Perioperative care in critical access hospitals

Holly is a perioperative nurse. She loves the intensity of the surgical environment. “Everything has to be ‘just so’ and there is a sense of urgency when the doctor needs anything, even if it is just another suture. I always wanted to have what they needed before they asked.”

After a number of years, though, she wanted to try her hand at something new. She embarked on a career helping hospitals with their finances and shares with us the revenue cycle lessons she has learned.

“Over the course of my career, I have seen a number of hospitals close down and I began to wonder how that could be prevented,” Holly says. “Now I feel like I am helping more patients than ever because I help critical access hospitals stay afloat.”

Between a rock and a hard place

Critical access hospitals cannot survive without strong attention to their finances. Invariably, budgets are tight and resources are limited. In this environment, every penny counts – but there is often not enough time to count them. 

“As I see it,” says Holly, “critical access hospitals have absolutely zero time to see if they are getting reimbursed properly. It’s all they can do to set up their system and process the charges. If something is off in any of that, it just gets missed.”

Like most health systems, critical access hospitals use levels of care or points systems to ensure proper reimbursement for each service and procedure. Unfortunately, these levels and points do not always accurately reflect the care being provided

“The issue for critical access hospitals,” explains Holly, “is that their patient populations often skew to older patients with more complicated care needs.” 

A need for clarity

Holly presents the example of two patients needing a knee replacement. One is a young woman in her 20s with a knee injury from a car accident. The other is a woman in her mid-sixties with a history of osteoporosis and arthritis. While the procedure being performed is the same, the type of care each needs is vastly different. The latter patient, due to her age and having underlying illnesses, is likely to need more care during recovery. Yet the way these cases are processed into the EHR results in these fundamental differences being ignored. The result is a lower reimbursement than the case warranted. 

Even more than other hospitals, critical access hospitals cannot afford to be under-reimbursed. So Holly sees it as her mission to make sure that these variations in care are properly figured into the hospital’s billing system. 

Revenue recovered

Holly explains that she works with hospitals by first reviewing their patient files and compiling all the cases where charges have been missed. She then updates their billing system and submits bills for the new charges. 

“I always strive to take as much of the work off the rev cycle team as possible,” says Holly. “They are so busy and I never want to add more to their plate. My happiest is when I can get all the pieces in place for them. Then all they need to do is post the new payments as they come in!”

The difference recovered can be sizable. Holly recollects one critical access hospital where she was able to help them recover $2.9 million. “For a critical access hospital, that’s a lot of money,” she says. “And because I’ve helped them reconfigure their system, they will get that income every time they provide those services. So that’s new revenue coming to them for years to come.”

And that’s a pretty great way to keep critical access hospitals afloat and serving their communities. 


Photo by SJ Objio on Unsplash