An article published in EHR Intelligence states that a hospital based in NY suffered losses of $38 million due to its EHR.
Administrative lapses can cost organizations dearly in terms of revenue loss, and Glens Falls Hospital exemplifies it more than anyone else. The community hospital lost $38 million in revenue, and the prime reason it appears is the Cerner EHR system the hospital was using.
The Cerner EHR reportedly malfunctioned causing billing errors persistently. According to Glens Falls CEO, Dianne Shugrue, the hospital prior to switching to Cerner, had implemented two different EHR systems GE Healthcare and Epic. Changing priorities of digitized healthcare in 2016 prompted the administration to switch to Cerner.
In the switch-over to different EHR’s, the hospital did not file claims worth $12.6 million in bills. Similarly, $9.2 million bills remained unclaimed over a period of three years. The pattern continued until 2017, the total unclaimed bills spiked to $54 million, of which the Cerner system alone accounted for $38 million.
Were these basic steps implemented before an EHR interchange?
EHR Implementation best practices:
- When practices transitioned from paper to electronic records, there were certain guidelines followed and implemented. When data is migrated from one EHR to another, the very same principles apply in the transitional phase.
- The only difference however being, that automation facilitates data migration from one EHR to another, in the case of paper to electronics it is manual.
- It is very important that when data is migrated in the automation scenario, the IT has to have a firm understanding of structured and unstructured data.
- For instance, structured data examples include spreadsheets or machine data. Unstructured data is human language data, this data does not fit into databases such as SQL.
- Apparently Glens Falls IT potentially messed up the data migration leading to data loss or wasn’t done in a timely manner for the billing department to file claims within a specified timeline.
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Another factor emerging in the media states that the staff at the Glens Falls Hospital was not familiar using the Cerner EHR.
Cerner EHR training:
- Administering a hospital is a collaborative process involving attending and consulting physicians, resident physicians, medical students, nurses, nurse practitioners, physician assistants, physical and occupational therapists, and others.
- Effective collaboration between each of these entities mandates that human interaction with an EHR have to be so simple that effective communication and collaboration within the team does not pose a challenge.
- Certainly, there were lapses by the hospital administrators in their choice of choosing the Cerner EHR, they potentially overlooked the ‘simplicity’ aspects of the electronic machine.
Yet another lapse in the media states that no regular audits were carried out by the hospital, and denials were far too extreme.
RCM Audits:
- Hospitals voluntarily initiate a series of audits to improve the quality of healthcare and revenue cycles. There are external audits, internal audits, clinical audits and audits of billing and coding accuracy.
- It is customary for all healthcare organizations to perform audits of all functions, importantly the ones that relate to billing. These are meant to offset the effects of payer audits and to prevent any revenue loss due to billing inefficiencies.
- The purpose of audits is to determine coding accuracy. It’s a known fact, coding inaccuracies result in denials.
- Billing departments generally establish efficient communication links between coding and denial management teams, but this wasn’t happening in the Glens Hospital case. The figures of denials are not known, but they seem to be substantial.
Glens Hospital is being blamed for not billing patients on time. Media reports attribute the fault to Cerner EHR system. The implementation led to a series of billing issues that resulted in delays.
Efficient Billing System:
- The Medical Billing process is not a ‘one man’ effort. It entails the involvement of front office staff, office administrators, back office staff, besides billers and coders. The billing process requires every entity to be on their toes, and despite it, if the EHR malfunctions, the billing staff can only throw their hands up in despair.
- There are host of other issues that cause billing delays, including incorrect patient information, incorrect provider information, incorrect insurance provider information and incorrect codes. Billing RIGHT is a man and machine effort. Glens Hospital appears to have failed on both the fronts.
Apart from the $38 million losses Glens Falls suffered due to billing issues, media reports also claim that the hospital lost another $12 million, to unpaid bills. These were not associated with the malfunctioning systems of the hospital. Most likely that they were denied cases,
Processing Denials:
The most common reasons attributed to denied cases include
- incomplete or inaccurate insurance information
- no prior authorization or pre-certification taken
- tests or procedures reports undocumented,
- coding errors related to diagnosis and procedures,
- claims filed after a time lapse,
- medical condition not justifying a treatment
- policy has co-pay, deductible or patient responsibility
An efficient revenue cycle management deals with denials in a most effective manner, generally, the first step following a denial is to know the appeal deadline since each payer has a different time frame for denial appeals. The range varies from forty-five days to three hundred and sixty-five days. Based on the deadlines the denials can be accordingly organized, and a review claim can be filed. Having simple appeal letter templates speeds-up the process, including the payers written and electronic wording in the denial document, is a good practice.
These are simple issues that probably the Glens Falls administration or its revenue cycle management team ignored, and brushed these issues under the carpet. The long term neglect accounted for the loss of $38 million, it may possibly have to be written-off.
