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The crossroads of the administrative record and the medical record is where the key to financial health lies for health care providers, suggests Jack Duffy, FHFMA, director and founder of Integrated Revenue Management in Carlsbad, CA. The access department is the basis of patient demographics — putting the patients’ charts together and making the initial code selection — and the physician lays the foundation of clinical messaging, Duffy says.
"Billing and contracts intersected with clinical messaging — that’s the source of all wealth coming into a hospital — and if there’s any lack of clarity, hospitals never reach the full value of the work they do." Too often, he adds, "each [process] spins in its own world, and they don’t intersect. It’s the most troublesome part of our business, and a big piece of overhead. Access holds half the deck; the other half is in the documentation/coding hand. Unless you play both hands together, you can’t move your organization to optimum reimbursement."
Ironically, Duffy points out, some of the moves that have strengthened the profile of access management also have contributed to this lack of communication. "Historically, there was the omnipresent business manager who knows both the front and the back end," he says, "but we’ve modified a lot of our reporting relationships to move access into clinical areas. There may be an emergency department [ED] manager, for example, while the business office has its own manager."
"The good news is it has elevated the [access] profession," Duffy adds. "The bad news is it disconnected some of the knowledge pieces."
Access professionals, he advises, "have to go back and reunite the knowledge base." As key members of the team that work toward this intersection of the clinical and the administrative records, "they must share with the team their payer-specific knowledge about what the drivers are that cause reimbursement to go up and down," Duffy says. "If they’re so isolated that they don’t know, then the first level of collaboration is to reacquaint with the [reimbursement] success and failure rate of their registered patients."
That means looking not only at how many accounts get paid, but at how many get paid at the rate the hospital contracted for, he points out. Along that line, Beth Ingram, CHAM, director of patient business services at Touro Infirmary in New Orleans, emphasizes the role of the hospital’s contracting arm and of physicians’ offices in ensuring the facility’s financial viability.
"It is essential that the data collection [in the access department] meet the payer requirements established by contracts and by regulatory agencies," Ingram says. "In addition, the clinical departments must develop their documentation/charging mechanisms to support the individual requirements of the payers. All of this is predicated on clear, accurate data from the physician office into the system, and continued documentation throughout the stay to support the care that is delivered and charged for."
Access managers can facilitate this marriage, she adds, by making sure that contracts and regulatory requirements are understood by their customer base, which includes all ancillary and clinical departments. They can help determine, Ingram notes, where a breakdown in the process limits reimbursement.
One simple example of the role access should play, she says, is in the handling of an order for a procedure that is received from a physician’s office. Before completing the registration, Ingram adds, the access department can verify that all the data needed for the ultimate coding and payment is present, including the diagnosis.
"Many access departments enter the diagnosis code on the front end, and in those cases this issue might not apply," she says, "but I have been in more than one organization recently where all coding is still performed by medical records. In those cases, medical records are dependent on the data collected at the point of entry. While this sounds very elementary," Ingram points out, "it is not as easy as it sounds unless the facility has a made a commitment to bridge the gap between administrative issues and clinical issues and has the cooperation of the medical staff."
Another way access managers can help their organizations optimize reimbursement is to look at ways that technology can be deployed to enhance the intersection of the two records. A number of companies, Duffy notes, are looking at extending the technologies of application service providers (ASP) into the health care arena.
One product that focusCore, an ASP and managed desktop company in Irvine, CA, is helping to develop is a software program for physicians, says Dawson Davenport, the company’s vice president and director of sales and marketing. One application of that software is that the physician can make choices regarding a patient’s diagnosis and treatment, marking them on a piece of paper that can be scanned into the computer system, he notes. In the future, the physician might use a personal digital assistant to do the same thing.
The software can fill in the codes and language associated with those choices, Duffy points out. Instead of the physician having to expand on and make sense of those notes later and manually enter them into the record, the software archives them, he says.
"Rather than being handled two or three times," Davenport notes, the information is entered into a computer file. "When integrated into the billing system, it allows acceleration of the billing process."
The physician doesn’t have to go back at the end of the shift and remember 40 or 50 patients, possibly forgetting some things, Duffy says. "Some of those [forgotten pieces] might be billable procedures." With new regulations such as ambulatory payment classifications in place, he adds, "There is a huge premium paid on how well records are documented."
Another product focusCore is helping develop is a machine — preconfigured to go to a hospital-specific portal — that allows patients or their families to order the items they need before leaving the ED, says David Upton, president and CEO.
If the patient needs crutches, for example, his or her family can go to this machine, place the order, and arrange the location at which it can be picked up, during the period when they’d otherwise be killing time in the ED waiting area, Upton explains. Although the machine currently is designed to be accessed at a kiosk, he adds, "eventually, we will shrink the kiosk to a handheld device."
Perhaps more significantly, says Duffy, that device also can be used by patients or their family members to review their demographic or insurance information and make any necessary corrections before they leave. As a customer service feature, he notes, the device could have a function that allows the people spending hours in the waiting room to shop or play games or otherwise entertain themselves. The hospital, as sponsor, would get a percentage of whatever revenue is generated, Duffy notes.
The kiosk option was expected to be available to hospitals by the second quarter of 2001, Davenport says, while the handheld device is one of numerous items being reviewed in the company’s laboratory. "We’re testing to make sure the [smaller devices] are durable enough and stable enough to be effective."
focusCore is partnering with a company called Bid Industries.com, Upton says, to offer health care providers assistance in integrating record keeping and billing. As with the other products being developed, the service happens through something called "subscription-based computing."
"[Bid Industries] provides a software package that can magically find a big portion of unpaid [accounts], and focusCore is tying our Internet widget around it," Upton adds.
Health care organizations make purchasing decisions all the time, Duffy says, and access managers are often involved in those decisions. "What I’m suggesting is that before you make the next purchase decision, ask these questions":