For those facilities which revenue continues to be based on total charges, providers can still significantly increase net revenue through a process of evaluating and improving current charge capture procedures.
Like most businesses, hospitals must record or "capture" patient use of services and physicians orders for charging purposes. After charges are captured and processed by the patient accounting staff, they are billed to patients and third-party payers. The processing of charges prior to billing includes satisfying payers' requirements for documentation and procedural coding to avoid payment delays or denials.
Reasons for poor charge capture can include:
· No charge capture process. Although a charge exists on the CDM, it is never recorded, billed, or reimbursed. Charges are simply not batched manually to data entry or directly entered through an order entry system.
· Staff not performing charge capture functions. Due to lack of training, difficulty of the charge captures process, unavailability of staff, or a conscious decision by a staff member not to use the process, patient care personnel may choose to or inadvertently omit taking the time to capture a charge or transmit a charge document. Frequently, patient care providers do not appreciate the implications of failure to capture charges.
· Inconsistent charge practices over time and/or between departments. Personnel responsible for providing services, such as nurses or laboratory technicians, may become confused as to which items are to be charged because policy has changed over time and/or they have been reassigned to different units or departments.
· Inadequate or incorrect charge documentation. In a manual batch process, it is common for patient information generally required for billing to be missing on a charge slip (for example, the diagnosis on an outpatient procedure). Also, if multiples of the same charge appear on a bill, billers do not know if it is due to an incorrect duplicate entry or a valid repeat service and may hold the bill for investigation.
Reimbursement lost due to coding issues:
Charges that have been billed accurately may still not be paid, or reimbursement may not cover the cost of providing those services, due to inaccurate or incomplete CPT or UB revenue coding. These codes should be reviewed regularly to ensure that the most current version or update is being used.
Benefits of charge capture and rate structure review:
Accurate capture of charges for services provides the most appropriate measurement of utilization of resources and, thus, resource management. When resource utilization is monitored concurrently (while a patient is in-house), timely charge captures for all resources expended is particularly important to identify potential utilization and/or quality review issues. Cost estimates of services are also important to minimize excessive use of supplies and equipment by personnel.
The most effective way to perform a clinical pricing review is to involve clinical and ancillary department managers, as well as financial and reimbursement specialists, in the process. Whether the review is performed using internal resources or outside assistance, a review team should be identified to direct the process, and team members should have both financial and clinical expertise.
Conclusion:
Conducting concurrent medical audit on monthly basis on both inpatient and outpatient accounts in order to identify charges that may indicate deficiencies in charge pathways and processes and verifying that charges on the detailed itemized hospital bill are accurate and that charges represent services rendered to the patient and are ordered by physician and are based upon standard hospital practices and/or nursing protocols and procedures is essential for a healthy revenue integrity charge capture system.