After an EHR implementation, flaws or errors in revenue capture end up costing healthcare institutions up to 5% of their gross revenue.
Piloting a new collaborative effort, several health systems have come together across institutional boundaries to avoid those post-implementation losses by optimizing the charge auditing program they have in common. Working together, the group has determined the audit software's most valuable "edits," or programmable logic that automatically flag mischarges or reporting errors before they are sent out. This article briefly describes this unusual collaboration and then lists the 5 charge auditing program edits they've found to have the greatest financial impact.
Cross-institutional collaboration: a pilot group expands
The health systems in this network were originally connected by a common consulting firm, McKinnis Consulting Services, now a part of Navigant. Navigant McKinnis was engaged to protect revenue throughout EHR implementations at these various institutions. These efforts included using and optimizing the EHR company's application for auditing charges. Working with clinical leads, revenue cycle managers, revenue integrity teams, and coders, Navigant McKinnis worked with each client organization to determine where they were losing revenue and what configuration of the system would stop those losses. While each organization had its own timing, routing, and set of priorities for these edits, some basic benchmarks emerged, and those benchmarks were shared within Navigant McKinnis and passed along to different clients.
This kind of mediated information-sharing is not unusual, but it tends to remain informal, yielding benefits haphazardly and with necessary time lags. The health systems in this case sought a closer, more consistent relationship, where information-sharing could happen without mediation. The result of that collaboration was not only more timely information about charge auditing fixes (and bugs), but also a growing repository of useful edits meant to create a "rising tide" of revenue cycle performance throughout healthcare.
What insights did this direct collaboration uncover? Among them was the recognition that while individual organizations have unique gaps in revenue performance, there are areas of opportunity, in charging in particular, that appear to be universal. These include:
Administrative Codes
• Incorrect administration codes are often responsible for gaps in revenue capture, especially when different codes apply to versions of the same procedure (an infusion of saline vs. an infusion of chemotherapy, for instance). Not only should nurses administering chemotherapy charge for the more expensive chemotherapy product, they must also code the infusion itself with a higher code.
The reasoning behind the differing list of administrative codes does not always translate to clinical commonsense, so having technological fixes that can automatically flag insufficient charges or other protocol problems is invaluable.
Anesthesia
• It is not always clear (or easy to recall) when two distinct aspects of a single procedure should be charged separately. Edits that automatically flag the absence of one or the other of these aspects have yielded great results in terms of capturing missing revenue. Anesthesia is one of the areas where these edits are having the biggest impact. Health systems now flag any procedure where anesthesia is typically used but where it hasn't been charged.
CT
• Automatic review of charges is also making revenue capture inroads in the radiology space, where CT exams can be given with or without a contrast agent. Like procedures that also require anesthesia, the CT exam must be charged first, but then the person entering the charge must also note that contrast was present in the exam.
ED Levels
• Downcoding in the emergency department—when a clinician neglects to categorize a high acuity patient in the appropriate designation—is a single error that can lead to more significant financial consequences downstream. Codes in the ED are responsible for direct reimbursement, as with the other examples in this article. But in the ED, these codes are also used to compute how performance-based reimbursement. If a high acuity patient is treated in the emergency department under a lower level designation, that simple mis-designation can decrease the acuity ascribed to the ED's patient group overall, which in turn raises the expectations about patient outcomes. If these inappropriate expectations are not met, the ED can lose revenue or even face substantial financial penalties.
Infusions
• Infusions are some of the most frequent charges in healthcare, and thus constitute an obvious target for auditing. Additionally, the complexities of the charges associated with infusions—the necessity of including both the start and stop times, the added issue of "carve out periods," and the difficult rules concerning what is and isn't a legitimate charge during an infusion—make logic-based edits around infusions a critical tool for clinicians entering charges. (An automatic flag for a missing stop time is one extremely simple, but extremely useful, fix.)
Collaborating with competitors has, of course, secured more effective financial performance for each participant. But it has also led to the better, more meaningful use of technology in healthcare, which has long been a goal of healthcare reform. Finally, with more accurate knowledge of what actions are being taken and to what effect, collaborations like this one can provide the necessary detail for ongoing efforts to quantify, and improve, care.
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