GARBAGE IN, GARBAGE OUT- THE IMPORTANCE OF CHARGE REVIEW
By Thomas Lanphear
Charge Review. For some, it’s a way of life. For others, it begs the question “why?”
Since I don’t like preaching to the choir, I’ll focus on the latter group. Charge review,
at its essence, is the process of making sure charges entered into an organization’s AR are
as “clean” as possible. Generally, a “clean” charge accurately represents the services
provided to a patient and the information needed to bill for those services. This includes
information like LOS (level of service), diagnosis code(s), DOS (date of service), patient,
account, provider and many others. Filing inaccurate and/or incomplete information into
your AR will invariably affect your bottom line in an adverse manner (you won’t make as much
money).
Let’s take a look at two different organizational approaches:
Organization A works under the assumption that it’s better to get a claim filed, and deal
with any denials on the back end. This company employs charge entry staff, but does not
provide an adequate process for correcting errors, nor do they empower this staff to make
corrections to data that may be questionable and easily remedied. Essentially, the charge
entry staff does little more than data entry, and nothing more than this is expected of
them. They are, however, capable of more than this and, in many cases, have better access
to necessary resources.
Consequently, Organization A spends a lot of time dealing with insurance denials. To be
fair, every organization deals with some percentage of denials. Most employ a staff of
highly trained Claim Specialists to deal with what are often complicated situations. In
the case of Organization A, however, the Claim Specialists are bogged down with so many
denials, that many claims go unpaid, or end up being paid at lower rates due to timely
filing or appeal issues. Rather than being able to focus on the high-dollar claims denied,
for example, because of prior authorization or referral requirements, they spend the bulk
of their time working on low dollar claims denied for valid billing providers, gender
mismatches and primary diagnosis issues. The processes for fixing these claims is
inefficient and time consuming, because the Claim Specialist must now go backward through
the process to get the needed information for resolution.
Organization B, on the other hand, takes a different approach. Here, the charge entry
staff are empowered, and many are certified professional coders (CPC). This organization
employs a proactive policy regarding charges and utilizes Epic’s charge review workqueues
extensively. Charges are checked for some errors as they are entered, and checked for
others after a charge session has been accepted. This method helps to ensure that the
person most likely able to fix the problem is the one that it is directed to. By catching
and fixing charge related errors at the source, Organization B files cleaner charges to
their AR and, by default, produces fewer claim related edits and denials. Cleaner charges
mean cleaner claims, and this allows Organization B’s claim specialists to focus on the
claims that really do need the expertise of individuals versed in insurance policies and
regulations, and the appeals process.
Epic provides very robust functionality with its charge review workqueues. With the
workqueues come a very good list of standard charge review edits and, more importantly, the
ability to create custom edits based on the specific issues that affect an organization. On
par with capturing charge related issues before they file, is ensuring they are getting to
the proper person/people for resolution. In addition to charge edits, Epic provides the
ability to route charge sessions containing edits in a variety of ways, such as provider,
department/location, specialty, the user that entered the charge or any field that is
available on the charge record.
In the end, the time spent working to correct charges before they become problematic claims
is generally far less than after the fact. By cutting down the amount of time that is spent
on getting good, clean claims out the door and paid, an organization ultimately makes more
money per claim, and that’s just good business.
Remember, as with any system or process: Garbage in = Garbage out! If you should have any
questions, please contact VCS at vcs@getvitalized.com
or (610) 444 1233.