Nanticoke Memorial Hospital, located in Seaford in rural southern Delaware, averages 5,000 admissions per year, with a staff of 81 community-based physicians.
Nanticoke Memorial Hospital
The hospital identified the need to review the revenue cycle process. Departmental processes were analyzed to determine areas with opportunities for improvement. The opportunities identified would result in a “culture” change with departments working collaboratively instead of in separate “silos.”
The registration team implemented a significant change with the use of electronic eligibility verification and medical necessity verification. Also, the team proactively ensures authorization for admissions, surgeries and high-dollar testing. A collaborative effort between case management, registration and the patient, has resulted in significant improvements throughout the continuum of care. Software was implemented to take a proactive approach in preventing denials at the point of registration. The program has served as an educational tool for both the patient and the physician. Patients can now make an informed decision about testing prior to the test being performed. This change took ancillary coding from coding staff to registration staff and resulted in a significant reduction in days not final billed. DNFB transitioned from $4.8 million to $2 million within 30 days of implementation.
Nanticoke Memorial developed a working relationship with a company to accomplish front-end Medicaid enrollments. This resulted in positive patient outreach.
The implementation of a claims administration IT system showed positive results immediately in billing cycle management. This afforded the billing staff the capability of reassigning claims to the responsible department head, thus improving turnaround time for billing. The use of the administrative dashboard, daily rounding and work queues has allowed management to review and fairly distribute workloads.
An automated call distribution program was developed by the business office staff and leadership, allowing equal placement of incoming patient calls.
CMS guidelines and order sets were used to help educate physicians in assigning patient status to right place, right time and right plan. Establishment of “expected date of discharge” upon admission gives all clinicians, patients and family an estimated time for length of hospitalization.
Education of physicians and department staff resulted in a strong collaborative effort in removing departmental silos resulting in a decrease in denial rates.
Our hospitalist group became our “physician champions,” driving change among peers. Operational and cultural changes were enhanced by use of criteria through individual accountability. These changes included the reporting of data, enhanced coordination of care and efficient utilization of practices.
A universal reporting delay line was established to identify obstacles resulting in delay of care.
Performance identifier software helps physicians to identify performance improvement opportunities in costs, charges, length of stay and complication and mortality rates. Physicians are able to use this data to compare their practice methods against their peers.
Implementation of these changes resulted in significant changes in length of stay. The length of stay in the fourth quarter of 2007 was 5.5 and ranked fourth among Delaware hospitals. Most recent Medicare Provider Analysis and Review data shows length of stay is 4.6 days, ranking Nanticoke Memorial first in the state.
A revenue cycle management team formed after a charge master revision identified opportunities for improvement. The team included all departments who provide and charge for patient services. Agenda items for meetings are focused on charging accuracy, compliance with the CMS, national coverage determinations, local coverage determinations, and ICD-9 and CPT coding compliance. The agenda items are interesting, challenging and always result in a positive and compliant outcome. Each department's “opportunity for improvement” is expected to be resolved in a timely fashion. The implementation of the revenue cycle team has identified ongoing opportunities for improvement, an increased awareness of the importance of charging and coding accuracy, and accountability throughout the organization.
A clinical documentation improvement program was implemented in the health information management department in an effort to work with, and encourage, physicians to document more accurately to reflect the severity of illness and complexity of care provided to our patients. The case mix index was at 1.27 at the time the program was implemented and increased to 1.37 within the first year, despite 300 fewer Medicare inpatient admissions. The case mix average has increased to 1.63 during the past year after the initiation of an interventional cardiac procedure program. The improvement in the case mix index resulted in more than $1 million after the first year of the clinical documentation improvement program, and over $3 million after the second year. The program has significantly improved both physician documentation and coding accuracy and compliance.
An electronic evaluation and management coding program was implemented in the emergency department in May 2009 to improve the accuracy and selection of the evaluation management facility levels assigned by the ED nursing staff. Most importantly, the program has resulted in a more consistent and accurate evaluation and management level assignment and an improvement in the evaluation and management facility level reimbursement for ED accounts by $1.4 million annually.
Nanticoke accomplished many shared goals with implementation of its system. An initial investment of approximately $750,000 has produced the following results:
- Reduction in accounts receivable days from 50 in 2007 to 37 in 2010
- Reduction in length of stay from 5.5 in 2007 to 4.6 in 2010
- Reduction in not final billed accounts receiveable from $4.8 million to $2 million in first 30 days
Technology makes it possible, but it takes people to make it happen. Removing silos and working together produces positive results.
Darr Hall is the chief financial officer at Nanticoke Memorial Hospital, Seaford, Del.
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