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.