Holding your clinical staff accountable

In the game of tug of war, will it be clinical or revenue integrity staff members who stand up to the challenge? When it comes to charge capture, it can be a struggle to know who should be held accountable. While some facilities may rely heavily on their revenue integrity team to pull the weight, others may choose to place accountability on their clinical staff.

At Grady Memorial Hospital in Atlanta, Revenue Integrity Director Bruce Preston, CPC, relies just as much on the clinical staff for accurate charge capture as he does on his own team. He sees value in having the clinical staff figure out the source of the missing charge.

“The clinical department needs to be responsible. They know their procedures better than we do,” says Preston. “It’s their opportunity to go back to their staff and see how they missed the charge in the first place.”

The challenge then, is keeping clinical staff engaged with the business side of operations, he says. While the revenue integrity team can continue addressing the issues on the back end, clinical staff may start to expect revenue integrity to update the charges for them.

According to Preston, it’s a constant challenge to provide support for the clinical staff while not taking away their responsibility to accurately address charges correctly the first time around. 

Despite the inclination to rely on the revenue integrity team on the back end, there are benefits for clinical departments to take proactive responsibility for accurate charge capture the first time around. One such benefit is productivity credit.

At Grady Memorial Hospital, productivity is illustrated on the monthly red/green report, which shows department productivity in relation to that department’s budget. Specifically, it shows whether the 2017 actual cost per workload unit is at or below the recommended volume-adjusted target as measured by the year-to-date efficiency rate.

If a department’s productivity metrics are down one year, it is less likely that the department will be granted another full-time equivalent for the next year, says Preston. It’s important to for departments to remember that charges have a direct correlation to productivity.

Two areas where clinical staff accountability has improved are inpatient and emergency room charge capture. “When I got here three years ago, we were decent about ambulatory charge capture from a nurse standpoint and trained really well on how to capture charges, but the same training was not done on the inpatient side of the house,” says Preston. “Inpatient nurses are only trained to capture supply charges for the most part, not bedside procedure charges.”

Through engaging IT colleagues, Grady Memorial Hospital leveraged Epic to improve inpatient hospital charge capture. As a 950-bed trauma hospital, honing in on provider professional fee charges in Epic helped ease the charge capture process.

Meanwhile, the coding staff at Grady are primarily responsible for emergency room capture. Because inpatient reimbursement is based on diagnosis-related groups (DRG), once a patient is admitted as inpatient, the focus transitions from charge capture with CPT® coding to ICD-10-PCS procedure codes.

As a solution, Preston and his team built an ICD-10 to CPT code crosswalk. Every time Epic flags for an ICD-10 diagnosis code and doesn’t see the corresponding CPT code captured on a charge, it throws the account into a work queue for someone to capture the missed charge.  

It was a challenge at first, because not everyone on staff understood the importance of emergency room capture.

“It wasn’t really important to everyone. Reimbursement is coming from DRGs anyways, so they thought it didn’t matter,” says Preston. “For revenue integrity, charges always matter. We try to educate the clinical staff.”

In fact, this reflects the number one challenge for Grady Memorial Hospital: getting the clinical staff to take ownership of the charge reconciliation process. While 80%–90% of issues in work queues are due to the lack of charge reconciliation, says Preston, nobody seems to have time to reconcile charges.

As the revenue integrity function comes to the forefront of hospital finance, the issue of who holds accountability for charge reconciliation will continue to be a hot topic throughout healthcare organizations. This is especially evident as charge capture gross charges continue to rise. According to Preston, this number has increased by millions of dollars; today, Grady Memorial Hospital is trending to $3.5 million in additional gross charges because of increased inpatient charge capture.

Editor’s note: Stay tuned for the January 2018 issue of the NAHRI Journal for an in-depth article on leveraging in-house technology versus third-party data analytics tools for charge reconciliation.