Audit and Productivity Assessment in the Health Care Revenue Cycle

Audit and Productivity Assessment
in the Health Care Revenue Cycle
Jason E. Gillikin, CPHQ
Manager, Revenue Cycle Informatics
Spectrum Health Hospitals
Joint Statistical Meetings, Miami -- August 2, 2011
Spectrum Health
• Integrated health network in West Michigan consisting of a
major regional health plan, a medical group with more than
200 physicians ,seven acute hospitals (mix of teaching, urban,
rural, CAH) and a rehab hospital.
• More than 1,500 total licensed beds.
• Roughly 1.5m annual patient registrations for the hospitals.
• Thompson Reuters Top 10 hospital for second year in a row.
• Recipient of multiple quality awards, including from Leapfrog
Group and HealthGrades .
• Winner of HFMA's "high performing revenue cycle" award last
two of three years.
Scary Stats
• JSM presentations require stats. It's the law.
• National Patient Safety Agency reports 236 wristband ID
issues resulting in patient harm, Nov 03 to July 05.
• CDC finding: Wristband error rate in 712 hospitals, median
bed size of 265, was <1% in 25%, 1.0-3.9% in 41%, 4.0-9.9%
in 25%, & >=10% in 9%.
• Very little clinical research on the root causes of wristband
Productivity Assessment
• Benchmarking: Unit of Service
• What is the right UOS for patient registration?
• What counts as a transaction?
• Views
• Update/modify
• "Cold" registrations
• What are the right numerators and denominators?
• Department FTE roll-ups
• Problem of false precision
• Benchmarking across organizations
• Process/procedure variations
• Can't schedule a person's ankles to work
Auditing Today
• Behold, the power of self-selection!
• Staff pick "face sheets" for review, submit to senior staff
• Seniors review for errors and presence/absence of data
• Items weighted and a percent-accurate score issued
• Inconsistent practice across departments
• ... but we compare them anyway
• Auditors have no knowledge of data accuracy
• No additional reviews performed
• Not much accountability
Auditing Tomorrow
• Focus on outputs, not inputs!
• 100% review of claim edits
• 100% review of payer denials
• 100% review of STARS incident reports
• Spot checks of face sheets/RevRunner use
• Scores: DPTO
• Unified audit log
• Standard audit/productivity reports to supervisors
Industry Barriers
• "We got some 'splaining to do."
• Revenue cycle vendors/consultants focus on percentaccurate scores and sell "QA" products that merely check
for field-level completeness.
• Institutional schitzophrenia
• Clinial departments "get" quality tools
• Revenue cycle heavily tilted towards CPAs who focus on
ROI but with less capacity for statistical thinking
• Questions
• Brief discussion
• Wild-eyed praise for the presenter