The Concern
Even without the concern of the Recovery Audit Contractors (RAC), it is time to recognize that the attention to improving inpatient reimbursement has not been extended to outpatient. Outpatient in many cases may be 50% of the Hospital’s revenue.
Programs to improve documentation touch on it, but Outpatient Services are so different than inpatient – many episodes of care by many departments. Much of it is highly dependent on the people in the individual departments “getting it right” every time.
The questions remain—Have we set up the tools so these people in every department can succeed? Do we know the “what” and “why” of how revenue is lost so it can be captured? Do our Department Managers understand how the little pieces fit together—and that no one is really checking on the accuracy unless there is an audit?
Barriers to Improving Outpatient Results
Over the years, the Department Managers have continued to manage their expense budget. At times we place the update of the charge master and encounter forms on them with little ongoing education. We tend to limit the education to “training” on the mechanical part of the process. The Patient Financial and HIM Departments work within their own framework, Finance within theirs and the clinical staff within theirs. There are different languages and at times, divergent goals. Adding the physician’s component causes additional stresses. By knowing the language of all – KHC bridges the gap.
Approach to Improvements
By evaluating and updating all the tools – charge master, medical records, forms, policies and procedures – as well as creating an understanding of why the CPT/HCPCS codes work the way they do, what is required by Medicare and other payers, how the physician reimbursement system is different than the hospital, and how others have been able to improve results. We add to this mix the realization that meeting the goals also means we need to listen for and minimize the issues and the daily hurdles.
