University of Pittsburgh Medical Center (UPMC) is the largest integrated health care delivery system in Pennsylvania and one of the leading nonprofit medical centers in the country. With more than 39,000 employees, it is the largest employer in western Pennsylvania. More than 4,000 physicians have privileges at UPMC hospitals including about 1,950 employed physicians. UPMC spans the full spectrum of health care delivery with its network of 19 tertiary, specialty and community hospitals and 400 outpatient sites and doctors' offices.
Historically, hospitals have manually contacted third-party payers to obtain eligibility and coverage information. Currently, many payers offer Internet access on a single patient inquiry basis or use service bureau firms that provide these transactions in a batch or real-time mode. However, these transactions have a cost associated with them, which are billed to the hospital. While very efficient for many hospitals, UPMC has visit volumes that make traditional per-transaction costs a significant budgetary burden.
UPMC turned to Boston WorkStation™. Boston WorkStation is a workflow automation and integration technology that provides an environment for on-demand process innovation and development. Boston WorkStation allows healthcare organizations to dynamically respond to changing business and compliance requirements by automating common tasks, creating complex processes, automating interaction with Web sites, or integrating new applications, systems and devices.
UPMC is using Boston WorkStation to go directly to payers’ web sites to electronically obtain real time insurance eligibility, and then automatically post that information to the patient accounting portion of their McKesson hospital information system. "With Boston WorkStation we have eliminated the service bureau costs and provided an alternative if the service bureau cannot support a payer. Given that UPMC has annual visit volumes of approximately 1.5 million (6,000 per day), we will see significantly greater efficiencies by using Boston WorkStation. In the next few months, UPMC will implement this automated workflow system for Medicare, WebMD and Pennsylvania Medicaid," said Don Riefner, vice president of finance at UPMC.
By completely automating the file movement process in both directions, the eligibility is handled as a production job that does not require human intervention, and may be run at any hour of the day or night.
In addition, new HIPAA transaction sets, labeled "276/277," require a hospital to obtain the current status of a claim within the adjudication process. This extremely valuable information allows UPMC to focus its claims status follow-up efforts with laser like precision and optimize the productivity of UPMC staff. Presently, very few payers support processing 276/277 transactions in a Web-based and/or batch mode. Using the Boston WorkStation technology, UPMC is implementing an automated electronic claims status process for commercial payers, Medicare and Pennsylvania Medicaid.
UPMC continues to set the standard for commitment to clinical excellence, education and research, and the application of innovative technologies. For the past six years, it was recognized as one of the most technically savvy hospitals by Hospitals and Health Networks. As a leader in revenue cycle management, UPMC is deploying innovative approaches towards process improvement and revenue enhancement.
