Successful completion of probationary period (6 months) QA score of 98% at Discharge Ability to work in more than one area Meet all attendance, tardiness, and KRONOS standards Meet the productivity expectations of your manager and supervisor Assist with backlogs and coverage for VHT/SICA/ALP Volunteer to serve on committees Assist coworkers No corrective action during October 1, 2015 to September 30, 2016, includes Written Counseling and above Passing Competency Score To move up the Career Ladder One must be performing at the next level: AR 88% or higher AR 60% - 69% PAR I 90% or higher PAR I 70% - 79% PARII 92% or higher PAR II 80% - 89% PARIII 94% or higher PAR III 90% - 100% March 2016

Monthly QA Trend by Department (Four out of eight departments displayed) Date July 31, 2015 Pre-Admissions Inpatient PFA Outpatient REVIEW Ending Pre-Verifciation % Acc. % Acc. Admissions % Acc. % Acc. Registration % Acc. % Acc. Registration % Acc. % Acc. MONTH Date Cases Errors FY16 FY15 Cases Errors FY16 FY15 Cases Errors FY16 FY15 Cases Errors FY16 FY15 JUL-D 3130 13 99.6% 99.2% 3042 8 99.7% 99.8% 18328 86 99.5% 99.5% 7/31/2015 JUL-B 26844 158 99.4% 99.4% 2740 3 99.9% 99.8% 3346 2 99.9% 99.9% 16698 25 99.9% 99.9% AUG-D 3367 25 99.3% 99.0% 3474 14 99.6% 99.7% 19264 105 99.5% 99.6% 8/31/2015 AUG-B 25723 194 99.2% 99.2% 3210 17 99.5% 99.8% 4063 3 99.9% 99.8% 21155 23 99.9% 99.9% SEP-D 3094 28 99.1% 99.3% 2467 5 99.8% 99.6% 17910 92 99.5% 99.4% 9/30/2015 SEP-B 26047 180 99.3% 99.3% 2770 5 99.8% 99.6% 3047 5 99.8% 100.0% 16944 23 99.9% 99.9% OCT-D 2771 21 99.2% 99.3% 2789 8 99.7% 99.8% 19174 74 99.6% 99.5% 10/31/2015 OCT-B 29331 200 99.3% 99.3% 2409 6 99.8% 99.8% 3113 9 99.7% 99.9% 18618 28 99.8% 99.9% NOV-D 2553 21 99.2% 99.6% 2845 10 99.6% 99.7% 15466 60 99.6% 99.3% 11/30/2015 NOV-B 25517 154 99.4% 99.3% 2479 5 99.8% 99.8% 3647 8 99.8% 99.7% 17861 25 99.9% 99.9% DEC-D 2638 18 99.3% 99.3% 2668 5 99.8% 99.6% 16694 91 99.5% 99.3% 12/31/2015 DEC-B 26361 132 99.5% 99.2% 2324 2 99.9% 99.9% 2875 3 99.9% 99.8% 14828 20 99.9% 99.8% JAN-D 2143 22 99.0% 99.4% 2745 10 99.6% 99.6% 17086 105 99.4% 99.3% 1/31/2016 JAN-B 27023 162 99.4% 99.2% 2073 3 99.9% 99.8% 2888 4 99.9% 99.7% 17383 36 99.8% 99.9% FEB-D 2568 25 99.0% 99.6% 2750 10 99.6% 99.6% 16358 108 99.3% 99.3% 2/28/2016 FEB-B 25957 221 99.1% 99.2% 2351 2 99.9% 99.8% 3456 8 99.8% 99.7% 17220 16 99.9% 99.8% MAR-D 3188 23 99.3% 99.5% 2673 7 99.7% 99.6% 18903 102 99.5% 99.5% 3/31/2016 MAR-B 27701 170 99.4% 99.2% 2903 5 99.8% 99.9% 2983 4 99.9% 99.9% 16913 16 99.9% 99.9% APR-D 2752 23 99.2% 99.6% 2502 7 99.7% 99.8% 17521 87 99.5% 99.4% 4/30/2016 APR-B 28357 141 99.5% 99.2% 2552 1 100.0% 99.9% 2706 3 99.9% 99.9% 18020 29 99.8% 99.9% MAY-D 3115 24 99.2% 99.6% 2600 7 99.7% 99.6% 16874 70 99.6% 99.5% 5/31/2016 MAY-B 26023 116 99.6% 99.3% 3099 7 99.8% 99.9% 3202 4 99.9% 99.7% 19027 28 99.9% 99.8% JUN-D 3085 21 99.3% 99.2% 2632 4 99.8% 99.8% 18126 92 99.5% 99.6% 6/30/2016 JUN-B 29151 149 99.5% 99.4% 2702 4 99.9% 99.8% 2778 1 100.0% 99.9% 15660 17 99.9% 99.9% Billed Totals 99.4% 99.3% 99.8% 99.8% 99.9% 99.8% 99.9% 99.9% Average Period 17

First Pass Yield The problem: Only 20% of the bills generated passed the electronic edits to move to the carrier 80% of bills originating in Patient Access had to be manually touched before advancing to the carrier Reimbursement was delayed or denied due to poor data quality 18

First Pass Yield (Continued) The Fix: Identify what we were missing by understanding the missed edits Used our trainers to QA accounts for these edits Our trainers then worked one on one with staff and incorporated the new information in the training curriculum. At first QA was manual and scores were published on the sample In 2006 an electronic product was implemented and provided 100% QA While the new system was not infallible, there was an instant and sustainable increase in the first pass yield 19

Average First Pass Yield Progress (Recorded in January for the Previous Year) 100% Annual Avg First Pass Yield 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% JAN-03 JAN-04 JAN-05 JAN-06 JAN-07 JAN-08 JAN-09 JAN-10 JAN-11 JAN-12 JAN-13 JAN-14 JAN-15 20

Upfront Cash Collections The problem On average, up front cash collections were around $4,000. per month ($48,000 per year) Staff did not know how to determine what to collect Staff was not trained to ask for cash and many were uncomfortable asking Staff honestly believed that $4,000 per month represented a great collection effort 21

Up front Cash Collections(continued) The fix: Again, training, training, training! The staff was required to go through cash collections training on how to ask for money They were taught to assume payments would be made by phrasing the question as How will you be taking care of your co-pay today? instead of Would you like to pay your co-pay today? The staff was also trained on how to explain that the request for co-payment was a condition set forth by their insurance carrier and NOT the hospital The staff was also empowered to take partial payment with a promise to pay within 30 days Tracking of collections was instituted by units within Access and results were published within the department and monetary incentives were implemented for success 22

Upfront Cash Collections (continued) $40,000,000.00 $35,000,000.00 $30,000,000.00 Revised Incentive Plan in 2014 $25,000,000.00 $20,000,000.00 $15,000,000.00 $10,000,000.00 $5,000,000.00 $- FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 Goal Actual 23

Cash Collections vs Departmental Expenses $40,000,000 $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $0 Total Collections Total Expenses FY 08 FY 09 FY 10 FY 11 FY 12 FY13 FY14 FY15 FY16 Percent of Expenses Collected 140% 120% 100% 80% 60% FY 08 FY 09 FY 10 FY 11 FY 12 FY13 FY14 FY 15 FY 16 24

Duplicate Medical Records The Problem: No face to face verification of data Staff selecting WRONG patient when several patients with the same name were indexed (Example: John Anderson (31 in index) No approved search method in place No validating software 25

Duplicate Medical Records (continued) The Fix Created a standard for search. We now search in this order: Telephone number (patient change addresses but usually not phone numbers) Name Date of Birth Address Ask patients to verify information. Do not feed patients the information If one or more pieces of information do not match and cannot be resolved, create a new MRN and report to QA Analyst for verification. Note the system that this may be a duplicate The QA Analyst then does the research and, if appropriate, merges the records after discharge. (Physician will be advised of both records if the patient is in-house) 26

DMRs vs Avoidable DMRs 27

Space Constraints The Problem While we now had the right number of staff for each unit, not every department had the physical space in which to house the staff The Fix Explore options such as desk sharing, shifts, etc. Those options were not viable because often the tasks required were only able to be accomplished during business hours Finally, the decision was made to experiment with utilization of telecommuters for telephonic tasks that did not require face to face interaction with the patient Criteria was developed to decide which employees would be offered the opportunity to work from home Our legal department developed a contract for the telecommuters to sign obligating them to all the same confidentiality and work ethic rules we require from on-site staff 28

Telecommuters Eligibility Requirements Must have reached PAR II status Must be in the department at least two years Must have 99% QA scores consistently one year prior to becoming a telecommuter Must have NO counseling during history with department Must be able to pass annual competency test Must be willing to work from home for a minimum of one year Must be willing to have home workspace inspected by leadership Must be willing to purchase renters insurance (if applicable) ** This is because the hospital provides all equipment to the telecommuter 29

Telecommuter Program Outcomes There are currently twelve telecommuters working at home for the Access Department Six of them have been home for eight years Two of them have been home for six years Two have been home for four years Two are new to the Telecommuter Program. Telecommuters are required to resolve 40 accounts daily. The typical productivity for our telecommuters is resolution of 50-70 accounts daily, depending upon the complexity of the account The telecommuters have always been and continue to be our highest producers of quality work 30

Newest Initiatives Implementation of Scheg/Reg Centralization of Cancer Center Authorizations In-house Eligibility 31

Implementation of Scheg/Reg The problem Patients complained of too many phone calls prior to arrival for their appointment Patients also complained of having to give the same information to several different callers The Fix: A unit was created to schedule appointments and pre-register the patient all in one call The unit started with four high volume clinics Every scheduler was required to spend two weeks in each clinic learning the practice Templates were built to accommodate each physicians individual schedule preferences Once the unit was operating at it s highest level of accuracy, two more clinics were added and have been operational for three years Two more clinics are scheduled for addition to the unit this fiscal year. Important note: This project was FTE neutral Because this is an enhancement to the physician practice, physician satisfaction has improved and they have become supporters of concept 32

Outcomes of Scheg/Reg Implementation Patient satisfaction scores went from 80% to 94% in the first year. Currently sustained at between 94-96% Data integrity improved significantly because trained registrars were doing the input The physicians began to see Scheg/Reg as an enhancement to their practice Registrars enjoyed learning the new scheduling skill which was apparent on the Employee Satisfaction Survey There is more ownership of the account by the schedulers Authorizations are timely and on a work queue 33

Centralization of Cancer Center Authorizations In July of 2015 Authorizations for the Samuel Oschin Comprehensive Cancer Center were centralized into a team of six people People with experience in cancer center authorizations were recruited and trained Each staff member was assigned three Cancer Center physicians Our goal was to reduce Cancer Center denials by 10% in the first year of operation Denials were reduced by 15% between July 2015 and July 2016 Denials in August and September of 2016 are the lowest in the documented history of the Cancer Center 34

Bringing Eligibility In House For many years, Cedars-Sinai paid an outside vendor and a contingency for all collected Medi-Cal accounts In 2015, an analysis was presented to senior leadership and the decision was made to bring the process in house Cedars hired a Department of Health Services eligibility worker for on-site approvals and three highly experienced intake workers The department saved the organization $4.7 million in the first year of operation Note: Because the department is relatively new and approval times with Medi-Cal differ greatly from case to case, the data is not yet available to determine the percentage of increase in approved cases 35

In Summary Major Change/ Improvement takes time, so make sure goal timeframes are realistic All the success achieved by this facility could not have been achieved without the investment in solid, applicable training Performance Standards are critical. Standards should be attainable but a stretch Track performance and be sure the staff KNOWS you are tracking it. Report it to staff every month. Watch for trends both positive and negative. Be diligent. Often a very small adjustment can create great improvement Celebrate every success View poor performance as an opportunity to retrain until that effort is exhausted. 36

The Future 37