Teamwork and Excel expertise lead to fewer on-hold’ accounts

Effort targets reasons behind DNFB, OPEX lists

Philadelphia’s Presbyterian Medical Center, part of the University of Pennsylvania Health System (UPHS), is dramatically reducing the number of accounts "on hold" in its DNFB and OPEX queues — and freeing up the revenue they represent — with multidisciplinary teamwork and the development of review and monitoring reports on Excel spreadsheets.

The project targets accounts in the "discharge not final billed" and "outpatient exception" categories, which — for a variety of reasons — have not been billed to the patient or the patient’s insurance company, says Anthony M. Bruno, MPA, MEd, director of patient access and business operations.

During a two-month period from March 7 to May 8, 2003, the number of DNFB accounts was reduced by 18%, representing a dollar amount of $3,818,057; while OPEX accounts were reduced by 2.3%, representing a dollar amount of $1,520,478, or 18.7%, he adds. OPEX accounts older than 90 days were reduced by 60.8%, Bruno notes, while the dollar amount of those accounts was reduced by 55%, or $1,338,632.

"We have been working to improve our revenue cycle management, and there are a lot of aspects — front to back — that my department and others must get involved in," he says. "One of the things we have been most concerned about on the front end is management of the DNFB and OPEX reports. We wanted to create tools to help us address and monitor both of those pieces."

The challenge was that removing the hold on these accounts requires interventions by a number of departments and a cooperative, collaborative effort to resolve the problems that caused them to be placed on hold in the first place, Bruno says.

There are several reasons accounts might be placed on hold status, explains Raina Harrell, manager of access and financial systems. "You can enter all the information and think you did everything you needed to do, and [the account] will look perfect; but for some reason, the bill doesn’t go out the door." That might be because there was an automatic bill hold, the guarantor information was incorrect, a diagnostic code was not entered, or for any of a number of other reasons, Harrell says. "But if you look only at the front end and the back end, [an account] may look correct."

In addition, Bruno points out, gaining access to the specific accounts that make up the DNFB and OPEX reports was a complex task that required obtaining and cross-checking several reports created by the hospital’s computer system, which is a product of Malvern, PA-based SMS (Shared Medical Systems). Once the reports were obtained, he says, they were difficult to read and time-consuming to review.

When they worked together at another health care system, Bruno notes, he and Harrell had experience in creating tools to simplify this process, but with the computer expertise of outside consultants, who helped download the reports from SMS and compile them in a web-based format that provided access to individual account information.

Using in-house resource

Without a budget for outside expertise, Bruno and Harrell drew on in-house resources, assembling a team that included participation from — in addition to Bruno’s staff — the director of medical records, the medical assistance coordinator, and a financial analyst from administration.

The team discussed and implemented the following measures:

  • developed and created a DNFB and OPEX review and monitoring reports on Excel spreadsheets;
  • ensured that the DNFB and OPEX spreadsheet reports provide easy access to specific account information that could be reviewed efficiently and in a timely manner;
  • examined root causes of why accounts were on hold on the DNFB and OPEX reports;
  • established benchmarks for the DNFB and OPEX by "hold" area of responsibility for accounts on the report;
  • established strategies to reduce DNFB and OPEX accounts and dollars;
  • created and established an approach that encouraged team members to work collaboratively to reduce those accounts and dollars.

Depending on the reason an account was being held, responsibility was allocated to a particular department, Harrell says. Bills holding for diagnostic information, for example, are the responsibility of medical records. Those with user holds — a manual bill hold put on an account because it is awaiting additional information — go to the business office.

The bill might be awaiting, for example, an authorization number from clinical resource management or from an insurance company, she explains. "The business office can use [the monitoring and review report] to ensure that it is getting timely feedback [on missing information]."

After learning about the report and its purpose, team members were asked to help set expectations for their departments, Harrell says. "For example, we asked the business office for the average amount of time it should take to receive an authorization number so we could remove the user hold, and that amount of time became our benchmark."

"As we get better and the number of accounts is reduced," she adds, "we will lower the benchmark."

The process also has helped identify information systems issues, Harrell notes. "Maybe we’ve done everything correctly, but [the bill] is sitting out there because the system is not right — like there are two insurances on the front end and only one passes to the back end, or guarantor information or mapping tables are not set up correctly. We wouldn’t know it unless we use the tools to look and find those problems."

Key to the project, Bruno notes, has been the participation of Carrie Moore, a financial analyst with hospital administration, who worked with Harrell to create the pivot tables. (See Reductions chart, below, and DNFB Weekly Analysis chart.) "We really tapped into her Excel and computer expertise," he says.

University of Pennsylvania Health System - Presbyterian Medical Cener
Recent DNFB and OPEX Reductions Using New System

Source: University of Pennsylvania Health System — 
Presbyterian Medical Center, Philadelphia.

Those tables, Harrell explains, are an Excel option that will summarize data in a spreadsheet. "They make it possible to report and summarize different information without having to sort the actual data. The user can click on the specific information in the pivot table in which they are interested, and only that data will drop into a new spreadsheet just for them."

"The biggest impact we’ve made," adds Moore, "is taking canned legacy reports from SMS and parsing them out to get at the actual information and make it more actionable for individuals. In the process, we developed a way to scrub a text file version of the canned reports and arrived at a way to see a summary and see the details." The summary shows the number of accounts in each category, Bruno notes, and by clicking on that number, the user can see the accounts behind it.

Make everyone aware

All the departments involved — admissions, business office, medical records now can focus on the accounts they need to work, he says. DNFB and OPEX reports are created and distributed each Monday to the work areas responsible for holds, Bruno adds, as well as to the Presbyterian Revenue Cycle Management team. "Everyone is more aware of the accounts, and more cognizant of what their responsibilities are," says Harrell. "They know what accounts are out there, how they got there, how they can remove them, and what [each department’s] role is."

[Editor’s note: Anthony Bruno can be reached at (215) 662-9297 or by e-mail at]