HI555 Unit 10 Cycle Improvement Proposal Example

Send It Back When It Moves: A Unit 10 Cycle Improvement Proposal to Re-Verify Authorization on Every Rescheduled Surgical Case

[Student Name]

Purdue University Global

HI555: Revenue Cycle Management

Unit 10 Cycle Improvement Proposal

[Instructor Name]

[Date]

Bellcourt Health, its hospitals, cases, rates and costs are composite; the sources cited are real.

Summary

Rescheduled surgical cases at Bellcourt keep authorizations issued for another hospital or date window, and they are denied for authorization about twelve times as often as cases that never move. This proposal adds an automatic re-verification step for moved cases, tests it for eight weeks at the north hospital with the main campus as a comparison, and needs roughly $45,000 over twelve months, weighed against an estimated $250,000 in avoided write-offs. If the test meets a stated threshold, the change goes to both hospitals; if it does not, it is revised or dropped.

The Problem

The front-end process map in Unit 3 showed moved cases flowing on to the pre-admission call with no stop at the authorization desk. About 40 cases a month move across the two hospitals. Over the last two quarters, moved cases were denied for authorization at 95 per thousand, against 8 per thousand for cases that never moved. The denial analysis in Unit 5 found that authorization denials originating in scheduling are overturned less than half the time, so most of these become write-offs. At an average expected payment of about $9,400 per outpatient surgical claim and a write-off rate after appeal of about 60 percent, the moved-case path costs roughly $250,000 a year. Payer authorization lists now reach far into outpatient procedures (Schwartz et al., 2021), so the path will not shrink on its own.

One Change, and Why Only One

The proposal deliberately makes one change. Several other improvements are tempting, such as electronic booking for every surgeon's office and a new authorization tracking field. Making them at the same time would make the result impossible to attribute: if denials fell, no one would know which change did it. Improvement methods favor trying a single change in a limited place first and widening it only after it works, so that its effect stays visible (Langley et al., 2009).

The Design

Trigger. A moved case fires the trigger when any of three fields changes after authorization is recorded: the date of surgery moves outside the authorized window, the hospital changes, or the primary procedure code changes. Other edits, such as a new start time on the same day, do not fire it.

What the authorization team sees. The case appears in the authorization work queue with a flag showing which field changed, the old and new values, and the authorization details on file. The specialist checks whether the existing approval still applies and, if not, requests a new one or an update from the payer.

The hard stop. A flagged case cannot be marked ready at the pre-admission step until the specialist records the authorization as confirmed for the new date, hospital and procedure. If it is not confirmed by 24 hours before surgery, the surgeon's office and the patient are called, and the case is either held or the patient signs an informed notice of possible financial responsibility, according to existing policy.

A case whose authorization no longer matches cannot reach the operating room schedule without a person deciding that it should.

Measurement Plan

The measures are defined before the test, following the practice of choosing outcome, process and balancing measures together (Provost & Murray, 2011).

1. Outcome measure: authorization denials per thousand moved cases, by date of surgery.

2. Process measure: share of moved cases re-verified and confirmed before surgery.

3. Balancing measure one: day-of-surgery cancellations for lack of authorization, which could rise if the hard stop catches cases too late.

4. Balancing measure two: operating room minutes left idle by canceled or held cases, which would show any cost the change pushes onto surgical services.

Data come from the scheduling system's change log, the authorization work queue and the remittance files, reported weekly.

The Test

The trial runs for eight weeks at the north hospital, which moves about twelve cases a month and has a single authorization specialist who can learn the new queue quickly. The main campus runs unchanged over the same weeks as a concurrent comparison. Because both hospitals share payers, enrollment changes or new payer rules during the trial affect both, so a gap that opens between the two hospitals points at the change far more convincingly than comparing one hospital with its own past would. Eight weeks will produce only about 24 moved cases at the north hospital, too few to prove a reduction in denials on their own, so the process measure carries the trial: if re-verification reliably happens, the denial effect follows from the mechanism shown in the earlier units.

Cost

1. Build and testing: about 120 hours of informatics analyst time at $95 an hour, roughly $11,400, one time.

2. Authorization staffing: a half-time specialist position, about $34,000 a year with benefits, to absorb re-verification work at both hospitals once spread.

3. Training: two one-hour sessions for schedulers and authorization staff, absorbed in existing meetings.

First-year cost is about $45,000. Avoided write-offs, if denials on moved cases fall to the level of unmoved cases, would be about $230,000 a year after the change, since a small residual rate will remain.

Decision Rule

At the end of eight weeks, the steering group will adopt the change at both hospitals if three conditions hold at the north hospital: re-verification is confirmed before surgery for at least 90 percent of moved cases; day-of-surgery cancellations for authorization do not exceed one a month; and idle operating room minutes from held cases do not exceed the main campus's rate. If re-verification falls short, the queue design will be revised and tested for another eight weeks. If cancellations rise, the 24-hour threshold will move earlier. The denial outcome will be tracked for six months after spread to confirm the effect.

Limits

The cost-benefit estimate depends on average surgical payment and write-off rates from two quarters. A payer that relaxes its site rules would shrink the benefit; one that tightens them would enlarge it.

References

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

Schwartz, A. L., Brennan, T. A., Verbrugge, D. J., & Newhouse, J. P. (2021). Measuring the scope of prior authorization policies: Applying private insurer rules to Medicare Part B. JAMA Health Forum, 2(5), e210859. https://doi.org/10.1001/jamahealthforum.2021.0859