Right charges, resource key to charge capture success

Consultant: Push job back to clinicians

When it comes to the crucial arena of charge capture — making sure that providers are paid at the appropriate level for all services rendered — it's all about "the right charges and the right resource putting the charges in," says Gala Prabhu, a New York City-based senior manager for Accenture.

If your patient access department is tasked with entering those charges, you should be pushing that job back to the departments providing the service, Prabhu advises. "Charge capture should be done by the people closest to delivery."

Tightly integrated charge capture and reconciliation processes are critical for hospitals, she says, pointing out that missing and/or lost charges have a significant impact on revenue for these reasons:

  • Items that are never charged cannot be billed to the patient's insurance company.
  • Missing charges adversely affect the level of reimbursement depending on payer (diagnosis-related group [DRG], fee for service, etc.).
  • Poor reconciliation or lack of reconciliation can lead to billing errors due to inappropriate charges being entered on the front end because of submission of late charges or missing documentation.
  • Missing charges impact census balancing and capacity management.

"There are different ways that charges get into the system," Prabhu explains. "One way is for the charge to drop as soon as an order comes in. Another way — as with pharmaceuticals — is for [the charge to drop] once a nurse indicates the drug has been given."

Radiology charges, she notes, in many cases don't drop unless the test has been read and the results dictated.

The goal is to make sure that if 10 patients came in for services, there are 10 sets of charges — that you're not missing revenue or documentation of charges, Prabhu says. "What we do is go in and say, 'How can you prevent lost or missing charges?'"

The solution, she adds, lies in developing internal controls and reconciliation mechanisms to verify that all eligible charges are accounted for and processed within 24 business hours.

"You make sure, by running exception reports, that you are tracking that you got the charges in, and that they actually hit the billing system — that they don't, for example, go to the wrong account," Prabhu explains.

In the operating room, charges typically are checked off as they are incurred, while the surgery is taking place, as with a super bill, she says. "The issue comes if you didn't pick the right patient or the right encounter. If someone is not doing reconciliation, the account just lies there. Sometimes a whole batch doesn't go through due to technical error, and sometimes staff on the back end don't know to ask, or who to ask."

While it is considered best practice for charges to be entered at the point of service by clinicians, she says, her experience has been that patient access staff continue to perform the job at many health care institutions.

"In the past, what's happened with some of the clinical departments is that they say they don't have time for administrative work, that they're too busy looking out for the patients, so it's pushed onto patient access," Prabhu says.

"A lot of the systems are not sophisticated enough or programmed appropriately to capture the charges [automatically], so a lot is done on paper," she adds. "Pages are missing and the department is always trying to follow up on missing charges. So they finally say, 'We'll get someone to come in and take over that responsibility.'"

That someone typically has been a clerical employee in patient access, Prabhu says. "They don't go to medical records staff — they're too expensive."

"What normally happens," she adds, "is clinicians fill out a super bill, and patient access has the responsibility of getting the charges in, doing data entry."

At the end of the day, Prabhu says, "the OR used to collect encounter bills and send them to the front end. Patient access staff could run back up and check with the nurse [if there was a question]. That was the thinking."

The problem with patient access staff performing the job, she contends, is that "they really don't own it. It's unfair for them to do it because they don't know what happened to the patient. It won't strike them to ask, 'How can a person have this knee surgery without an implant [listed on the bill]?'"

With the new technology and software now available, Prabhu says, "things are changing. [Technicians] are punching into a handheld device or directly into the legacy system that they gave the patient this drug, instead of filling out a super bill."

Data entry should be done at the point of service by clinical persons, she emphasizes. If patient access staff are doing this, they should be saying that it's best practice for it to be done by the clinician delivering the care."

(Editor's note: Gala Prabhu can be reached at sumangala.prabhu@accenture.com.)