Technology: Friend or Foe to the Revenue Stream

Hospitals have, for years now, depended on information technology for the billing of services provided. The billing and reimbursement rules have continued to change and get more complicated as technology diversity and capabilities have grown by leaps and bounds. Where there was once one vendor driving all the charge and billing activities, now there are many legacy systems supporting the various clinical departments and their clinical documentation and charge processes.

Although it is often prudent for clinical departments to have “best of breed” IT systems to support the provision of care and the documentation and billing for services, the independent systems can have a dramatic impact on the revenue picture. Most of these systems all have their own charge master which is “presumably” in sync with the hospital’s charge master. When coding is done in part by HIM and in part by charge entry at the clinical department, it is presumed that IT interface rules correctly govern what coded and/or charge entry data travels to the bill. These presumptions must be tested routinely in order to assure that the Hospital is capturing all revenue that it is due.

In this consultant’s experience, there are very significant revenue opportunities to be gained by not blindly trusting the IT interfaces and the inner workings of the billing data stream and by systematically examining the presence, absence and integrity of all clinical and demographic data that was intended for the bill. This can be an arduous task and cannot be accomplished by running billing data through any software program. One needs to compare key sets of data to be certain that everything that was intended for the bill, indeed got there. Key data sources include:

• charge documents from the clinical site;
• medical record documentation;
• clinical documentation from the legacy systems;
• charge masters (the main Hospital CDM and charge masters resident in the legacy systems)
• the Patient Accounting System data;
• the UB; and
• the Remittance Advice.

The discrepancies among these data sources (which will exist) then needs to be investigated and the “root” cause of the discrepancy pinpointed, fixed and tested. The identification of the problem and the solution is best tackled by a multi-discipline manager group led by an individual who can transcend the often “silo” views of the various department managers. Solutions usually have an impact on more than one department and thus need to be examined by managers who understand and can articulate the impact of any change on related work and system processes.

Some of the types of issues that this consultant has encountered include:

• Diagnostic and procedure data is entered at the clinical site for endoscopy procedures by a clerical person based on the scheduled procedure. These procedures are then coded by HIM. The system is “supposed” to transport the HIM coded data to the bill; however the data entered at the clinical site is what ends up on the bill.
• Pharmacy items dosed in the pharmacy system do not translate correctly to billable units in the billing system; thus underpayments and denials result.
• Time in the OR for ambulatory surgery overwrites the procedure that was done resulting in lost revenue under APCs.
• A diagnosis entered at a clinic site for a clinic visit populates the UB diagnosis field for an MRI/CAT/PET thus resulting in denials for medical necessity.
• Hospital charge codes for services in oncology, dialysis, cardiac are not in “sync” with the charge codes in the legacy systems and thus incorrect services are billed for or not billed at all.
• Modifiers attaching to the wrong CPT on the bill due to “hard coding” issues.

Revenue opportunities related to working through these sometimes laborious challenges are significant. This consultant has been able to bring opportunities in the millions for many of their valued clients. The efforts reap dramatic results.