Are you losing $250,000 of revenue each year?

Would it surprise you to know that your emergency department (ED) may be missing out on $250,000 a year of legitimate payments? Due to high patient volumes in EDs, minor billing errors can result in significant revenue loss, says Jeffrey Bettinger, MD, FACEP, founder of Bettinger, Stimler, & Associates, a Pinecrest, FL-based organization specializing in health care reimbursement. Bettinger estimates that many EDs are losing $10 of net revenue per encounter. "For EDs with an annual volume of 25,000 patients, that equates to $250,000 of lost revenue per year," he says.

Here are three ways to improve your revenue:

1. Don’t undervalue the ED level of service. Selecting the level of service is a surprisingly subjective process in most EDs, according to Marty Karpiel, MPA, ambulatory care consultant for the Karpiel Consulting Group in Long Beach, CA, which specializes in operational and financial process improvement for EDs. "Oftentimes, nursing staff are expected to not only care for the patient, but also to determine the appropriate level of service," he adds.

As a rule, clinicians tend to undervalue services, Karpiel says, adding that you need a methodology that accurately assigns the level of service. He notes that the physician level of service may differ from the facility’s. For example, with conscious sedation, the physician provides the orthopedic or laceration repair care, and a nurse subsequently has to monitor the patient for an hour. "Clearly in that situation, the resource intensity is significantly greater for the facility than the physician," Karpiel says. However, he says that some facilities will use the physician level of service regardless. "I often find an incredible variance between the services provided and the way hospital charges for them," he says.

Karpiel recommends using a point-based system to allocate a certain amount of points to each nursing activity, with the sum of those points determining the level of service.

2. Make sure there are no missing procedures. Poorly documented records are a major source of revenue loss, says Bettinger. "Each provider should be trained on the most effective ways to accurately describe the patient encounter," he says.

Nurses usually chart medications consistently because they have to draw and administer these, but they don’t always document procedures that are more physician-involved, such as laceration repairs or fracture reductions and splint applications, he says.

An individual who understands what goes on in the ED should review all your charts, such as a former nurse or paramedic or ED tech, Karpiel says. "If services are missed or not documented, that feedback should be provided to nursing staff on an individual basis," he advises.

3. Avoid lost billing for patients. Often, not every patient seen by the ED physician has a bill generated, Bettinger says. "Records can disappear prior to being sent to the billing agent," he says. "This typically happens on admitted and transferred patients, or those that have transcribed medical records."

Use the ED log as a control document, and have a process in place to account for 100% of all ED visits, Bettinger recommends. He suggests performing a 100% reconciliation with the ED log and the number of records sent to the billing agent. However, since a complete set of records often is not available until several days after the date of service, Bettinger notes that someone needs to perform the laborious, detailed job of tracking down the medical records for every name on the ED log. "If this job is not performed in a diligent manner, many medical records will not be sent to the billing agent, leading to significant loss of revenue," he warns.

4. Don’t exceed time limits for billing. Exceeding time limits for billing often is a problem when EDs have a high turnover rate of physicians, since many payers, especially Medicare and Medicaid, require all invoices to include the provider identification number (PIN), Bettinger says. "Often, the PIN takes months to be obtained," he says. "If there is not tight control of the process, many invoices will become too old to allow them to be submitted to the payers."

Typical problems are provider delays in filling out the forms, lost paperwork, and inaccurate submission of information, Bettinger says. "Someone needs to take ultimate responsibility for walking the application completely through the process," he says. "It’s really a matter of using simple tracking mechanisms to make sure that no one is dropping the ball."


For more information about reimbursement, contact:

• Jeffrey Bettinger, MD, FACEP, Bettinger, Stimler, & Associates, P.O. Box 565940, Pinecrest, FL 33256. Telephone: (888) 568-4993 or (904) 247-4993. Fax: (904) 247-4878. E-mail:

• Marty Karpiel, MPA, Ambulatory Care Consultant, Karpiel Consulting Group, 6475 Pacific Coast Highway, Suite 402, Long Beach, CA. Telephone: (562) 597-1108. Fax: (562) 597-7448. E-mail: