The problems are real, but the solutions are within reach.
EDITOR’S NOTE: This series of articles were published in 2021. The complete article is offered for your edification.
When we hear the word “hospital” or “healthcare,” our thoughts automatically go to patient care, which is not unreasonable. Yet one must remember that there is also a business side to healthcare. If it is not treated as a business, there will not be enough revenue to fund it for survival. It has been said that the operating or profit margin for healthcare entities dropped by 55.6 percent in 2020, mostly due to the COVID-19 pandemic. Still, the pandemic put a squeeze on nonprofit hospital margins last year as well, according to a recent Moody’s report that showed the median operating margin was 0.5 percent in 2020, compared to 2.4 percent in 2019.
Reimbursement for services provided is low, payors are constantly clawing back payments with denials, and pharmaceutical and vendor charges are high, among other financial challenges. This article will focus on hospitals and healthcare systems specifically, and the clinical revenue cycle.
To ensure the integrity of care and appropriate reimbursement, documentation, most of which is the responsibility of physicians, is a critical factor. There is a definite lack of education for physicians on the business side of healthcare. Other areas such as nursing, physical therapy, dietary, wound care, and others document in the medical record, but these components must be included in physician documentation to count. It is this documentation that must be accurate to support the codes utilized for final billing. This documentation involves telling the patient story from admission to discharge, with initial and final diagnoses, tests being ordered, medication given, test results, revised diagnoses, physical therapy, diets, patient progress or lack thereof, etc. All this information resides in an what is referred to as the electronic medical record (EMR). Everyone who has anything to do with a patient’s care has to properly document anything to do with that care in the EMR.
The EMR is also used in the business aspect of the hospital, as it was originally designed to be a billing tool. Since it contains everything there is to know about a patient’s stay, it serves as the basis for proper and accurate coding, for billing purposes. Only accurate coding will translate into sustainable revenue for services rendered. In today’s world, hospitals and healthcare facilities are constantly dealing with payment issues and denials, for a multitude of reasons. A major one is that insurance companies are constantly denying payments (and based on their contracts and standards, they have that right).
With that as background, it is important to note that from admission to discharge, a hospital stay is a complicated episode, wherein there are so many involved parts, multifactorials, collateral, and unique situations. As opposed to non-healthcare industries, the medical world tends to focus more on correcting the errors that occurred at the end of the episode, as opposed to finding means of prevention of the occurrence. If one looks at the Saturn V rocket that took astronauts to the moon, the number of errors that occurred were miniscule, due to extreme efforts to prevent them during development. Why cannot this concept be accomplished in healthcare?
In order to delve deeper into defining the myriad of problems that exist (and finding solutions of prevention), a small team of experts (all listed as co-authors) in their field was gathered to study this and brainstorm. These experts understand that there are people in healthcare living with these problems, and it is well-known that they are knowledgeable and extremely creative. They will always find a way to fix a problem, hopefully without resorting to workarounds. Their knowledge of the processes is priceless.
However, there is another side to this, because as much as they can help, they can also unknowingly impede improvement. They may be so involved on the tasks and functions that they might not have the ability to see the overall picture. The purpose of this team of experts is to serve as process improvement specialists, as they have the ability to see the entire picture from a 10,000-foot view – and they understand how the process should be. As the old expression goes, they can see the forest through the trees from that view. The staff doing the work, those boots on the ground, can be so entrenched that they do not have the ability to see the entire forest and can’t simplify the situation.
Think of it this way, with a football analogy: the moderator of this brainstorming team has a background as a coach of a football team. As we all know, the players play the game, and the coach doesn’t. However, the coach has the ability to sit in the press box and get an overall view of the entire field, which allows him to see things happening that the team can’t. Working together, they can make the right changes to win the game.
Process Utilized for Brainstorming
As with any process, regardless of the industry, a successful process must have the following criteria, with the acronym MPDT:
M – Mission
P – Prevention
D – Dashboard
T – Teamwork
This brainstorming took the direction of clinical documentation integrity (CDI) as a foundational component for the business of healthcare. During the initial meeting, each member of the brainstorming team was asked to provide his or her view of what they perceived as a problem, with the following results:
- Trying to quantify problems, determine where they occur, and get others to recognize them;
- Utilizing standardization and accountability;
- Identifying silos as they exist;
- Acknowledging that there are very convoluted systems and too many people; and
- No accountability, no control, lack of communication and coordination.
The team agreed to the following mission statement: “fostering documentation integrity in pursuit of capturing the patient’s clinical story.”
The following is a list of the described players in the process and their role:
Utilization Specialists – work to review the medical necessity in the documentation and recommend level of care for patients in the hospital;
CDI – (quality assurance) ensures that the quality of the documentation provided supports the codes that are used for billing;
Case Managers – are responsible for the navigation and coordination of the progression and transition of patient care;
Physician Advisor – provides expertise to all of the mandatory components as a clinical resource, bridging the gap between clinical and non-clinical aspects, and aids in the recommendation for level of care beyond commercial criteria;
Coding – converts documentation to supportable codes;
Physicians – provides, directs, and evaluates the medical care of the patient and documents and communicates this appropriately in the medical record;
Nursing – performs and helps provide the patient care, ensuring that physician orders are carried out, helping the patient and family navigate throughout the hospital encounter, and documenting appropriately – can include wound care, as well as initial and follow-up care, including documentation;
Central Business Office (CBO) – reviews claims and ensures that they are accurate at the time of billing at the back end and paid appropriately in compliance with the UB-04; they are also the clearinghouse for denials of payments;
Quality – ensures that everything occurs at the highest standard of evidentiary practices (excluding medical records);
Compliance – ensures compliance with regulations, standards, orders, and rules, leveraging integrity and accountability to meet standards of the medical record (auditing);
IT/Informatics/Analytics – manages the EMR and security, such as HIPAA regulations;
HIM/Medical Records – serves as repository of the medical record, oversees policies regarding the EMR;
Practice Providers (PPs) – serve as physician extenders, providing much of the care and documentation;
Dietary – assesses and manages malnutrition and other disease states, and documents accordingly;
PT/OT – assesses, manages, and documents accordingly, contingent on patient’s clinical condition; and
Speech – assesses, manages, and documents accordingly, contingent on patient’s clinical condition.
These are best practices, as listed by the team:
- Everyone tries to do their job to the best of their ability, which includes all the necessary investigation and rework to ensure quality patient care and accurate documentation that gets coded properly for billing purposes.
- In CDI, the number of queries can range from 20-40 per day, depending on the size of the facility.
- CDI reports tend to monitor tasks rather than the impact of their work.
- Coding is often:
- Complicated and not standardized;
- Difficult; good coders know they need to do their due diligence when assigning codes; and
- Reactive and not proactive.
- Problems typically start with the onset of documentation. It has become abundantly clear that doctors typically do not document well in the hospital setting. There are many possible reasons for this deficiency, such as:
- It is not taught in medical school
- Doctors are more concerned about care and less about documentation
To further complicate the issue of poor physician documentation, executives of a hospital often are not willing to address it. Simply talking about a problem isn’t addressing it. There has to be discovery, follow-up, and consequences for failure to improve. Simply put, if there isn’t a consequence for speeding, why would people stop speeding?
However, this can be a double-edged sword for hospitals. Potential solutions:
- It seems that they should want to hold doctors more accountable, but if they become too prescriptive, there is a fear that the doctors just might take their services to another hospital. This could have a significant bearing regarding finances, revenue, and reputation. It would take a concerted effort by many hospital communities to rectify that situation.
- Another possible solution is either instituting documentation improvement in medical school, or a government mandate with specific standards (neither of which will happen anytime soon).
Unfortunately, the major emphasis currently seems to be on correcting the problems, with very little effort made toward being proactive with prevention.
To alleviate these problems, one needs to focus on prevention, a dashboard, and teamwork. People tend to concentrate on issues that are both important and urgent: a crisis, pressing problems, and deadline-driven matters. Actually, people who continually work out of this quadrant are considered to be urgent-dependent.
Below is the Eisenhower Decision Matrix, which comes from business thinker Stephen Covey, who popularized it in his book, The 7 Habits of Highly Effective People. It is intended to help individuals make the distinction between what’s important and not important, and what’s urgent and not urgent:
For a proactive approach, one needs to prioritize efforts on important issues that are non-urgent, as outlined in quadrant II above. Topics that fit that criterion are preparation, prevention, planning, true re-creation, and empowerment.
Everything listed in that quadrant is very important, but as you can see, none of them are urgent. Nothing listed in that quadrant is deadline-driven, a pressing problem, or a crisis. However, concentrating on the topics listed in quadrant II will make your organization that much better, and in time will actually reduce the number of issues that are presently urgent.
It takes both determination and a concentrated effort to shift both your focus and others to these topics. Plus, all the pressing problems and deadline-driven items will eventually consume your attention once again. It is highly recommended to schedule an hour a day to these topics. As circumstances permit, try to increase that time.
Concentrating on prevention, not correction, is the first step to achieving the goals of revenue preservation in the business of healthcare. Problems will constantly arise, especially when 20-40 queries occur daily, depending on the size of your facility (just looking at CDI as one area of concentration). We know that these problems are being fixed, but unfortunately, the next step of prevention often doesn’t occur because it is not necessarily a natural sequelae. In essence, urgency is satisfied because the problem has been fixed. So, off to the next problem.
For continuous improvement, it is important to take the next step when a problem has been resolved. Simply ask, what can be done to prevent future occurrences of that problem? One of the common answers to that question is that “it does not happen that often.” Well, that can’t be the answer for 40+ queries. Queries, per se, are not the problem, but focusing on the number of queries daily as a key performance indicator (KPI) is. One must monitor the process, not the tasks.
In order to gauge a solution, a standardized approach must be undertaken. It is important to log the problem, the correction, and the preventative actions. It will come into play in the future. People will remember problems when they re-occur, and it will be a great reference to see what corrective and preventative actions were taken in the past. In fact, knowing previous preventative action that didn’t resolve the actual problem will be instrumental to hone in on the root cause.
These simple questions can help accomplish this:
- What are you trying to accomplish?
- What have you tried before?
- What are your goals?
- What are your indicators of success?
Correcting a problem is just that: it is doing what is necessary to correct what is wrong. For example, coding sometimes doesn’t know what the correct code is to ensure payment. The appropriate people get together and correct the record so it can be coded properly. However, what was the root cause of the problem? What caused the problem in the first place? That’s what preventative action does. It forces us to find the root cause of the problem and implement action to fix it. Only then will future occurrences be stopped.
Continuing on the CDI component, a simple dashboard that tracks a couple phases of queries should be created. It needs to track the quality of the system and serve as the finger on the pulse of the situation. Based on the information extracted from the aforementioned brainstorming session, the initial tracking item should be queries, and it should consist of the following:
- Queries issued per day;
- Queries resulting in a correction per day; and
- Queries wherein prevention was investigated and action taken.
The quantity of suggested items can vary from day to day. Therefore, one should also track the total quantity on a weekly basis and create a line graph. This will allow for trend analysis. Are things getting better, worse, or staying the same? This is a key factor. The dashboard is a work in progress, and might require changes once data is being captured.
Teamwork is crucial to continuous improvement. Coaching is also important, but again, it is the team that wins the game. The team being proposed is not a department team; it is a cross-departmental or cross-functional team. This team should be comprised of the people who can actually work toward the goal. Each department has its responsibility to ensure that everything comes together as a whole. But it must be a holistic approach, wherein no one part is more important than the whole.
The personality composition of these teams is very important. A mixture of four types is needed, as gleaned from the DISC personality profile, and it is essential that each personality is represented by the following:
D – Dominance
Decisive, organized, optimistic, and strong-willed. Very task-orientated.
I – Influencing
Easygoing, witty, optimistic, and outgoing. Highly relationship-oriented.
S – Steadiness
Pessimistic, soft-spoken, and artistic. Good at analyzing and goal-oriented.
C – Cautious
Pessimistic, strong-willed, and soft-spoken. Good at analyzing.
An inspirational person is needed to celebrate the victories. A cautious and steady person is needed to ensure quality. They are good at analyzing the data. The driven person is needed to ensure that the process runs properly and meets the daily requirements. The important thing to remember is that each personality sees the task at hand differently. Working together, collaboratively, holistically, they will accomplish a great deal.
The brainstorming team created two teams as a proposed template for success:
The Consensus Team should have weekly meetings and consist of the following areas:
- Denial team
Note: the members of this team will be the people actually doing the work and serving as managers.
The Consensus Team will request ad hoc members as needed, to include:
- Clinical Staff – nursing, physicians, physician advisors
- Revenue Integrity
The purpose of the team and meeting include:
- Review of the amount of queries
- Review of the amount of repetitive queries
- Review of the method or resolution in correcting the problem
- Most importantly, review of preventative action and its effectiveness
- Ensure that preventative action has been implemented
Issues that cannot be resolved by the Consensus Team can be sent to the Escalation Team.
This team will meet as needed and will consist of the following:
- Working managers from the Consensus Team and the directors of those areas
Both the working managers and directors will request ad hoc members to the meeting as required. The ad hoc members will consist of the same areas as listed for the Consensus Team.
As with anything, there are always caveats, with the two biggest being “change is hard to implement” and “avoiding conflict;” both are viable concerns. Change is hard to implement. Everyone has a comfort zone, and implementing change can take you out of it. Secondly, when change is being implemented, conflicts can arise.
Many people do not like challenges, but don’t allow challenges to start the “blame game.” Placing blame doesn’t fix anything. Others are conflict-averse and don’t confront the problem, so nothing changes. Stick to the facts of the situation. Only when one exhausts all other possibilities is it time to look at the operator.
This process starts with keeping your eye on the mission, which is the integrity of patient care and appropriate reimbursement. And it all starts and ends with documentation. Accurate documentation is the vehicle for success. But remember that CDI cannot and must not do it alone.
Refocusing efforts is key to making this happen. Change the focus from fixing the problem to preventing it. Over time, the problems will be eliminated. Step back and schedule time each day for prevention. Besides fixing the problem, take it another step further and determine how to prevent future occurrences of the same problem.
Refocus data collection to support the mission. Remember, monitor the process, not the tasks. Task-oriented data only monitors quantity, which doesn’t support the mission. Instead, collect data that monitors the quality of your process and documentation. Monitor preventative action. How many problems have been prevented from happening again? How many problems re-occurred even after preventative action was implemented? Monitor the success of the mission.
And most importantly, build cross-functional teams. Trust and empower the team to do the right thing. Coach them. Remove the barriers that hinder them. The people that do the work are the key. They know the problems. Help them refocus on prevention.
If possible, have someone oversee things from a distance; like a drone, they see more. Questions need to be asked. Challenging others can be uncomfortable, but done correctly, it inspires creativity.
So, if you are unhappy with what you got, then change. And if that change didn’t work, then change again.
Jim Zelem EE, Process Improvement Engineer
Author of “Stepping Stones of Leadership”
Tiffany Ferguson, LMSW, ACM
Chief Executive Officer at Phoenix Medical Management, Inc.
Jennifer Foskett, MBA, RHIA, CPC
Healthcare revenue integrity analyst, healthcare business intelligence analyst
Sonal Patel, CPMA, CPC, CMC, ICD-10-CM
Healthcare Coder and Compliance Consultant at Nexsen Pruet, LLC
Podcast Creator and Host for the Paint the Medical Picture Podcast series
Dr. John Zelem
Physician Owner at Streamline Solutions Consulting, Inc.