Vol. 14 •Issue 2 • Page 32
“Unbilled” is not a Bad Word
Cleaning up and/or maintaining a facility’s unbilled cases is not an impossible task
The most common area overlooked in the revenue cycle is patient claims that have never been billed. Hundreds and sometimes even thousands of cases sit idle for 45 days up to two years. By that time, the claim filing deadline is long past due. On the average, a facility with both inpatient and outpatient services has an average case worth approximately $1,500. If the average facility had more than 2,000 cases sitting “unbilled” in their over 45 day aged bucket, the hospital has the probability of losing close to $3 million. Most hospitals and clinics can’t afford to give up that kind of revenue. What they do not realize is that the time and cost of unbilled case recovery is far less than what can potentially be lost.
A medical facility’s unbilled report listing may carry different identification names, such as discharge, not final billed (DNFB), “unbilled,” pre-bill list, missing elements (MER), missing criteria for billing (MCB) and others. Most hospitals do not monitor or review their unbilled reports, and those that do, do not analyze them to their fullest potential. I have witnessed many patient accounting managers, health information management (HIM) directors, financial advisors and consulting groups analyze “unbilled” data. It appears they all seem to come up with the same cause for billing delay: that the unbilled cases on these reports “just need to be coded.” However, from a coder’s perspective, it is easier said than done.
Typically, an HIM staff member would be required to recover the unbilled listing (given to them by the accounts receivable or finance department). First, they would pick some of the higher dollar cases or possibly the oldest cases, which would make the most impact. One by one, they would go into the file room, pull the patient’s chart, go to the date of service that was lacking diagnosis or procedure codes, and code the case. But, what if the documentation isn’t in the chart? Where do they go next? In most instances, the case on the report is skipped, and the next one is attempted to be located and coded. What happens to those cases not found the first time around? Are they looked for day after day, week after week? Is there a case-by-case follow-up process in place? Do the lower balance cases ever get a chance to be recovered? If not, do the lower balance cases begin to accumulate and gradually increase the unbilled grand total?
Many questions can arise when analyzing these “lost” and “unbilled” cases. Was the documentation ever sent to the HIM department? Does the case truly exist? Was documentation of the service rendered created? If so, where is it? Does the service area maintain copies of this information? Is the patient care note misfiled in the HIM file room? Is the whole patient chart missing from the file room? Did the patient have services in another department recently and was the chart mistakenly not signed out to that service area?
Let’s say the patient never had services on that date. Were the patient care services performed on a different date, and the wrong case was used to post the charges? Were the charges posted to this patient’s case appropriate or do they truly belong to another patient (i.e., mis-posted charges)? There are unlimited reasons for billing delays, and they vary from case to case. To have a determination that an unbilled case “only needs to be coded” is an unresearched, inaccurate and vague excuse.
How are the unbilled cases researched or recovered? Is the HIM staff member qualified or have enough knowledge of the patient path to determine the cause for a case not to be billed? Do they understand what types of errors could occur as early as when the physician office schedules the appointment? Do they know the process taken by the registration staff to pre-register that case with the proper or accurate service codes, patient types and system information? Did the patient have multiple services from multiple service areas, creating various charges and various documentation pieces? Could the patient have two cases for the same date of service, only to find that the documentation is on one case and the charges are on the other?
Do the staff members have the knowledge of the documentation process and forms utilized by all departments providing patient services? For example, is the HIM staff familiar with radiology dictation, nursing documentation, and physician documentation and dictation, as well as other notation avenues utilized by various patient care areas? How is that documentation delivered to the HIM department for processing, filing, analysis or coding? Are only a few outside departments or nursing units conscientious enough to send their completed documentation to HIM in an orderly and timely manner? Are there bottlenecks and inaccuracies stemming from outside department’s delivery processes? Are there chart and documentation tracking programs or processes in place?
Capturing the flow of information of an individual case can be a monumental task, not to mention the other hundreds or thousands of cases produced during a common hospital or clinic day. Standardizing the flow and timeliness of that chart/documentation flow can many times be out of reach for the HIM director and his/her managers and staff. All departments providing patient care should have a good working relationship with the HIM department. With that, they should also have a check point system set up to assure that the documentation is completed and sent to the HIM department for processing in a timely manner. Without this, the service areas could take the chance of the case not being coded, which would have a negative long-term impact on that service area. If the case is not coded, there will be no payment or revenue returned to the department that provided the service for the patient. It would be like performing or providing the service to the patient for free.
Organization of data and intra-department processes are necessary to accurately track all patient information from pre-registration to the time the claim is paid. Proactively having the knowledge of the patient path and tracking the documentation that travels along the path is a must for the HIM department. Without this knowledge and process, the HIM department falls vulnerable to become a bottleneck or brick wall in the revenue cycle.
Cleaning up and/or maintaining a facility’s unbilled cases is not an impossible task. With the proper knowledge, computer systems support and process changes between the HIM department and the patient care areas, the “unbilled report” would not be a bad word.
Barbara Allgire is co-owner/analyst of Pro-Active Revenue Solutions Ltd., Maumee, OH.