Hospitals, despite all the financial pressures they are facing, continue to ignore opportunities to recover missed revenue from their emergency departments. After all, it is easy to ignore a situation you don’t see. So here are the three areas where hospitals should look to begin recovering ER revenue.
The most obvious way hospitals lose out on ER revenue is when charges are simply overlooked.
Let’s take an example of a patient presenting to a rural hospital with chest pain. The patient is in his mid-50s and he arrives late on a Saturday evening via ambulance. The ER team follows their cardiac protocols, the patient is diagnosed with a STEMI and, happily, survives. The entire process is entered into the EHR and, supposedly, all appropriate charges will be captured.
The problem arises when aspects of the patient’s care are not clarified in the charges. This is not an obvious error; it’s an error of omission. Unless someone is actively searching for these omitted charges, no warning bells will go off. The charges will simply not be captured and the revenue will never be collected.
To counteract this, hospitals need someone with clinical knowledge of the emergency room as well as detailed understanding of the billing process. To detect what is hiding, they need to know what steps are required in any given procedure, even if they were not listed as a charge.
A similar situation occurs with ER levels. These are designed to capture a variety of procedures and patient care services yet they are rarely audited for accuracy. As a result, hospitals wind up using levels that are ineffective – which can be a costly mistake.
By not auditing their levels, hospitals are missing a great opportunity to recover sufficient revenue to adequately address the cost of care. For example, take two cases of patients presenting in the ER with a broken leg. One is a 23-year-old woman and the other is a woman in her 80s. The amount of nursing support alone for these two patients is going to differ significantly. The different medications prescribed may also differ considerably. Yet some leveling methods would lump these situations together, causing the hospital to be insufficiently reimbursed for the care of the elderly woman.
Inaccurate points systems
Not all hospitals use levels in their emergency departments; some use points systems. This approach is intended to help account for precisely these variances in patient need. Unfortunately, points systems are just as prone to error as levels. Where levels may group very different patients together under the same procedure, points systems may fail to assign sufficient points for their care.
And, just as with missed charges and levels, inaccurate points systems can easily go undetected. Unless someone is actively reviewing the points and comparing them to the care actually provided, there would be no way to detect discrepancies.
Clinical expertise and rev cycle knowledge
In order for hospitals to recover ER revenue, they need to first be aware that it is missing. The three most common missed revenue opportunities fly so low under the radar that hospitals never see them. Yet a skilled clinician with deep understanding of the revenue cycle can help hospitals detect these opportunities and capture that missing revenue.
Photo by Camilo Jimenez on Unsplash.