As an aspiring physician, I like learning about how things work. Since medical students learn very little about the “business” of medicine in school, this led me to pioneer a project on missed billing by hospitalists at a medium-sized hospital in the northeastern US. Although hospitalists do a tremendous amount of work, they do not always bill for what they are doing. The question became: Why are hospitalists missing charges and what can we do to stop it?
Shortly into my study, I recognized there was little daily communication between the administrators and the hospitalists; neither the hospitalists nor administrators understood the different dynamics that the others faced in their own workplace. It became apparent that administrators needed to learn what was important to hospitalists and to address them at their level in order to bring about change.
Some trending themes emerged as I started shadowing the hospitalists. Many of them asked how this project would benefit them. They argued that administrative needs should be dealt with at the administrative level. A major point was made that current incentives, such as the bonuses given for exceeding a certain number of RVUs, were not the motivating force behind their work ethics. From my observations, the motivating factors were the quality of their patient care, the needs of their patients, and teaching. The hospitalists also were eager to teach and continually instructed me on clinical skills and how to be a better medical student.
Bonuses or notoriety didn’t seem to be the main incentives for them. However, efficiency – especially in rounding – was important, and that became the focal point of the project. I found several studies that showed that improvements in aspects of rounding led to increased quality of patient care, decreased burnout, increased patient satisfaction, and decreased workload and discussed some of those findings with the hospitalists.1-10 When the hospitalists felt that their concerns were being heard, they became even more involved in the project, and the administrators and hospitalists started working together as a team.
One hospitalist spent two hours helping me design the platform that would be used for hospitalists to report barriers in their rounding process that may cause them to miss a charge. Once we identified those barriers, we discussed the possibility of standardizing their workflow based off these data. Many hospitalists argued that each physician has unique skills and practices that make them successful; therefore, the disruption of an already established workflow may cause a decrease in efficiency.
The hospitalists and I talked a lot about the importance of them rounding more efficiently and how that could positively affect the time that they have with their patients and themselves. We discussed that due to the additional work missed billing causes, minimizing this burden can possibly help decrease burnout. As a result, seven hospitalists, the administrative staff, and I met and created thirteen best practices, six of which they were able to get approved to use immediately. To note, hospitalists bill differently; some use a software company, fill out paper forms still or have integration within their EMR. Although these solutions were made for a program which has the ability to bill within the EMR, many of the principles will apply to your program too.
The 13 best practices that the seven hospitalists agreed upon are the following:
When a doctor signs a note, it opens a charge option or there is a hard stop.
Charge delinquencies are sent via email to the hospitalist.
Standardize that hospitalists charge directly after writing a note consistently as part of their workflow.*
Prioritize discharges before rounding.*
Standardize the use of the “my prof charges” column, a feature of this hospital’s EMR system that tells them if they had made a charge to a patient or not, in order to remind them to/confirm billing a patient.*
Create reports by the EMR system to provide charge data for individual providers.
Create a report for bill vs note to help providers self-audit. At this hospital, this feature was offered to the administrators as a way to audit their providers and doctors.
Ensure that when a patient is seen by a physician hospitalist as well as an NP/PA hospitalist, the appropriate charge for the physician is entered.
Notifications get sent to the physician hospitalist if a charge gets deleted by another person (e.g., NP/PA hospitalist).
Handoff of daily rounding sheets, or a paper copy of the patients assigned to a hospitalist for his/her shift, at the end of the shift to the project specialist.*
To keep the rounding sheets a complete and accurate account of the patients seen by the hospitalist.*
Hospitalists are to complete and check all billing at the end of their shift at the latest.*
Hospitalists are to participate on Provider Efficiency Training to optimize workflow, by creating more efficient note-writing behavior using Dragon.
*Indicates the practices the hospitalists were able to implement immediately. Practices 1, 2, 6, 7, and 9 request EMR changes. Practice 8 was already an established practice the hospitalists wished to continue. Practice 13 was suggested by the Lean Director for the continuation of a previous project.
Six of the best practices were easier to implement right away because they were at the discretion of the hospitalists. We found that the hospitalists who had the highest billing performances were more likely to start writing notes and charge earlier while rounding. Those who had poorer billing performances were more likely to leave all note writing and billing towards the end of their shift. The few exceptions (hospitalists who left all note writing and charging to the end of their shift yet had high billing performances) were found to have a consistent and standardized workflow. This was unlike the hospitalists who had the lowest billing performances. Having practices that help remind hospitalists to bill will surely help prevent missed billing, but because of the findings from this project, it was important to have consistent and standardized practices to additionally improve missed billing.
When we followed up with the hospitalist division two months later, we learned they were making great progress. Not only were hospitalists using their best practices, but in working with the administrators, they were designing sessions to further educate fellow hospitalists to prevent further missed billing. These sessions outlined shortcuts, resources and ways hospitalists may modify their personal EMR accounts to prevent missed billing. None of the progress could have been made without first understanding and addressing what is truly important to the hospitalists.
In summary, we noted these general observations in this project:
- Hospitalists favor solutions that benefit them or their patients.
- Hospitalists want to be part of the solution process.
- Hospitalists were more likely to accept ideas to improve their rounding if it meant they could keep their routine.
Obstacles exist in our health care system that prevent administrators and hospitalists from working together as a team. The more we are able to communicate and collaborate to fix problems in the health system, the more we can use the system to our mutual advantage. With the ongoing changes in medicine, especially during uncertain times, better communication needs be a major priority to affect positive change.
Ms. Mirabella attends the Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, Conn., in the class of 2022. She has interests in internal/hospital medicine, primary care, and health management and leadership. Dr. Rosenberg is associate professor at the Frank H. Netter MD School of Medicine at Quinnipiac University where she is director of clinical skills coaching. Dr. Kiassat is associate dean of the School of Engineering and associate clinical professor at Frank H. Netter MD School of Medicine, at Quinnipiac University. His research interests are in process improvement in health care, using Lean Six Sigma.
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