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Use a physician advisor to bridge the communication gap

Patient Financial Services Weekly Advisor, April 30, 2004

It is generally well accepted that case management, utilization management, quality, and patient safety should have some sort of physician support on an ongoing basis.

However, the business office, as part of the financial revenue cycle, often is separated from components of the clinical revenue cycle. This silo effect can result in significant lost opportunities for revenue recapture and frequently results in underbilling or not billing as allowed under contractual terms.

Physician advisors can help link the two sides. I was recently contacted by a revenue-cycle department representative and asked to decipher a case that involved a patient who was hospitalized for two separate reasons that are contracted differently. It serves as a valuable example when financial and clinical revenue cycles collide:

A 34-year-old woman came in 38 weeks pregnant with a fever and abdominal pain, and was diagnosed with cholecystitis. She was treated with intravenous antibiotics for four days and improved. On day five of the hospital stay, she delivered her child and recovered from the delivery on day six. On day seven, she underwent a cholecystectomy.

The hospital had an obstetric case rate, and initially was planning to include the gallbladder treatment as part of the case rate. As physician advisor, I assisted the business office in working with the insurance company to come to an agreeable compromise in which the obstetric care was separated from the surgical care.

This agreement took place only 10 days after discharge and avoided any significant impact on accounts receivable aging. Most importantly, we were able to secure appropriate compensation for medically appropriate treatment.

This sort of team approach-reaching across clinical and business office silos-should occur as a matter of course, not as an exception, if the revenue cycle is to be managed appropriately and revenue is to reflect the care we deliver to our communities.

This tip was written by Joseph Zebrowitz, MD, executive vice president and senior medical director at Executive Health Resources in Drexel Hill, PA.

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