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Here’s a concept that could make an access manager’s day: Each department in the hospital is responsible for being educated on reimbursement within that discipline — be it cardiology or oncology or radiology — and taking an active role in understanding its impact.
"Who knows more about cardiology than the director of cardiology?" notes Robert Lynch, director of cardiovascular and pulmonary services for Morton Plant and North Bay hospitals in Clearwater, FL. "You can’t have access services people in every department to assist with documentation every time a person goes from cardiology to surgery. It’s the people there who are accountable."
While in years past the personnel in oncology or cardiology or radiology concentrated only on the clinical, he says, they now must understand that running a hospital requires a three-legged stool management approach and the legs are service, outcomes, and cost.
An initiative known as the revenue capture program, which drives home this point to personnel at the Morton Plant Mease Healthcare, a community health alliance that is part of the Baycare health network, has been responsible for adding millions to the bottom line at his hospital alone, Lynch adds.
"The key is to move reimbursement out of the basement," he explains. "It needs to be moved up to the department level. The people there are taking care of patients, but they’re also running a business, and they have to understand business management and make sure they get paid for the hard work they do."
With that in mind, Morton Plant Mease offers a course — for the directors and managers of all revenue departments — called "Capturing Reimbursement and Documentation." Another course is called "Capturing and Auditing the Revenue." A process flowchart used in the course illustrates where the hospital is at risk for not getting paid. (To see illustration, click here. Source: Morton Plant Hospital, Clearwater, FL.)
What happens in his organization that does not occur at most other hospitals, Lynch points out, is that personnel from the various departments go to the physicians’ offices and help them with reimbursement and documentation issues. "What we’ve been able to show physicians is that by improving their processes for documentation in the hospital, they can substantially increase revenues in their own practices."
Key to the success of his own department, he notes, was the reallocation of a registered nurse who had a strong interest in reimbursement, coding, and documentation. That person interacts on a daily basis with all the departments related to cardiology and facilitates the revenue capture process, Lynch says. "I know it is difficult to take staff away from your area, but reassigning based on a priority is sometimes best for all."
The foundation of a successful revenue initiative, he emphasizes, is a good hospital-physician relationship. "The physicians and the hospital administration and the team members have to believe that there is a symbiotic relationship. If that’s not there, you’re in trouble."
It’s one thing for the hospital to have an internal auditing process and to look at ways of saving money through its own internal processes, Lynch says. "When you get into the revenue capture arena, you really get serious about it. You’re looking at all your providers, and you cross the boundaries from internal to external."
Questions to be asked, he adds, are, "Do you have the right information? Is that information brought down to the level of site of service?"
If everyone involved doesn’t really understand what the program is about and know all the building blocks, Lynch points out, they won’t be able to interact appropriately. "I’m a strong believer that people have to understand why they’re doing something, not just be told to do it."
One example, he says, is all the talk about the importance of physician compliance in documentation to Medicare and in the HMO approval process.
"They talk about all these rules [physicians] are supposed to know, but there are actually two sets of rule books — InterQual and Milliman & Robertson," Lynch adds. "Medicare uses InterQual, and Medicare HMOs and PPOs sometimes use Milliman & Robertson."
Adding to the potential for discrepancy, he says, is the fact that medical schools often have a different lingo than that contained in the Correct Coding Initiatives, and that the language the physician is familiar with varies according to when he or she attended medical school.
"It’s real important to know that if you go into a department and try to teach documentation, it’s a little like teaching medicine," Lynch notes. "You have to know the root cause and origin."
If a patient comes into the emergency department (ED) and says, "Doctor, my chest hurts," he continues, that could indicate a pulmonary, cardiac or skeletal-muscular problem. If the physician admits the patient for chest pain, there are problems right off the bat, Lynch adds, because some payers say some individuals with chest pain should be classified as outpatients and others as inpatients.
If tests are done and it turns out the person has gastritis or a hernia and so is discharged, then because the classification was "inpatient," there is a denied admission, he says. On the other hand, if the person is admitted as an outpatient, and then serious cardiac problems are discovered and no one changes the admission criteria, the hospital may end up receiving an outpatient payment for a coronary artery stent placement, Lynch adds.
That’s why, he says, "you can’t lay down a set of arbitrary rules and expect anybody to follow them."
Instead, Lynch explains, his organization uses an algorithm or decision tree in key areas such as the ED, cardiology, and radiology. "You compile a revenue and reimbursement profile, building each episode of care onto the next episode, so it’s concurrent."
Specially trained nurse case managers work in the ED and make daily rounds on the floors to assess the documentation for patient status and for the revenue and reimbursement profile, he adds. "This process has proved to be extremely successful in reducing rework on claims denials and improving our reimbursement status."
That means, Lynch says, that after the initial admission to the ED, someone will say, "What should it be?" and after the heart catheterization, "What should it be?"
"After each event," he adds, "you should reassess the patient’s reimbursement status as well as the clinical status. But what happens in most institutions is that it’s all done retrospectively, after discharge. Then they realize the proper documentation didn’t occur somewhere during the stay, and so we didn’t get paid for the work we did."
Another part of the revenue capture program, he notes, is that every day all patient services departments get an audit from patient accounts of everything that was charged the previous day and how that compares with what was actually done.
"As good as we are, we still find discrepancies," Lynch says. "Putting in charges is not [a clinician’s] priority, so it’s not unusual for them to forget some item during a critical time, or for the documentation from the physician to be more symptomatology than diagnosis."
There’s a big difference between the two, he adds. "A lot of physicians write more symptoms than diagnosis, but you code off diagnosis. We audit every day just to make sure everything was documented appropriately the day before. We have no idea yet if we got paid, we’re just checking for appropriate documentation."
It’s key that the audit be done daily, Lynch notes. It’s not unusual for hospitals to do a monthly audit, he adds, but that just wouldn’t be meaningful for his department, which does 25 or 30 heart catheterizations a day.
Every other day, he says, each department gets a list of cases, including "name, type, everything," that coding or patient accounts personnel have had a problem with. "Then we can retrospectively go down and assist admitting and coding employees." People in most departments are trained to perform that function, he says. "It’s the responsibility of the department [personnel] to know their service."
"We’re able," Lynch adds, "through a very positive interactive relationship with coding and patient accounts, to either help them get paid for what we do or identify the documentation errors and fix them for next time."
"Site of service" is the operative phrase, he emphasizes. "What’s important is, wherever the service is provided, taking action along the way to make sure the proper steps are taken. We’ve come a long way, and we have a long way to go, but we’re realizing just how valuable this is."
[Editor’s note: Robert Lynch can be reached at Morton Plant Hospital, 300 Jeffords St., Mail Station 135, Clearwater, FL; telephone, (727) 461-8173; e-mail, email@example.com.]