Missing, Lagging Charges Lead Provider Revenue Concerns
Although a large majority of providers characterized charge capture as “essential” to their organization’s success, 40 percent discuss charge capture no more than once a month.
Jan. 18—Provider organizations’ leading challenges in the revenue cycle are missing and lagging charges, according to a new survey.
Respondents to a recent survey of revenue cycle leaders said their most significant charge capture challenges were missing charges and charge lags. Those concerns were followed in order by general inefficiency, integration with the electronic health record (EHR) or other technologies, coding errors, adoption adherence, and compliance, according to the survey of 104 revenue cycle leaders in 35 states by Ingenious Med, a charge capture and practice performance analytics vendor.
David Kelly, director of revenue cycle and managed care at Mary Rutan Hospital, an independent hospital in Ohio, said his facility’s chief charge capture challenge is lagging charges.
“Physicians want to focus on the medicine—but in a physician billing environment that’s really driven on their documentation, if they don’t get it signed off then we can’t submit a charge,” Kelly said in an interview.
Among lagging facility charges, the hospital has particularly struggled with delayed charges from the operating rooms. And a lot of that delay stems from slow invoicing by supply vendors. As implants become more complex, the billing associated with those supplies also has increased in complexity.
“There’s always a lot of new devices that they are using that we are trying to get our hands around as fast as possible,” Kelly said.
In response, Kelly’s organization is implementing bar code scanning as part of a coming update for its EHR.
“We believe that with supplies, that will greatly expedite our charge capture,” Kelly said. “And we think it also may improve accuracy.”
The hospital also plans to implement physician scorecards, which will be used in part to check whether physicians meet minimum timeliness standards for charge capture and use accompanying incentives.
Russell Smith, chief portfolio officer of Ingenious Med, said “addressing top challenges, like missing charges and charge lag, are what top-performing healthcare organizations make a high priority.”
The survey also found that EHRs are the default charge capture approach used by providers. Specifically, 84 percent of providers rely at least partly on their EHRs for charge capture, while half use it exclusively.
Exclusive reliance on an EHR for charge capture is the approach used by SUN Behavioral Health, according to Eduardo Medeiros, CFO for the organization.
Even though the charge capture is simpler in behavioral health than in other parts of health care, Medeiros said in an interview, using the EHR requires regularly reviewing inputs to ensure their accuracy. His organization uses both internal reviews and outside auditors.
“It’s a critical piece of what we do,” Medeiros said.
Kevin Conroy, CFO of CareMount Medical, a 600-provider multispecialty group in New York state, said his organization has added custom templates to improve the usability of its digital charge capture system. A bridging tool to connect the EHR and practice management system also has helped to separate clean, easily processed charges from those that require coder review.
Despite the reliance on electronic charge capture systems, only 10 percent of respondents were net promoters of their system; more than half (52 percent) were detractors.
“Nobody likes it, but it is not disliked enough where we would make a change,” Conroy said in an interview.
Over three-quarters (78 percent) of respondents characterized charge capture as “essential” to their organization’s success, but leadership teams at 40 percent of organizations talk about charge capture no more than once a month. Conversely, one-third discuss it weekly.
Physicians Vs. Coders
While physicians are held slightly more responsible for charge capture than coders, according to the survey, coders spend significant time tracking down the information they need from physicians.
Two in five revenue leaders said the physician and the coder should be equally responsible for accurately capturing charges. Nineteen percent believe the responsibility rests more on the coder, while almost a third (31 percent) said the physician should be held more responsible.
Conroy said the physicians provide most charge capture, while coders focus on complex cases.
“I believe the physician has more responsibility than the coder because the physician is the one who is there with the patient and providing those services,” said Nicholas Pesarcik, finance manager at Mercer Bucks Orthopaedics, a multispecialty practice with 17 physicians in Pennsylvania and New Jersey. “The coder is kind of the armchair quarterback to check the physician, review the notes, and see if there is anything we could suggest for them to add next time.”
To help the process, Pesarcik has started sending the organization’s coders into office sessions and even the operating room to shadow providers. Then, the charge capture by the coder and the physician is compared to that of a third-party coder, who was not present.
“What we’re trying to do is educate the physicians on what codes are available for their use and at the same time educate our coders on what the physicians are dictating to see they are describing it in the same manner that we are interpreting it,” Pesarcik said.
More than half (53 percent) of providers surveyed said their coding department spends between 10 and 25 percent of its time tracking down information from physicians, while 12 percent reported that their coders spend upwards of a quarter of their time on that task. Twenty-eight percent said their coders spend less than 10 percent of their time tracking down information from physicians, and 7 percent did not know.
One approach Conroy has used to speed up physician responsiveness is to designate part of his coding team as trainers.
“So, where we see physicians struggling or they have issues with respect to the process, we’ll go out and help them,” Conroy said.
A majority of survey respondents said up to 20 percent of charges are either under- or over-coded; they also have experienced at least one audit.
Conroy said every physician at his organization is internally audited every quarter, and low-scoring physicians are immediately sent to charge capture training.
When asked if their organization has ever faced an audit by a health plan or the Centers for Medicare & Medicaid Services (CMS), 56 percent said they have been audited more than once, 3 percent have been audited once, 33 percent have never been audited, and 8 percent were unsure or unwilling to share.
Smith said optimizing the accuracy of charges is critical as CMS and health plans increase their scrutiny and the number of audits.
“Not only is this critical to profitability right now, but as the industry moves from fee-for-service to fee-for-value, having accurate documentation of patient history and care delivery is also a critical part of the quality equation,” Smith said.
Medeiros has an outside auditor review his organization’s charges every quarter and cover any training needs that those audits reveal.
“They need to be cleaned up regularly and watched regularly, as they are subject to recoupment and fines, and you may not be charging the patients right,” Medeiros said.
Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare