Ambulatory Care Quarterly: A billing analyst can find $300,000 for your ED

A dedicated billing analyst for your emergency department (ED) can generate hundreds of thousands of dollars that goes straight to the bottom line instead of just flying out the window, say two managers who have added about $300,000 a year. And that’s a net increase in revenue after accounting for contractual discounts and reimbursement levels, and after subtracting the salary of the billing analyst.

The ED at Carondelet St. Mary’s Hospital in Tucson, AZ, has had a billing analyst in place since 1996, and she has greatly improved the financial status of the department, says Cassie Pundt, RN, clinical manager of emergency services. "I know that we’re capturing tons and tons of revenue that otherwise would have been missed," she adds.

The other billing departments and coders don’t look at things as closely as they do, so many items are overlooked, Pundt says. "Other hospitals use their own billing departments and train people specially for ED charts, but we have a dedicated person for just reviewing ED charts within our own department," she explains.

The difference all comes down to the degree of expertise and how much the analyst can focus exclusively on ED charts, she says. Having one person who is experienced in the ED and can focus entirely on its charts yields far more revenue than just urging staff in the hospital’s billing department to look more carefully at the ED charts, Pundt continues.

The St. Mary’s ED billing analyst reviews all charts before they leave the ED and looks for missing documentation or errors that might result in reduced reimbursement. If anything is missing, she can go directly to the appropriate nurse. If the nurse has miscoded the acuity level, the analyst can study the care provided and has the authority to raise the acuity level when appropriate.

The St. Mary’s billing analyst program was started by Maggie McClellan, RN, MBA, now director of emergency critical care services at sister hospital Carondelet St. Joseph’s Hospital in Tucson.

She recalls that her ED in 1995 routinely was losing out on money it was rightly due.

"Every day, I would get a pile of either lost charges or inability to charge from our charging department because of inappropriate documentation or lack of charge slip being sent to that department," she says. "I had an employee who was on light duty, and I was looking for something for her to do. So I had her start checking records before they left the department to see how we could capture charges better."

That modest effort started paying off, so McClellan put more effort into it. The St. Mary’s ED developed a process for using bar codes based on charges, and then the billing analyst used those bar codes and a thorough catalog of procedures to check charts for the necessary documentation.

Within a couple of months, she realized that the ED was recouping more money than it was spending on the billing analyst.

After a year of success with the effort, McClellan proposed to the hospital that it create a permanent position for an ED billing analyst. After she showed hospital leaders the numbers from the past year, they couldn’t say yes fast enough.

Over that first year, the St. Mary’s ED billing analyst identified more than $1 million of charges that would have been lost, McClellan says. After applying the hospital’s standard contractual discounts and other factors that reduce the actual reimbursement level, the ED actually received about $400,000 in additional revenue for the year. The billing analyst made about $12 an hour, so with her salary and benefits deducted from that sum the hospital was left with about $300,000 per year in new revenue.

"That’s held steady for a while now," she says. "It’s clear that you can recover far more than you pay for the billing analyst. It’s kind of a no-brainer when you look at the numbers."

When she moved to the St. Joseph’s ED across town, McClellan instituted the same program and is seeing the same results. Experience in the ED is important to making the billing analyst effective, so she looked for someone who had been there long enough to know the staff and intricacies of how the department worked.

She also wanted someone who could be extremely focused and "willing to be very nitpicky and thorough when reviewing the charts." She found a clerk who had been there for 15 years and moved her to the new billing analyst position.

McClellan says you can expect to pay between $12 and $17 per hour for a dedicated ED billing analyst.

St. Joseph’s considered providing a bonus program to the analyst tied to the amount of revenue she generated from chart reviews but ultimately decided against it.

Such a bonus program could encourage the analyst to be too liberal in assessing charts and lead the hospital into fraudulent charges. Instead, the analyst participates in a bonus program open to other employees but not tied directly to the amount of revenue she generates.

The St. Joseph’s ED sees more than 60,000 patients a year, and the billing analyst must review each of their charts before it leaves the department.

"She’s busy but stays pretty well current," McClellan explains. "Mondays are bad because she has to do charts from the whole weekend. She has three days to do the reviews and usually makes it."

Aside from the increased revenue, McClellan points out one benefit of the billing analysis: She gets to see exactly how well individual staff members are documenting patient care.

"It does allow us to do focused reviews from a staffing standpoint to see who is appropriately documenting and who isn’t," she says. "The nurse manager will speak to the billing analyst and see who isn’t documenting appropriately and then speak to them or provide additional training."