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
error.
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
Wrap-Up
• Questions
• Brief discussion
• Wild-eyed praise for the presenter