BILLING EDUCATION FOR TRAINEES:

EVERYONE WINS

Jeff Waugh, MD, PhD

Fellow in Pediatric Movement Disorders

Massachusetts General / Boston Children’s / Harvard University

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THE PROBLEM Over two audit cycles in 2011, our largest insurer markedly increased the stringency of audits

For Residents and Fellows: - 97% of all inpatient notes were downcoded - 53% of all outpatient clinic notes were downcoded Mean outpatient value lost : $232 per note Inpatient notes lost 71% of billed value

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ELIMINATING OUTPATIENT DOWNCODE

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0

20

40

60

80

100

Before In-tervention

April '12

June '12

Fall '12

% of “Correct” Notes

Over one year, we reduced downcodes from 54% to zero.

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HOW DID WE DO IT?Three key changes:

- Identified group weaknesses - Identified individual weaknesses - Found incentives that benefitted both trainees and

department

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WHERE DO THESE ERRORS COME FROM?WHAT DO THEY COST?

Conservative savings estimate: $23,892/individual/year

x 26 fellows + residents: $621,200 per year

ROSNot newMedical Dec MakingPhysical ExamUndercodedOvercodedHistory

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A BULLETPROOF ROS

1.Family fills it out while waiting2. Clinician reviews, signs, and dates it3. Admins scan into medical record

4/12/12

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SYSTEM CHANGE + EDUCATIONELIMINATED GREATEST SOURCE OF LOSS

93%

% of ROS meeting “Complete” criteria

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HOW DID WE DO IT?Three key changes:

- Identified group weaknesses - Identified individual weaknesses - Found incentives that benefitted both trainees and department

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DO TRAINEES CARE ABOUT THE BUSINESS OF MEDICINE?

A Survey of Residents and Fellows:- Anonymous, Internet based survey

- 24 responses: 8 fellows; 16 residents

Survey results: Residents and Fellows stated that they Had not been adequately trained in the business of medicine: (100%)

Would like feedback on their own billing performance: (76%)

Could adjust their billing to fit the visit level: (46%)

Several residents added that they recognized their knowledge gap, but had no one to teach them.

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IDENTIFIED INDIVIDUAL WEAKNESSES

One-on-one sessions with every trainee, 3+ notes each

Utilized a very powerful force: righteous indignation Rather than hours of tedium, trainees learned the few points that needed polishing

Emphasized that clinical care and clinical billing are separate but dependent skillsets – one is useless without the other

strengths

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HOW DID WE DO IT? Three key changes:

- Identified group weaknesses - Identified individual weaknesses - Found incentives that benefitted both trainees and department Primary motivator of trainees: saved time - Notes go faster when you know the rules

- Low code? Titrate dictation accordingly - Shifted learning from day one of 1st job to progressive throughout residency

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CORRECT NOTES USE FEWER WORDS

Words used per noten = 76 notes, 3+ for each trainee

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MEASURING SUCCESS: INCREASED NOTE LEVEL

Fall 20113

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5

June 20123

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5

Average Level: 3.4 Average Level: 3.8 We improved average level by 11%,

Improved average note value by

16%

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MEASURED IMPACT OF INCREASED LEVEL

44 clinics per year x average of 4 hours (patients) per clinic x $96/note in improved mean level x 26 residents and fellows

$438,000/y in improved billing, just from resident clinic. Spillover benefits?

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THANKS TO: Scott Pomeroy, MD, PhD

Frank Davis, MHA Angeliki Medrano, CPC, CPMA

Please Contact me with Questions:

Jeff.Waugh@Childrens.Harvard.edu