Clinicians put brakes on lost charges

By getting financial staff to understand the clinician's point of view and finding a way to work together, Scripps Memorial Hospital in La Jolla, CA, has been able to capture millions in additional revenue, including $10 million just from the operating rooms.

Thousands of charges are lost at hospitals, either because they aren't inputted correctly or on time, or they don't adequately reflect the care that was provided. This situation was happening at Scripps as recently as three years ago, says Lisa Thakur, CPA, MBA, FACHE, FHFMA, corporate vice president of operations, clinical and support service at Scripps Health in La Jolla.

"The individual departments were supposed to be inputting their charges and then reviewing them on a daily basis to ensure their accuracy, but that is not really their focus," explains Thakur. "We found that a lot of charge sheets were not even getting inputted. They were being dropped or being done after the bill was dropped, which really is not helpful."

Thakur concluded that tasks such as charge entry should be handled by financial staff and that clinicians need added resources to help with documentation. She implemented a centralized charge capture system that involved assigning two people from revenue cycle to handle all charge entry. This requires people with knowledge of the revenue cycle to have a very different type of relationship with clinical management, says Thakur. "Clinicians don't understand all the rules and requirements [for billing and reimbursement], and it gets into a lot of details, but you are leaving money on the table because of this."

According to Mimi Johnson, manager, of access and scheduling services at Scripps La Jolla, during the transition they "discovered several areas in need of process change and improvement to ensure charges being entered are accurate, validated, and completed in a timely manner." For example, inservices on accurate documentation were provided to RNs and their managers. "This includes the OR and the floors and units," Johnson says.

Documentation specialists were assigned to the ORs across all five Scripps hospitals. They work with clinicians to make sure care is properly documented. Thakur worked with clinical managers to develop a review and audit process. "When they enter the charges, they validate them, and then they are reviewed and audited [by supervisors] so that we can ensure that not only was [the care] documented, but it actually was entered on a timely basis, so we carved out that piece," says Thakur. "We decided we needed people under revenue cycle to do that type of work rather than assuming that clinical management is going to do it. We estimate that the net revenue [from this process change] just on the OR piece is $10 million per year."

Materials coordinators work with the leaders of each service line, says Sally Super, RN, OR manager, Scripps Memorial Hospital La Jolla. "Prior to this collaboration, many items went shipped overnight, borrowed from other facilities, or cases were having to be cancelled due to the lack of coordination with all responsible staff and physicians," Super says.

While previously five cases per year were being cancelled due to supplies not being available, now no cases are being cancelled, Super says. "Cancelling cases are a huge dissatisfier for patients' families and physicians as they make many plans to coordinate their office time and OR time, and families take off from work or drive a great distance to have their procedures done," she says. Also staff members' satisfaction increased when they didn't need to be off work, due to flex time.

Many bills previously were held up because of inaccurate documentation. Now, "that has been eliminated because all members of the team are aware of what needs to be charged, and follow-through from our materials coordinators has been instrumental to the completeness and accurate documentation," Super says.

The OR staff work weekly, and sometimes daily, with the materials coordinators to ensure materials and supplies are available for specific cases. "Clinicians are able to focus on patient care, and working collaboratively as a team with Charge Master and materials [coordinators] has been a huge payback in terms of reimbursement and accurate documentation," she says.