Against this backdrop, the research team first considered developing a system to record the major exceptions in each stage of the reimbursement cycle; this would allow tracking them over a period and know where to focus our efforts. Further, EMC lacked a system to track the amount of claims submitted to payers (for medical services provided to patients), what it could have claimed for those services (by not missing any procedures and treatments that were given to the patient), and what was finally reimbursed by the various payers. If we could compile and publish the claim-related financial information, it would help to focus on “the money left on the table” by identifying ways in which the claimed amounts matched the charges for the services provided by the hospital and the amount reimbursed by the payers. However, as discussed in Chapter 2, EMC was a resource-constrained organization: they had few IT personnel to create the required information systems, and little or no budget to buy such systems. Therefore, the question before the research team was, how can we obtain the information in a cost-effective manner?
Prior research experience and technical expertise of the research team helped in this process. The research team considered ways of using IT to develop appropriate interventions in EMC’s revenue cycle. One option was to focus on the front-end; that is, beginning with the admissions process, which included scheduling, pre-registration insurance verification, and registration. The registration department had high turnover, so the staff was typically new and inexperienced. As a result, the registration staff did not always understand the implications of their actions. For them, a missed field, such as payer information on the EMR system’s registration screen, was not a significant cause of delays in reimbursement or denials of claims (although it led to a revenue loss for EMC). Therefore, there was a need for some education for the registration staff, and
Singh | Dissertation | PROBLEM-SOLVING CYCLE 98 across the revenue cycle, including better understanding of what the process was, what the problems were, and how each person could help to improve the process.
Based on this initial understanding of the problems in the revenue cycle, the research team’s goal was to create an efficient and effective reimbursement system. However, since EMC was financially constrained, any potential solution had to be a low cost one. Thinking thus, the research team communicated an initial diagnosis of the problem situation at EMC and proposed some possible ways forward (see Table 7.3-1). This communication became the basis of our interventions.
Table 7.3-1 Initial Diagnosis and Proposed Interventions at EMC
Excerpt from communication to EMC’s chief financial officer in April 2008 We thank you for inviting us to visit your hospital and meet with your colleagues. We had very interesting and fruitful discussions at the workshop and during the hospital visit. We look forward to continuing and strengthening this collaborative relationship with your hospital.
During the hospital visit, we met with key people involved in the various activities of the reimbursement process. We had opportunity to observe the details of the process, we discussed the different exceptions and breakdowns that typically occur, and we discussed what management information was currently collected about, or related to, reimbursement for medical services to patients. The workshop and the subsequent hospital visit gave many important insights:
1. Patient information validation: There is a need to identify ways to improve the validity
of patient information to ensure follow-up and access.
2. Insurance eligibility and co-payment verification: It is essential to verify eligible
insurance benefits and related co-payment systematically for all patients during admission process and before any patient encounter. This can be achieved either through manual procedures or through adoption of verification software. Both options should be analyzed from a cost-benefit standpoint and one of them should be implemented.
3. Patient charge capture: At present, there is no standardized way to capture and monitor
charges for all services provided to the patient. Unless such a system is in place, many charges will continue to be missed.
4. Exception improvement tracking: Currently, exceptions are tracked through the reports
Singh | Dissertation | PROBLEM-SOLVING CYCLE 99 information for admission, coding, billing and other tasks each month and then start comparing it across months. Such monitoring would help to identify, track, and support improvements in the reimbursement process.
5. Reallocate exception handling: Currently, most exceptions are identified and fixed
during the billing process. A reallocation should be based on the principle that the place where exceptions were caused should be accountable for fixing them. Therefore, while exceptions may be identified during billing, they should be aggregated and fed back to the responsible department for reprocessing. Such practices are likely to support learning and lead to fewer future exceptions.
6. Information-based accountability: There is a need to develop accountability at
individual and department level so people use and act on information available about exceptions and improvement initiatives. This should be facilitated by joint management interventions and support.
Thus, following collaborative practice research methodology (Chiasson et al. 2008; Mathiassen 2002), the diagnosis of the problem situation led to a portfolio of focused interventions. As we dug deeper into EMC’s revenue cycle and related activities over the next two years, other problems surfaced that required additional interventions. Moreover, as we gained more knowledge about the revenue cycle, we modified each intervention cycle for better alignment with the objectives of the action research project. Thus, during the entire period of action research engagement, we continued to evaluate and refine current interventions and add new interventions. For each intervention, we worked closely with the steering committee and individual problem-solving teams. The sequence of specific interventions was not always pre- determined; at times, it emerged as the problem-solving cycle progressed.
Chapter 10 describes the context of these interventions in detail. The design, implementation, and review of outcomes of these interventions provided rich data that allowed us to gain better understanding of the revenue cycle related challenges faced by EMC. We also gained better understanding of the informational challenges as well as the specific information consumed and produced at each stage of the revenue cycle.
Singh | Dissertation | DATA COLLECTION AND ANALYSIS 100
8
DATA COLLECTION AND ANALYSIS
In this chapter, I discuss the data collection and analysis procedures used in this research. First, I discuss the data collection, including identification of primary and secondary data sources at the research site, EMC. Next, I discuss the analysis of the data collected between March 2008 and April 2010, with a follow up visit to EMC in June 2011.