EMR - Codes, Bean Counters, Oh My

[Ad2b]

Winged gave me permission to post here and before going further with my ask, disclosing:

I am not a resident or even a med school student; just a wee premed with a very, ultra non-trad background (i.e. I'm old, worked for 2 decades in finance/accounting/IT/consulting) who has applied to hopefully join you fine folks one day.

However, in the interim, I find myself in a position to streamline processes around the revenue cycle at a multi-speciality, small to mid sized clinic somewhere in the US. What I have found in my short time with said clinic (held by a bigger behemoth who makes decisions and then pushes them downward), are the following:

1. Rejections of claims runs amok due to a myriad of issues - many being the insurance companies just simply rejecting because it's the company's de facto policy (reject the claim first, hope the clinic never resubmits or resubmits too late and we can deny again saving the money) AND codes are not entered correctly from system to system, coders enter it wrong, physicians don't enter all the codes for the patient visit, physicians don't attach all the "unknown" documents required by insurance company (one in particular is pretty vague about what they require until they first reject along with required documents )

One proposal was for the docs to enter more information, free form text, into a field in the EMR to hopefully help the coders apply the appropriate codes and get the potential rejections reduced in addition to the SOAP notes, etc already included.

Internally, I balked at that thinking docs already do a great deal of paperwork and thought maybe there might be affiliated and credentialed staff that could do this as well with the doc giving final approval.

Thoughts?

2. What are your thoughts on incentivizing better compliance to coding by docs? If RVUs are paid at $1 or $2 more than now for a certain level of compliance, is that sufficient? Laughable?

3. You're sitting in your office reviewing charts and find out the bean counters have implemented a new system that you have to use. What would facilitate greater adoption of that system?

If you prefer to reach out to me privately, that works as well. Thank you!

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[Ladholyman]

"many being the insurance companies just simply rejecting because it's the company's de facto policy "

What the hell? Is this really true?

 

[AdmiralChz]

I read a recent report that only 10-20% of electronic medical records notes contain actual useful information. Most of it is regurgitated auto-populated vital signs, physical exam (very often not updated day to day), social and family history (which doesn't change day to day) and laboratory values (all of which is easily found in other tabs quickly) to satisfy billing requirements. Amongst my colleagues - how many of you skip the note and just scroll to the end, and how often is that after a multi-page diatribe of random stuff? The pre-populated medication list in each progress note is often useless since it contains things like heparin flushes and saline locks for IVs and invasive lines.

It's ridiculous, but part of the reason a couple EMRs have come to dominate the market is that they aid in capturing insurance reimbursements very well. It's an adaptation to deal with the system that we have. Sucks, but it is what it is.

 

[PTPoeny]

For number three, the only thing I have seen make doctors do the new thing is to put it in the EMR as a hard stop. There will be lots of complaints.

 

[Ad2b]

"many being the insurance companies just simply rejecting because it's the company's de facto policy " What the hell? Is this really true?

Untied Hell does this. Yes. Have friends who work there in Minneapolis and it is a widely known, but unwritten policy

Bile Crust does not automatically reject 1st but they are known to pile on the requests for further information in hopes that the further information never arrives and therefore, time limitations are not met and claim can thus be rejected on that basis.

The others are pretty decent - rejecting claims that should be rejected.

I just did an analysis today:

Last week, over 50,000 submits were rejected by the interfaces due to claim edits not being appropriate. Those are just claim edits not going through (docs didn't code right, etc).

Of the $6M in claims submitted, just over $500k were already rejected by... Untied Hell and Bile Crust. You can't tell me that's not an auto-reject on their part.

@PTPoeny - what do you mean by hard stop?

@AdmiralChz - the system purchased for RCM was very expensive and is likely one you are referring to. However, just like the body, bad junk with no process in coupled with sloppy dressing = poop out, or in this case, rejections.

 

[PTPoeny]

@PTPoeny - what do you mean by a hard stop?

A hard stop is where the Emr won't let you past a specific screen or to sign your note or sign orders without putting some information in.



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[calvnandhobbs68]

A hard stop is where the Emr won't let you past a specific screen or to sign your note or sign orders without putting some information in.

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Yeah usually pops up as a big red stop sign or something. Super annoying and I doubt the utility anyway. For instance, we have lots of hard stops in that we have to give a reason ALWAYS for discontinuing an order (or overriding an antibiotic in shortage, or ordering duplicate orders on the same med, etc etc). I no joke just always pick the first option on the reason list which is "clinically indicated". You think that gives any info at all to anyone reviewing that chart? Hell no.

Now if someone paid me a couple dollars (or even gave me a piece of candy, residents are easily bought off ) to type a well thought out line for every hard stop, I'd do it no problem. Incentives work but hard to know if those low incentives would work if I was being paid 4x as much.

 

[calvnandhobbs68]

Winged gave me permission to post here and before going further with my ask, disclosing:

I am not a resident or even a med school student; just a wee premed with a very, ultra non-trad background (i.e. I'm old, worked for 2 decades in finance/accounting/IT/consulting) who has applied to hopefully join you fine folks one day.

However, in the interim, I find myself in a position to streamline processes around the revenue cycle at a multi-speciality, small to mid sized clinic somewhere in the US. What I have found in my short time with said clinic (held by a bigger behemoth who makes decisions and then pushes them downward), are the following:

1. Rejections of claims runs amok due to a myriad of issues - many being the insurance companies just simply rejecting because it's the company's de facto policy (reject the claim first, hope the clinic never resubmits or resubmits too late and we can deny again saving the money) AND codes are not entered correctly from system to system, coders enter it wrong, physicians don't enter all the codes for the patient visit, physicians don't attach all the "unknown" documents required by insurance company (one in particular is pretty vague about what they require until they first reject along with required documents )

One proposal was for the docs to enter more information, free form text, into a field in the EMR to hopefully help the coders apply the appropriate codes and get the potential rejections reduced in addition to the SOAP notes, etc already included.

Internally, I balked at that thinking docs already do a great deal of paperwork and thought maybe there might be affiliated and credentialed staff that could do this as well with the doc giving final approval.

Thoughts?

2. What are your thoughts on incentivizing better compliance to coding by docs? If RVUs are paid at $1 or $2 more than now for a certain level of compliance, is that sufficient? Laughable?

3. You're sitting in your office reviewing charts and find out the bean counters have implemented a new system that you have to use. What would facilitate greater adoption of that system?

If you prefer to reach out to me privately, that works as well. Thank you!

1. Get rid of the damn insurance companies. Problem solved.

But seriously, you'd have to someone indicate what you want out of that note. You can't just throw a text box out there with a star in it and expect the doctors to know what to put in. Now if you have a system that anticipates what information they need to not get rejected for the most common or most expensive diagnoses and put "supporting information needed" above the box, that would be helpful in guiding what specific clinical info they need to provide. Doctors aren't providing the right info either because they don't know its a problem or because they just don't have the time to look up that crap in between 15 minute patient visits, not because they hate getting paid.

2. If we're talking $2 an RVU to try to look up all requirements (who even knows where we'd find this info quickly for each insurance company.....), no time is better spent actually seeing people than running behind trying to code correctly.

3. Carrot or stick. This part isn't really mind blowing. Of course, the main problem is use too many carrots and you won't be able to afford all the incentives. Use too many sticks and people will start bailing for better farms. However, if you want to have to use less of a carrot or stick, make the system easier to use. Make it one step to do all the things you have to do in that system. Have a really good search engine if you're needing to search for diagnosis codes. Have reminders or instructions for needed supporting information for frequent or high reimbursement diagnoses.

 

[anonperson]

"many being the insurance companies just simply rejecting because it's the company's de facto policy "

What the hell? Is this really true?

Not surprising in the least.

I'm usually mildly amused by the hoops some of these companies make physicians go through. Even if you have a perfectly documented note, they will request more arbitrary information and generally make it a pain in the a$$ to do a peer-to-peer (difficult to get ahold of the physician reviewer etc).

 

[Ad2b]

Make it one step to do all the things you have to do in that system. Have a really good search engine if you're needing to search for diagnosis codes. Have reminders or instructions for needed supporting information for frequent or high reimbursement diagnoses.

Unfortunately, I'm not a developer and the system is already configured by a team that was, perhaps, not the best from either the client or the software company.

What I found today is that F codes aren't matching the E&M so the charge gets lost in the system.