Consumer assessments have become an important tool for monitoring the accessibility and quality of health services. Health plans and systems routinely conduct consumer evaluations to monitor their performance and alter the delivery of care in order to retain and attract customers (Maciejewski, Kaweicki, and Rockwood 1997). Clinicians use consumer or patient satisfaction ratings to determine how they can better meet the needs of patients and, potentially, improve patient compliance (Sherbourne et al. 1992) and treatment outcomes (Kane, Maciejewski, and Finch 1997; Smith 2000). Finally, purchasers of health insurance plans such as employer groups and consumers themselves sometimes examine ratings when deciding which plan to choose (Farley et al. 2002; Spranca et al. 2000).

Consumer ratings are, of course, subjective and thus may be influenced by various demographic, social, and health status factors. Health status has been shown to be correlated with consumer satisfaction, with persons in poorer health tending to have lower ratings (Aharony and Strasser 1993; Hall, Milburn, and Epstein 1993; Kane, Maciejewski, and Finch 1997; Lee and Kasper 1998; Rubin 1990; Smith 2000). Other research suggests that demographic factors, such as gender and age (Locker and Dunt 1978; Nelson-Wernick et al. 1989), as well as socioeconomic factors, such as educational attainment and income (Lee and Kasper 1998), are associated with evaluations. In the largest study to date of ratings by Medicare managed care beneficiaries, Zaslavsky and colleagues demonstrated that health status, age, education, and interactions between region and health and education, respectively, were important case-mix adjusters (Zaslavsky et al. 2001).

Other individual differences, including attitudes about health care, may affect consumer assessments. Donabedian points out in his discussion of quality that satisfaction is party a function of individual as well as societal expectations (Donabedian 1988). Expectations can be shaped by a variety of experiences with previous medical care as well as deeply held attitudes. One concept that may capture such attitudes is skepticism toward medical care. Medical skepticism has been shown to be predictive of fewer physician visits, a lack of a usual physician, lower use of hospital care, and lower health care expenditures (Fiscella, Franks, and Clancy 1998) as well as mortality (Fiscella et al. 1999). A logical extension of these findings is the hypothesis that consumers shape a cognitive evaluation of their health care that conforms with their skeptical attitudes. In other words, consumers who are skeptical about medical care would be expected to have worse evaluations of health services as compared to those who are not skeptical.

In addition to attitudes about medical care, other individual differences may help to explain variation in ratings. As mentioned earlier, health status has been shown to be associated with satisfaction, but there are countess ways of assessing health. Measures of the presence/absence of disease are frequently available either from billing data or clinical records and can be merged with consumer assessment data. Perceived health-related quality of life measures, such as the Short-Form 12 (SF-12) (Ware, Kosinski, and Keller 1996) are sometimes used to control for differences in health. An additional brief measure that has the potential to reflect health status and affect the degree to which individuals evaluate their health care is their worry about their own health. Worry about health status has been shown to be predictive of greater utilization of medical services among the elderly, but has not been studied to determine if it associated with evaluations (Wolinsky and Johnson 1991).

The primary purpose of the present paper was to examine whether medical skepticism and worry about health affect overall care ratings (OCR) and personal doctor ratings (PDR) among the noninstitutionalized elderly, or persons aged 65 years and older, a group that has gone relatively understudied as compared to the general population of adults (Lee and Kasper 1998). Global ratings of care, such OCR and PDR, reflect multiple dimensions of satisfaction with care (Cleary and McNeil 1988), rather than specific dimensions of the quality or accessibility of services, and are used to make summary judgments and comparisons of health services across health plans or health systems. Specific hypotheses tested were:

H1: Elders who are skeptical about the benefits of medical
care have lower OCR and PDR than those who are not skeptical

H2: Elders who worry about their health have lower OCR and PDR
than those who do not worry about their health.

METHODS

Study Design and Setting

The study was conducted in a southwestern region of the United States, the 105 counties comprising West Texas, an area stretching between the U.S.-Mexican border on the west, the cities of Wichita Falls and Abilene on the east, the Texas Panhandle on the north, and the Permian Basin region on the south. Data were collected through a telephone survey of some 5,000 community-dwelling elders’ health status, health care accessibility and quality, and other health-related factors. Telephone surveys are frequently conducted to assess consumer satisfaction, and their suitability has improved in recent years. Within Texas, only 4.18 percent of households are estimated to have no telephone service available (U.S. Census Bureau 2000a). Comparisons of estimates from the National Health Interview Survey between all households and households with telephones indicated very small (less than 1 percent) differences in health-related variables (Anderson, Nelson, and Wilson 1998).

In their quest for efficiency, physician practices must cope with the inclusion of EMRs, the business impact of HIPAA and an ever-changing vendor landscape.

Anyone who has shopped for a practice management (PM) system knows how hard it is to bridge the gap between clerical back office functions and the clinical aspects of patient care.

Most PMs are standalone solutions that can readily handle the administrative and financial demands of a growing practice. But with the growing acceptance of electronic medical records (EMRs), physicians and administrators are often forced to purchase separate PM and EMR systems–and they seldom work well together.

Efforts are underway to design PMs that include an EMR component, but developers are split over whether this is the best solution. Some believe that managing a practice includes everything from billing to clinical documentation–and that a single software package should support every aspect of the practice. Others say a better solution is for the physician to buy the PM and EMR systems best suited to his particular practice, then integrate the two.

Populating the Landscape

David Winn, M.D., believes a successful PM solution should combine the administrative and clinical functions of a practice into a single, integrated system. As founder, CEO and chief software architect of Cedar Park, TX-based e-MDs, Winn has developed an integrated suite of clinical and financial information management solutions for physician practices and groups.

David Winn, M.D.
CEO and President
e-MDS
500 W. Whitestones Blvd, Ste. 200
Cedar Park, TX 78613
Tel: 512-257-5200
Fax: 512-335-4375
E-mail: dwinn@e-mds.com

e-MDs’ topsSuite solution is an integrated system that automates the three primary areas of medical practice–charting, practice management and scheduling–into a networked trio of modules so information can be seamlessly passed from one software module to another.

The efficiency of integration is underscored by John C. Durham, M.D., chief medical officer at Greenway Medical Technologies in Carrollton, GA. “Data collected in one module doesn’t have to be re-entered into another module,” he says. “Most systems that are not integrated don’t have this capacity.”

Durham says that since the software required for scheduling and billing modules is easier to write than the clinical components, most developers have concentrated on the administrative aspects of PM automation. Like Winn, he believes solutions should be fully integrated. As a result, Greenway is planning a full launch in early December of its Web-based PrimeSuite of products that combines charting, scheduling, registration and billing components into one PM/EMR solution.

Others, though, take an entirely different approach. Neil Simon, chief technology officer and vice president of operations at Millbrook Corp. in Carrollton, TX, is bucking the trend toward a one-suite-fits-all solution. He believes physicians should buy a best-of-breed EMR system and a best-of-breed PM system, and then integrate them if necessary. By using both client-server and Web-based technologies, the Millbrook Practice Manager[TM] system runs on Windows NT with an SQL server, Simon says. Since it uses a pure Microsoft architecture, “it’s also Microsoft BackOffice–certified,” he adds.

Peter Kaufman, M.D.
Chief Medical Officer
DrFirst.com
3206 Tower Oaks Blvd., Ste. 310
Rockville, MD 20852
Tel: 301-231-9510 Ext. 146
Fax: 301-231-9512
E-mail: pkaufman@drfirst.com

But Millbrook also offers the “Millbrook Integration Kit.” This Microsoft Windows NT system service creates seamless integration between a variety of systems, applications and facilities.

Another company charting its own course between integrated systems is Rockville, MD-based DrFirst.com. According to Peter Kaufman, M.D., the company’s chief medical officer, DrFirst.com is an application service provider (ASP) that provides physicians with communication, practice management, EMR and business productivity solutions.

Through an alliance with Philadelphia-based MicroMed, DrFirst. com offers clients “NextGen,” a Windows-based suite of proprietary software systems that include EMRs, appointment scheduling, billing, claims processing and managed care plan implementation. It also offers its own secure Internet messaging, Web- and PalmOS-based e-prescribing and charge capture applications.

The EMR Factor

For Kaufman, at least, the Internet has become one of the best tools for integrating existing PMs with newer EMR systems, and he says this integration is crucial. “Practices already have PM applications and often are not willing to go through the additional pain of switching. If it weren’t too complicated, they would like a seamless interface between the new EMR and their current PM.”

But Simon says if a practice purchases an EMR that doesn’t integrate with the PM system, staff usually have to double enter everything. Rather than do that or upgrade their whole system to accommodate an EMR, the practice may limit or forgo its use of the EMR.

To assess the financial impact of the inpatient rehabilitation prospective payment system (PPS) on its future revenues, the MetroHealth Center for Rehabilitation (MHCR), Cleveland, Ohio, undertook a three-phase process using data from calendar year 2000 to estimate its potential profit or loss for each case-mix group (CMG) identified in the final rule. This process entailed developing a database to facilitate the combination and comparison of patient-charge and clinical data by CMG, using the combined data to estimate costs by cost center, and using payment information included in the final rule to estimate revenues by CMG. Following the assessment, the MHCR decided to expand the database to assist clinicians in making informed decisions in their patient-assessment and care-delivery processes that would account for cost and revenue considerations under the PPS.
On August 6, 2001, the Centers for Medicare and Medicaid Services (CMS–formerly HCFA) published the final rule outlining the new prospective payment system (PPS) for inpatient rehabilitation services. (a) Previously, rehabilitation hospitals and units were excluded from the DRG-based PPS established for acute care hospitals by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 because the resources required to provide postacute rehabilitation services tended to vary dramatically among patients with the same diagnosis. Instead, TEFRA established a payment system for rehabilitation hospitals based on reasonable costs up to a ceiling payment (the TEFRA limit), which was determined for each hospital on the basis of various cost, demographic, and geographic factors.

A-Life Medical, Inc., the leading provider of Natural Language Processing (NLP) for the healthcare industry, announced the release of Fusion3, the first practice management system that utilizes patented NLP technology for medical billing.

Fusion3 integrates documentation management, patented NLP coding, billing, collections, denial management, and auditing into a Windows®-based platform, providing the most advanced technology available today. A-Life Medical’s Fusion3 was designed to effectively streamline the code to collection process.
Fusion3 streamlines coding and billing office operations and expedites reimbursement. A-Life Medical’s advanced practice management system can code medical records, and submits charge data on the same date of service. The denial management module automatically tracks denials, sends appeal letters, and generates secondary filings without user involvement.

Fusion3 integrates a complete electronic document management system. Users have instant access to ABNs, transcriptions, insurance cards, EOBs, CMS-1500 forms, or any scanned document. The Fusion3 document management system improves the flow of information, reduces paperwork and inventory costs.

Fusion3 is a unique solution, providing coding and billing audit functionality. Fusion3 identifies a statistically representative sample of claims data and pulls electronic records from a centralized database. Detailed audit reports are automatically created to assist in the auditing process.
“Fusion3 is the first end-to-end practice management system of its kind. We’ve combined our patented NLP technology with billing to effectively streamline the code to collection process. In addition, Fusion3 allows our users to automatically perform random, statistical audits on coding, charge data, and payer information. Combining documentation management, patented NLP coding, billing and auditing into one system is unlike any other offering in the market today,” stated David Byrd, A-Life Medical’s Vice President of Sales and Marketing.

About A-Life Medical, Inc.

A-Life Medical is the leading provider of Natural Language Processing (NLP)-based solutions for the healthcare industry. A-Life Medical’s products extract meaning from unstructured free text and automate tedious, complicated and labor intensive tasks. A-Life Medical’s mission is to provide world-class solutions to streamline and computerize the code to collection process and to fundamentally advance the way the healthcare industry gathers, applies and reports on patient information.

North Adams Regional Hospital administrators wanted to automate the hospital’s medication delivery process to enhance clinical operations and reduce the potential for medication errors, especially at the point of care. The hospital provides primary care services, specialty physician services, and diagnostic and treatment services to citizens in northern Berkshire County, Mass., and southern Vermont. Each year, North Adams performs more than 2,200 surgeries, and its emergency department treats more than 20,000 patients.

To help meet its medication delivery goals, the hospital chose Deerfield, Ill-based Baxter Healthcare’s Patient Care System, an integrated medication management system that uses bar code scanning technology and personal digital assistants (PDAs).
Before automation, North Adams’ nurses relied on a traditional hospital unit-dose system with a 24-hour cart exchange. Automated dispensing from electronic medication carts on the nursing unit now provides the nurse with immediate access to new medications as soon as the order is entered in the pharmacy system. This improves patient care by eliminating the delivery time involved in 24-hour cart dispensing. In addition, pharmacy staff can view the exact time when a medication is administered compared to the scheduled time.

Reporting from this system will provide North Adams with very discrete data regarding medication administration times and any problems that might arise. Pharmacy technicians can now restock the electronic medication carts based on inventory data in the pharmacy since they no longer fill 24-hour medication carts. Pharmacist time is saved, since checking medication carts is no longer necessary.
North Adams installed the pharmacy system in April 2003 and began deployment of medication carts and bedside bar-coded medication verification the following December. The hospital is working unit by unit, and the next golive is scheduled for this spring. The manual system is still in place on units that have not yet implemented the Baxter system. Pharmacy Manager Mark Kester expects that nurses on all hospital units will use the new program by late summer or early fall.

Bedside Bar Codes

Upon admission, every patient receives a bar-coded bracelet. New medication orders are electronically entered into the system, and nurses and pharmacists can immediately view the information. The pharmacist then checks all orders electronically for drug interactions, allergies, duplicate therapy and dosage errors. Next, the pharmacist prepares unit-dose prescriptions, which are packaged, bar-coded and sent to the nursing floor. There, the doses are stored in a wireless mobile medication cart.

Before she begins her rounds, the nurse reviews a to-do list from a handheld PDA or the nurse workstation. She accesses the medication for each patient from the medication cart and pulls up the patient’s electronic medication administration record on a handheld scanner or touchscreen computer on the mobile cart. Only medications requiring administration at that time are shown, and the nurse is directed to the correct drawer, bin and medication within the mobile cart.

She then scans the bar-coded medication to confirm the right medication and dose, and the patient’s bar-coded bracelet to ensure that the right patient is receiving the right dose of the right medication at the right time via the right administration route. The medication is administered, the patient profile is automatically updated and then it is tracked to the patient’s electronic medical record. Information is also tracked by the pharmacy and updated in the hospital’s inventory and patient billing records.

Seamless Integration

Clinicians were hesitant to integrate a medication management system with North Adams’ legacy healthcare information system architecture. North Adams’ has relied on its MEDITECH HIS for 12 years, so the new pharmacy system had to integrate with the existing network. “When we replaced the pharmacy system, we had to make sure the new system would integrate with our current billing application, the application for transferring and admitting patients, and the laboratory information system,” Kester says. Patient Care System interfaced seamlessly with ADT (admissions, discharge, transfer) and the billing applications, and the hospital currently is testing the laboratory interface.

Change management has also played a key role. Baxter provided client service representatives to aid the North Adams team in building the database, training the staff and helping to work through the change management process that’s needed to successfully implement the system. Baxter also worked with North Adams’ IT organization to ensure that all interfaces were seamless.

North Adams experienced few training issues with its pharmacy system, but training nurses was “a more intense situation. A bar code system presents a very different practice environment for nurses that required a lot of practice change and workflow examinations,” Kester says. “In pharmacy, we have to be much more cognizant of the nurses, because what we do affects them in real time. If we don’t have the order entered by the time they want to give it, they’re looking for the order.” The biggest challenge, he adds, was helping the nurses become more familiar with the handheld computers they use to verify medication at the bedside.

Purpose-To develop and implement a billing process that fully integrates all activities of a pediatric nephrology and transplant program, by facilitating and coordinating data from patients, physicians, hospitals, and third-party billing services to maximize revenues.

Methods-Financial operations were analyzed via a randomized audit of patient charts that focused on office procedures and revenue collection. Results based on monthly reports documenting revenue received and outstanding, procedures billed, and patient registration accuracy.
Results-The combination of improvements in patient registration, chart documentation, new billing sheets with procedure and diagnosis codes, physician in-service education, upgraded charges, and the recredentialing of all practice physicians realized an increase in revenue collections from 18% in 2000 to 89% in 2001.

Conclusion-The need to integrate and coordinate information is vital for both billing accuracy and revenue collections. Integration of clinical services and billing procedures has maximized performance, profitability, and accuracy while decreasing administrative time and costs.
When Saint Barnabas Medical Center made the decision in 1996 to initiate a pediatric nephrology and transplant program (PNTP), the mission was to expand the scope of pediatric specialty services offered within the medical center, as well as fill a vital need for renal care for the children of our community. The PNTP was initially established as a subspecialty under the Department of Pediatrics, and was subsequently reassigned to the Transplant Division in 2001 for administrative purposes. The program, which consists of 2 pediatric nephrologists, 1 pediatric nurse specialist, 1 pediatric social worker, and 1 secretary, grew more rapidly than the hospital had anticipated-even expanding consultative services to 3 other affiliate hospitals throughout the state. In 1996, the PNTP provided services for approximately 600 patient procedures and visits, and performed 1 pediatric transplantation; in 2001, however, the PNTP performed more than 1500 patient procedures and visits, and accomplished 5 pediatric transplantations-without any increase in staffing. Over time, the PNTP developed ad hoc policies and procedures so that patient services were provided adequately, but these policies and procedures were largely inefficient. Although the PNTP’s growth and success were a tremendous accomplishment, the program lacked a critical administrative infrastructure, which gradually created organizational issues. For example, charts were disorganized, incomplete, and difficult to locate; billing sheets were deficient, lacking proper codes and diagnoses, which prohibited claims collection; and the physicians were not participating in many large-area insurance networks. Additionally, program growth initiated an increase in requests for materials and manpower, which prompted financial review by the hospital’s fiscal administration. Salaries for the 5 staff members comprised the majority of the program’s expenses. Revenues for the program are generated by the services provided by the 2 pediatric nephrologists, and are billed and collected by a third-party biller. Surprisingly, the financial analysis showed that despite dramatic growth, revenues had actually decreased. Even with this depressed financial picture, the hospital was committed to maintaining this extraordinary subspecialty service. Inadequate revenues were considered to be the result of either the complicated nature of dialysis and transplant finances, payer mix, and/or problems due to improper billing and collection. Because the Transplant Division had a history of demonstrated fiscal accountability, the hospital’s administration subsequently decided to have the Transplant Division oversee the PNTP administration and finances, while maintaining PNTP clinical ties to the Department of Pediatrics.

The Transplant Division at Saint Barnabas Medical Center consists of pretransplant, transplant research, transplant short stay, and posttransplant departments, and performs approximately 190 transplantations annually. The division utilizes a multidisciplinary approach to finance, which integrates clinical, financial, and contracting components, and deals with the technical component of charges. Despite limited experience with physician reimbursement-the transplant physicians are in private group practice and are not hospital employees-the Transplant Division lent its administrative support and assistance to the struggling PNTP. To begin, a review of office practices and procedures for the PNTP was performed, which revealed the absence of any defined or coordinated operational process. An additional benefit of this analysis was that financial concerns with respect to billing and reimbursements were uncovered, as well as issues involving medical record documentation. A project that began as an update of the PNTP billing sheet quickly evolved into an in-depth analysis of the PNTP. The results showed an obvious need for the development and implementation of a billing process that fully integrated all activities of the PNTP by facilitating and coordinating data from patients, physicians, hospitals, and the third-party billing service to maximize revenues. The creation of an operational system was necessary to allow for efficient, effective, and profitable performance, as well as to allow for the PNTP to accomplish the delivery of excellent pediatric patient care services. Research and inquiries also revealed that this pattern was prevalent in many other physician practices. The disjointed and duplicative processes that were in place added another level of complexity. The clinical and financial information had to be consolidated for operational efficacy.

In just a few years, consumer-directed health care has moved from the shadows of healthcare policy to the center stage of healthcare reform. Employers, the purchasers of health insurance for most working Americans, are rapidly moving toward these mechanisms to give workers and their families more choices (something consumers have been demanding for a long time) and to rein in spending by transferring the up-front costs and more overall financial responsibility to their employees.
Although employers and developers of consumer-directed health plans are marketing them as pathways to progress through consumerism in health care, no one knows for sure whether these plans will actually produce the promised improvements. Many industry observers and policy experts see significant gaps between the theory of informed, satisfied consumers and a potential reality of confused, frustrated patients. The sudden rise of CDHPs does not necessarily mean that they are a good idea or viable solution to the vexing problems of paying for health care.

However, CDHPs and their funding mechanisms–health savings accounts, medical spending accounts, and other health reimbursement arrangements–are ushering in a critical era for finance departments in hospitals and medical groups. Providers will increasingly be drawn into personal healthcare financing for consumers on multiple fronts. For better or for worse, the emergence of new financial realities for healthcare consumers creates serious and unprecedented challenges for leaders in healthcare finance.
Developing Consumer-Friendly Pricing

Consider a fundamental aspect of CDHPs: the belief that consumers will use a wealth of data to make informed healthcare decisions. With millions of consumers now covered by plans built on this premise, hospitals and medical groups will need to adapt quickly to the new world of consumer-directed health care. First, providers need to develop information systems that produce the quality and cost data being demanded by employers, consumers, and public and private payers. Second, providers need to be directly involved in developing the mechanisms that will be used to define value from the purchasers’ points of view.

For starters, providers will need to make sure their billing statements are clearly understandable to patients. Successful organizations will need to learn how to work with consumers who engage in price-based comparison shopping. Consumers paying the first few thousand dollars of care with their own money (not to mention coinsurance beyond the new, higher deductibles) will want to know prices in advance. Because payment has never been consumer-centric, however, pricing medical services remains one of the least transparent elements in our opaque healthcare system. Providing a comprehensible and accurate answer will not be easy, but neither will it be avoidable as rising consumer responsibility for health services becomes fact.

CFOs will need to analyze the true costs of every service that patients want to buy, whether it’s a gall bladder operation, hip replacement, or normal childbirth. “It depends” will no longer be an acceptable answer to the question, “How much does it cost?” for price-conscious, value-seeking CDHP patients who are shopping for elective care. Open-ended pricing will be acceptable only in the case of unpreventable complications and life-saving emergency care. Indeed, CDHPs may be the development that finally forces providers to standardize care (i.e., to eliminate avoidable deviations from acceptable practice) according to the imperatives of patient safety, error reduction, and evidence-based medicine.

In a sense, CDHPs will force providers to do for consumers what the prospective payment system forced upon hospitals with diagnosis-related groups in the 1980s and upon physician practices with resource-based relative value scales in the 1990s. Much like Medicare announcing it would henceforth pay only standard, predetermined prices for comparable services, consumers enrolled in CDHPs will oblige providers to offer consistent pricing across all categories of basic care. In short, transparent, up-front consumer pricing will be to the first decade of the 21st century what prospective payment was in the last two decades of the 20th.

Very important, hospitals will be pressured to develop bundled pricing for the majority of their services. There will always be exceptions–unusual procedures for which it will be impossible to estimate costs in advance. But exceptions will represent a tiny percentage of all services. As a general rule, a growing number of consumers with CDHP-style coverage will expect to be quoted a reasonable base price for a needed health service. Many price-conscious health consumers will also want to know the price of “extras,” such as 24-hour nursing care or a private room, in much the same way they would consider adding a bigger engine, more memory, or a first-class cabin once they know the base price of a ear, a computer, or a vacation cruise. Like their retail counterparts, healthcare providers will need to learn how to make profits from the add-ons, not the basic products.

A-Life Medical, Inc., the leading provider of Natural Language Processing (NLP) for the healthcare industry, announced the release of Fusion3, the first practice management system that utilizes patented NLP technology for medical billing.

Fusion3 integrates documentation management, patented NLP coding, billing, collections, denial management, and auditing into a Windows®-based platform, providing the most advanced technology available today. A-Life Medical’s Fusion3 was designed to effectively streamline the code to collection process.
Fusion3 streamlines coding and billing office operations and expedites reimbursement. A-Life Medical’s advanced practice management system can code medical records, and submits charge data on the same date of service. The denial management module automatically tracks denials, sends appeal letters, and generates secondary filings without user involvement.

Fusion3 integrates a complete electronic document management system. Users have instant access to ABNs, transcriptions, insurance cards, EOBs, CMS-1500 forms, or any scanned document. The Fusion3 document management system improves the flow of information, reduces paperwork and inventory costs.

Fusion3 is a unique solution, providing coding and billing audit functionality. Fusion3 identifies a statistically representative sample of claims data and pulls electronic records from a centralized database. Detailed audit reports are automatically created to assist in the auditing process
“Fusion3 is the first end-to-end practice management system of its kind. We’ve combined our patented NLP technology with billing to effectively streamline the code to collection process. In addition, Fusion3 allows our users to automatically perform random, statistical audits on coding, charge data, and payer information. Combining documentation management, patented NLP coding, billing and auditing into one system is unlike any other offering in the market today,” stated David Byrd, A-Life Medical’s Vice President of Sales and Marketing.

About A-Life Medical, Inc.

A-Life Medical is the leading provider of Natural Language Processing (NLP)-based solutions for the healthcare industry. A-Life Medical’s products extract meaning from unstructured free text and automate tedious, complicated and labor intensive tasks. A-Life Medical’s mission is to provide world-class solutions to streamline and computerize the code to collection process and to fundamentally advance the way the healthcare industry gathers, applies and reports on patient information

To assess the financial impact of the inpatient rehabilitation prospective payment system (PPS) on its future revenues, the MetroHealth Center for Rehabilitation (MHCR), Cleveland, Ohio, undertook a three-phase process using data from calendar year 2000 to estimate its potential profit or loss for each case-mix group (CMG) identified in the final rule. This process entailed developing a database to facilitate the combination and comparison of patient-charge and clinical data by CMG, using the combined data to estimate costs by cost center, and using payment information included in the final rule to estimate revenues by CMG. Following the assessment, the MHCR decided to expand the database to assist clinicians in making informed decisions in their patient-assessment and care-delivery processes that would account for cost and revenue considerations under the PPS.

On August 6, 2001, the Centers for Medicare and Medicaid Services (CMS–formerly HCFA) published the final rule outlining the new prospective payment system (PPS) for inpatient rehabilitation services. (a) Previously, rehabilitation hospitals and units were excluded from the DRG-based PPS established for acute care hospitals by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 because the resources required to provide postacute rehabilitation services tended to vary dramatically among patients with the same diagnosis. Instead, TEFRA established a payment system for rehabilitation hospitals based on reasonable costs up to a ceiling payment (the TEFRA limit), which was determined for each hospital on the basis of various cost, demographic, and geographic factors.

The inpatient rehabilitation PPS promises to bring significant change to this sector of the healthcare industry. Therefore, inpatient rehabilitation facilities should prepare immediately for implementation of the new PPS.

The MetroHealth Center for Rehabilitation (MHCR), a member of the Cleveland, Ohio-based MetroHealth System, undertook an initiative whose primary long-term goals were to facilitate comparison of the financial impact of the new system with the existing cost-based payment structure, identify opportunities for cost savings, and clarify the financial implications of clinical decision making under the PPS. The initiative involved integrating clinical information from the organization’s patient-assessment system with financial data from its billing and cost-accounting systems.

PPS Provisions

The Balanced Budget Act (BBA) of 1997 authorized the inpatient rehabilitation PPS. Under the BBA (with amendments under the Balanced Budget Refinement Act of 1999), CMS was to phase in the PPS over a two-year transition period starting with cost-reporting periods on or after October 1, 2001, and its budget effect was to be fixed, initially at 98 percent and then at 100 percent of the amount spent under the old cost-based payment system. The start date was changed twice, first to April 1, 2001, and then to January 1, 2002. In addition, CMS was charged with establishing:

* The payment unit (later determined by CMS to be per discharge);

* Case-mix groups (CMGs), the inpatient rehabilitation equivalent of DRGs, to be determined by factors such as a patient’s level of impairment, age, comorbidities, and functional capabilities;

* Weights for each CMG;

* The method to be used for classification of patients into CMGs;

* The payment rate;

* Policies regarding outliers;

* Area wage adjustments; and

* Transfer payment policies.

The final rule for the inpatient rehabilitation PPS establishes 100 CMGs under which inpatient rehabilitation facilities may receive Medicare coverage. Of these CMGs, 95 are divided among 21 rehabilitation impairment categories (RICs–eg, stroke, brain injury, spinal cord injury), and the remaining five are placed in a special category for short-stay/expired patients. (b)

The 95 CMGs included in the RIGs are defined using clinical scores based on a slightly modified version of the Functional Independence Measure (FIM) system, a widely used rehabilitation assessment tool developed by Uniform Data Systems, Buffalo, New York. Each of these GMGs is defined by a motor score expressed as a range (with possible scores ranging from 12 to 84). Also, where appropriate, GMGs are defined by cognitive scores (with possible scores ranging from five to 35), and by age criteria.

Because most rehabilitation providers already are familiar with the FIM system, its inclusion in the inpatient rehabilitation PPS should help minimize the amount of additional training needed for facilities to ensure patients are properly assessed and categorized into the appropriate CMGs. In addition, FIM data on past discharges can provide a good basis for modeling the PPS’s financial effect.

Under the final rule, each CMG is divided into four “tiers,” based on the presence or absence of certain comorbidities, as defined by IGD-9 codes. Payments for each CMG will vary depending on the tier to which a patient is classified.

Purpose-To develop and implement a billing process that fully integrates all activities of a pediatric nephrology and transplant program, by facilitating and coordinating data from patients, physicians, hospitals, and third-party billing services to maximize revenues.

Methods-Financial operations were analyzed via a randomized audit of patient charts that focused on office procedures and revenue collection. Results based on monthly reports documenting revenue received and outstanding, procedures billed, and patient registration accuracy.

Results-The combination of improvements in patient registration, chart documentation, new billing sheets with procedure and diagnosis codes, physician in-service education, upgraded charges, and the recredentialing of all practice physicians realized an increase in revenue collections from 18% in 2000 to 89% in 2001.

Conclusion-The need to integrate and coordinate information is vital for both billing accuracy and revenue collections. Integration of clinical services and billing procedures has maximized performance, profitability, and accuracy while decreasing administrative time and costs. (Progress in Transplantation. 2003;13:197-202)

When Saint Barnabas Medical Center made the decision in 1996 to initiate a pediatric nephrology and transplant program (PNTP), the mission was to expand the scope of pediatric specialty services offered within the medical center, as well as fill a vital need for renal care for the children of our community. The PNTP was initially established as a subspecialty under the Department of Pediatrics, and was subsequently reassigned to the Transplant Division in 2001 for administrative purposes. The program, which consists of 2 pediatric nephrologists, 1 pediatric nurse specialist, 1 pediatric social worker, and 1 secretary, grew more rapidly than the hospital had anticipated-even expanding consultative services to 3 other affiliate hospitals throughout the state. In 1996, the PNTP provided services for approximately 600 patient procedures and visits, and performed 1 pediatric transplantation; in 2001, however, the PNTP performed more than 1500 patient procedures and visits, and accomplished 5 pediatric transplantations-without any increase in staffing. Over time, the PNTP developed ad hoc policies and procedures so that patient services were provided adequately, but these policies and procedures were largely inefficient. Although the PNTP’s growth and success were a tremendous accomplishment, the program lacked a critical administrative infrastructure, which gradually created organizational issues. For example, charts were disorganized, incomplete, and difficult to locate; billing sheets were deficient, lacking proper codes and diagnoses, which prohibited claims collection; and the physicians were not participating in many large-area insurance networks. Additionally, program growth initiated an increase in requests for materials and manpower, which prompted financial review by the hospital’s fiscal administration. Salaries for the 5 staff members comprised the majority of the program’s expenses. Revenues for the program are generated by the services provided by the 2 pediatric nephrologists, and are billed and collected by a third-party biller. Surprisingly, the financial analysis showed that despite dramatic growth, revenues had actually decreased. Even with this depressed financial picture, the hospital was committed to maintaining this extraordinary subspecialty service. Inadequate revenues were considered to be the result of either the complicated nature of dialysis and transplant finances, payer mix, and/or problems due to improper billing and collection. Because the Transplant Division had a history of demonstrated fiscal accountability, the hospital’s administration subsequently decided to have the Transplant Division oversee the PNTP administration and finances, while maintaining PNTP clinical ties to the Department of Pediatrics.

The Transplant Division at Saint Barnabas Medical Center consists of pretransplant, transplant research, transplant short stay, and posttransplant departments, and performs approximately 190 transplantations annually. The division utilizes a multidisciplinary approach to finance, which integrates clinical, financial, and contracting components, and deals with the technical component of charges. Despite limited experience with physician reimbursement-the transplant physicians are in private group practice and are not hospital employees-the Transplant Division lent its administrative support and assistance to the struggling PNTP. To begin, a review of office practices and procedures for the PNTP was performed, which revealed the absence of any defined or coordinated operational process. An additional benefit of this analysis was that financial concerns with respect to billing and reimbursements were uncovered, as well as issues involving medical record documentation. A project that began as an update of the PNTP billing sheet quickly evolved into an in-depth analysis of the PNTP. The results showed an obvious need for the development and implementation of a billing process that fully integrated all activities of the PNTP by facilitating and coordinating data from patients, physicians, hospitals, and the third-party billing service to maximize revenues. The creation of an operational system was necessary to allow for efficient, effective, and profitable performance, as well as to allow for the PNTP to accomplish the delivery of excellent pediatric patient care services. Research and inquiries also revealed that this pattern was prevalent in many other physician practices. The disjointed and duplicative processes that were in place added another level of complexity. The clinical and financial information had to be consolidated for operational efficacy.