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We talk and read frequently about revenue cycle management for physician billing. Usually, the topic relates to physicians working in outpatient settings, benefiting from their ambulatory EHR that generates accurate billing based on their clinical visit note. We hear less about the challenges of accurate and efficient billing for hospital-based physicians. They (anesthesiologists, emergency physicians, hospitalists, radiologists, pathologists, neonatologists) work primarily in an inpatient setting where computer systems are provided by the hospital. These physicians are increasingly organized into large, multi-state groups that contract their services to multiple hospitals, all with disparate IT systems.
Hospital-based physicians have logistical and IT challenges related to billing that are not typically experienced by office-based physicians. For example, they normally aren't employees of the facilities in which they work, so their billing staff or outsourced billing company is usually located remotely. This introduces an additional time lag between seeing the patient and billing for the visit. In addition, they must deal with conflicted priorities. The hospital is concerned about facility charges, while the non-employed physicians are concerned about capturing and billing professional fees.
 Whether small or large, these provider groups struggle with the efficient and effective capture of accurate professional fees electronically, and they have no control over the IT systems and strategies at the various hospitals where they work.
Hospital Vs. Physician Group Priorities
Since the computer systems that hospital-based physicians interact with are usually purchased by the hospital and focused on hospital needs, they often don't handle professional fee capture, leaving the physicians to their own devices as to how to accurately record their charges and get them to their billing department in a timely fashion. If the institution uses an EHR for physician documentation, which most do not, the professional charge is not usually an automatic by-product of the EHR as it is in most ambulatory EHR systems.
The professional fee billing challenge is compounded by the fact that most hospital-based physician documentation is paper-based. For example, 90 percent of hospitals use paper anesthesia records. A similar percentage use paper for the daily progress notes documented by hospitalists. Further, the lack of instant feedback from traditional paper documentation means that documentation compliance rates (i.e., completion of required quality- and billing-related information for the visit) average only 80 percent. Errors necessitate a lengthy and disruptive feedback loop to the physician from the billing department to correct deficiencies.
In a typical scenario, hospital-based physicians use paper charge tickets or mobile charge capture devices (e.g. an application on a smartphone) to capture their charges and send them to their billing department. Since this process is separate from the clinical documentation, there is a risk of missing charges for some encounters and of the clinical note not accurately reflecting what was charged. Under- and over-coding are common, leading to either lowered revenue or audit risks, respectively. This separate coding process also requires the physician to be knowledgeable of the many billing rules that go into making up an Evaluation and Management (E&M) code.
Benefit of Charges Generated from Clinical Documentation
Ideally, professional fee coding should be generated directly from clinical documentation and electronically delivered to billing systems. Benefits include:
- It ensures accurate charge levels that match the documentation - no lost revenue, no audit risks.
- It shortens the charge lag - time between incurring the charge and billing for it - because the charge is accurate (no going back to the physician for clarification), and it can be interfaced directly into the billing system at the end of the visit.
- Pushing accurate coding to the point of care significantly reduces data entry work by centralized coding staff.
- It prepares physicians for ICD-10 coding where the tie-in to the clinical documentation is even more critical.
"Smart" Form Solution
By using software tools that ease the transition from paper documentation to electronic health records, physicians can use the same forms they document on today without changing their workflow or their facility's IT systems and strategies. Rules and logic embedded into these "smart" forms warn physicians automatically of errors and omissions, leading to improved documentation completeness and cutting down on the typical time involved with manual identification of chart deficiencies and the subsequent feedback loop.
The embedded logic also derives codes from the documentation, enabling the capture of diagnoses and generation of accurate E&M levels. The resulting data is electronically passed to hospital EHR and physician group billing systems, shortening the revenue cycle and reducing data entry work for billing staff.
With a variety of data input options feeding the software platform, hospitals and physicians can individually choose their preferred method of documentation, whether it be paper form-based or tablet-based.
While the group benefits from a more streamlined revenue cycle across disparate care settings, each of its hospital partners has immediate electronic access to the patient note by any stakeholder in the patient's care with simultaneous capture of key quality metrics without disrupting the physician's normal workflow.
Stephen S. Hau is the CEO and president of Shareable Ink.
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