Clinicians, Tech Help St. Joseph’s Health Increase Charges by $39.6M

Beth Kushner, DO, always starts lectures with residents at St. Joseph’s Health with a simple philosophy.

“You should get paid for everything you do, nothing you didn't do, and make sure that you can provide high-quality care for the most amount of people,” says Kushner, who serves as the New Jersey-based health system’s chief medical information officer.

Accurate charge capture is key to the success of St. Joseph’s Health, a safety-net hospital and the largest provider of charity care in the state of New Jersey. The system treats very few patients covered by higher-paying commercial health plans. Instead, its providers see larger volumes of Medicaid managed care patients compared to other hospitals.

“You can imagine how that really does play into our revenue cycle with charity care,” Kushner explained to RevCycleIntelligence.

Even small inaccuracies in clinical coding and documentation can lead to significant differences in reimbursement, which is already on the lower part of the spectrum for safety-net providers.

But providers are not always aware of the impact their charting can have on the bottom line, Kushner stated.

“I am a practicing physician, so I will take complete ownership. We are not really good at understanding the financial impact of what we do,” the emergency medicine physician said. “We also get caught up in patient care. You see multiple patients in a row and then sometimes things just slip through the cracks.”

One of those things that have slipped through the cracks though has been the documentation of complicated, high-paying procedures like the placement of a tunneled dialysis catheter, for example.

“I happened to be looking at one of my patient's charts and they had a tunneled dialysis catheter placed while they were in the ER by one of our vascular APNs. I was looking for something else, and I said, ‘Hey, that's interesting, I don't see a charge in the system for this very complicated procedure that was done.’ So, I started doing a little bit more digging, a little bit more research, and when I ran a query of his notes that he had done, I realized that we had not billed for this procedure,” Kushner explained.

Kushner and other leaders at St. Joseph’s Health realized they needed to empower providers to understand what and how they document in patient charts impacts revenue and, therefore, the health system’s ability to deliver high-quality care to as many patients as possible.

To do that, the system turned to revenue cycle technology.

Health system leaders leveraged new revenue cycle and clinical solutions from Cerner to identify the most common charges that providers used according to their specialty. Then, they made those charges visible in the EHR system for physicians to see while charting.

“Visual reminders are a very important way to help make sure our physicians are the most efficient at getting the charges in the system,” Kushner said.

The new charge capture workflow has helped St. Joseph’s Health increase charges by $39.6 million, according to data from Cerner. But the workflow has also been instrumental in improving provider education around clinical coding and documentation, which has also contributed to increased charge capture, Kushner stated.

“A very common misconception is that at some point along the way, someone teaches physicians about billing and coding,” Kushner stated. “And I know throughout my residency, I learned I should write a chart, it should be a complete chart, and I should have never lie in the chart. But aside from that, I've never really learned the components of what is supposed to go inside the chart.”

Clinicians are not necessarily missing a lesson, though. A recent survey of revenue cycle leaders found that most – 40 percent – do not discuss charge capture with staff regularly even though the majority of respondents said between one and ten percent of their total changes are impacted by either under- or over-coding.

“We build that relationship from the start,” Kushner emphasized, which begins with welcoming hospital-employed providers and introducing them to the coders who will be auditing their charts and can help them “be the most they can be” through complete, accurate charting.

“One of the things that we started to do is, when you get onboarded as a physician, we have a physician orientation day,” Kushner explained. “Part of that is meeting with some of our coders for the professional end of care, and you can ask the billion-and-one questions that you've never really been able to ask and you know are important.”

The health system is also addressing the root cause of charge capture challenges according to surveyed revenue cycle leaders: lack of integration between EHR systems and other technologies used by healthcare organizations.

Prior to transitioning to Cerner’s revenue cycle and clinical solutions, St. Joseph’s Health encountered charge capture challenges associated with fragmented systems and processes. Consequently, the health system developed a Revenue Cycle Collaborative team to guide the technology transition and the education coming out of it.

The team has been central to ensuring new charge capture workflows work for providers across the system regardless of the billing or practice management system they use. It has also been key to getting providers involved with revenue cycle.

In addition to leveraging technology for more automated, convenient charge capture, health system leaders have also used reporting in the solutions to give clinical department leaders data on charge capture, productivity, and other key performance indicators.

“Physicians are highly motivated. They like analytics; they like data,” Kushner stated. “By providing that data to our providers, it gives them feedback in as much real time as we can do.”

This process is informing the health system’s next steps, which include making sure providers are getting credit for the high-quality care they are delivering to patients, including one-off procedures or one-off providers to ensure the health system is optimizing revenue for those services.

But the most important factor to successfully leveraging technology is collaboration, Kushner highlighted.

“The most important thing for the success of technology and revenue cycles together is to have a collaborative team where you have people from the revenue cycle who truly understand coding, billing, and lots of things that physicians never learn,” Kushner concluded. “I very much work in a collaborative environment, and without my revenue cycle counterparts who really understand the financial aspect of life, we would be not nearly as successful with our numbers.”