Billing Quality Is Medical Quality

Efforts to improve the billing accuracy of robotic-assisted thoracic surgery through education, updated procedure cards, and electronic medical record system changes

Precise medical billing is essential for decreasing hospital liability, upholding environmental stewardship and ensuring fair costs for patients. We instituted a multifaceted approach to improve the billing accuracy of our robotic-assisted thoracic surgery programme by including an educational component, updating procedure cards and removing the auto-populating function of our electronic medical record. Overall, we saw significant improvements in both the number of inaccurate billing cases and, specifically, the number of cases that overcharged patients.

Reported Variation in Hospital Billing Quality

This study examines how US hospitals perform on billing quality measures, including legal actions taken by a hospital to collect medical debt, the timeliness of sending patients an itemized billing statement, and patient access to a qualified billing representative.

Development of billing post competency evaluation index system for nurses in China: a Delphi study

AIM

This study developed a set of competency evaluation indicators for billing nurses in China.

BACKGROUND

In clinical practice, nurses often take up billing responsibilities that are accompanied by certain risks. However, the competency evaluation index system for billing nurses has not been established in China.

METHODS

This study consisted of two main phases of research design: the first phase included a literature review and semi-structured interviews. Individual semi-structured interviews were conducted with 12 nurses in billing departments and 15 nurse managers in related departments. Concepts distilled from the literature review were linked to the results of the semi-structured interviews; this phase produced the first draft of indicators for assessing the professional competence of nurses in billing departments. In the second phase, two rounds of correspondence were conducted with 20 Chinese nursing experts using the Delphi method to test and evaluate the content of the index. The consensus was defined in advance as a mean score of 4.0 or above, with at least 75% agreement among participants. In this way, the final indicator framework was determined.

RESULTS

Using the iceberg model as a theoretical foundation, the literature review identified four main dimensions and associated themes. The semi-structured interviews confirmed all of the themes from the literature review while generating new themes, both of which were incorporated into the first draft of the index. Then two rounds of the Delphi survey were conducted. The positive coefficients of experts in the two rounds were 100% and 95%, respectively, while the authority coefficients were 0.963 and 0.961, respectively. The coefficients of variation were 0.00-0.33 and 0.05-0.24, respectively. The competency evaluation index system for billing nurses consisted of 4 first-level indicators, 16 s-level indicators, and 53 third-level indicators.

CONCLUSION

The competency evaluation index system for billing nurses, which was developed on the basis of the iceberg model, was scientific and applicable.

IMPLICATIONS FOR NURSING MANAGEMENT

The competency assessment index system for billing nurses may provide an effective practical framework for nursing administration to evaluate, train, and assess the competency of billing nurses.

Not Clearing the Air: Hospital Price Transparency for a Laparoscopic Cholecystectomy

INTRODUCTION

In 2019, Centers for Medicare and Medicaid Services (CMS) established a new requirement that all hospitals publish information on the standard costs of services provided. Increased price transparency allows patients to compare healthcare costs and make informed decisions about their care. We investigated compliance with this rule with regards to laparoscopic cholecystectomy, a commonly performed operation and one of the 70 shoppable services (SSs) included in the CMS requirement, among prominent hospitals in the United States.

METHODS

The 2021-2022 US News "Best Hospitals for Gastroenterology and GI Surgery" was used to identify the top 50 hospitals for gastrointestinal surgery. Each hospital's website was assessed for the presence of a machine-readable file (MRF) as required by CMS. Each MRF was then evaluated for inclusion of all seven required elements: description of item/service, gross charge, payer-specific negotiated charge, deidentified minimum and maximum negotiated charges, discounted cash price, and billing code. The presence of a consumer-friendly display of SSs was also evaluated. The Current Procedural Terminology code 47562 (removal of gallbladder with an endoscope) was used to search for all six required elements: payer-specific negotiated charge, discounted cash price, de-identified minimum and maximum negotiated charges, campus location of the SS, and billing code. The SS display was further evaluated for provision of additional information on ancillary charges, which are recommended but not required. The MRF and SS were also evaluated for accessibility and date of last update. Hospitals were analyzed according to rank. Compliance with CMS requirements was compared between hospitals.

RESULTS

Fifty one hospitals were included. Of these 51 hospitals, one (2%) provided all the required information for both MRF and SS, 44 (86%) did not provide all necessary components of both the MRF and SS, six (12%) had all necessary elements of an MRF only, and two (4%) had all necessary elements of the SS only. The MRF was accessible in 80% (41) of studied hospitals and 76% (39) provided a gross charge but just 35% (18) of hospitals included the discounted cash price. The SS specified location for all hospitals, indicated a billing code in 96% (49), and provided a payer-specific charge in 96% (48), but less often provided de-identified minimum (30; 59%) and maximum (30; 59%) charges. Thirty nine (76%) hospitals reported that the listed price included an ancillary charge. There was no significant difference between hospitals in having all required elements of both the MRF and SS or the MRF only or SS only.

CONCLUSIONS

Hospitals are providing healthcare consumers with standard charge information, although with significant variation in what is disclosed. There is no association between hospital reputation and provision of standard charge information.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study

OBJECTIVE

This study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits, wage garnishments and liens.

DESIGN

Cross-sectional study.

SETTING

We examined state and county court record systems to measure the magnitude and prevalence of these practices at the largest 100 hospitals in the UA between 1 January 2018 and 31 July 2020.

MAIN OUTCOMES MEASURES

The main outcome of this study was the number of lawsuits, wage garnishments and liens. A secondary outcome was the characterisation of a hospital's safety, charitability, size and financial practices.

RESULTS

Between 1 January 2018 and 31 July 2020, 26 hospitals filed 38 965 court actions (lawsuits, wage garnishments and liens) against patients for unpaid medical debt. For 16 of 26 hospitals, the dollar amount pursued in the court claim was available for 100% of cases, totalling US$71.8 million. The average aggregate amount sought by hospital lawsuits during the study period was US$4.5 million. Three hospitals filed US$56.2 million in amounts pursued in court, or 78.3% of the total amount pursued by all hospitals in the sample. In the remaining 74 hospitals, the study team did not identify extraordinary collection actions through the court system.

CONCLUSIONS

Standardised medical debt collections best practices and metrics of medical debt collections quality are needed to increase public accountability for hospitals, particularly non-profit hospitals. There is a need to re-evaluate Internal Revenue Service rules pertaining to non-profit hospitals' tax-exempt status to ensure tax-exempt hospitals provide community benefits commensurate with the value of tax exemption.

Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis

OBJECTIVE

To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases.

STUDY DESIGN

Cross-sectional analysis.

SETTING

2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database.

METHODS

All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications.

RESULTS

An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, P < .001) and required longer hospital admissions (68.7 vs 33.2 days, P < .001) than children without tracheostomy-related complications. Mean costs ($459,324 vs $397,937, P < .001) and mean total charges ($1,573,964 vs $1,099,347, P < .001) were increased if a tracheostomy-related complication occurred. These events occurred more often in those with bronchopulmonary dysplasia (24% vs 12%, P < .001), heart disease (24% vs 12%, P = .001), gastroesophageal reflux disease (31% vs 19%, P < .001), short gestational age (24% vs 14%, P < .001), and subglottic stenosis (9.9% vs 5.4%, P = .001). The estimated 30-day readmission rate was 24% (SE, 1.7%) but did not increase after tracheostomy complications (27% vs 15%, P = .04). Tracheostomy-related complications were predicted by gastroesophageal reflux disease (odds ratio [OR], 1.50; 95% CI, 1.14-1.97; P = .004), younger age (OR, 1.12; 95% CI, 1.04-1.22; P = .002), and lengthier hospitalization (OR, 1.00; 95% CI, 1.00-1.01; P < .001) on multiple logistic regression analysis.

CONCLUSION

Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.

Health care Affordability and Associated Concerns Among Adults Aged 65 and above in Florida

OBJECTIVE

This study assessed affordability of care in a diverse sample of Floridians aged ≥ 65 to ascertain concerns about health care costs.

METHODS

We surveyed 170 adults (40.6% white, 27.6% black, and 31.8% Hispanic) and conducted three race/ethnic-stratified focus groups (n = 27).

RESULTS

Most participants had Medicare (97.1%). Among whites, 11.6% reported problems paying medical bills in the past 12 months versus 14.9% of blacks and 24.1% of Hispanics. In addition, 13% of whites, 19.2% of blacks, and 20.4% of Hispanics reported not getting needed prescription drugs because of costs. The most frequently identified concerns from the focus groups were the cost of prescription drugs, out-of-pocket expenses, and medical billing. Concerns about medical billing included understanding bills, transparency, timely postings, and uncertainty about who to contact about problems.

DISCUSSION

Our findings suggest that practices that help older adults effectively manage medical bills and costs may alleviate their concerns and guard against financial burdens.

Trends in Hospital Lawsuits Filed Against Patients for Unpaid Bills Following Published Research About This Activity

IMPORTANCE

Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice.

OBJECTIVE

To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020).

EXPOSURES

Publication of a research article and subsequent media coverage.

MAIN OUTCOMES AND MEASURES

The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis.

RESULTS

A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that research leading to public awareness can shift hospital billing practices.

Financial burden, distress, and toxicity in cardiovascular disease

Cardiovascular disease (CVD) is a major source of financial burden and distress, which has 3 main domains: (1) psychological distress; (2) cost-related care non-adherence or medical care deferral, and (3) tradeoffs with basic non-medical needs. We propose 4 ways to reduce financial distress in CVD: (1) policymakers can expand insurance coverage and curtail underinsurance; (2) health systems can limit expenditure on low-benefit, high-cost treatments while developing services for high-risk individuals; (3) physicians can engage in shared-decision-making for high-cost interventions, and (4) community-based initiatives can support patients with system navigation and financial coping. Avenues for research include (1) analysis of how healthcare policies affect financial burden; (2) comparative effectiveness studies examining high and low-cost strategies for CVD management; and (3) studying interventions to reduce financial burden, financial coaching, and community health worker integration.

Understanding Surprise Out-of-Network Billing in Hand and Upper Extremity Care

Surprise billing occurs when insured patients receive unexpected out-of-network charges and fees even when the emergency department, facility, or primary physician who provided care is in their insurance network. This issue is particularly relevant for hand surgery. The multidisciplinary nature of hand care and the number of ancillary services involved result in various levels at which out-of-network billing can be introduced, even when the hand surgeon is in-network for the patient. In addition, surprise billing is often associated with emergency department encounters, elective surgeries, and ambulance and helicopter transfers. In this article, we review surprise billing as it pertains to hand surgery. Little is known about surprise billing in hand care; however, we believe that these practices may substantially affect the patient population. We define key elements of surprise billing, review the literature, discuss the relevance and potential of surprise billing in hand surgery in various settings, and provide an overview of the status of health policy surrounding this practice. It is imperative for hand surgery as a field to understand the prevalence, operationalization, and policies of surprise billing better to prevent the exploitation of patients.

The Increasing Financial Burden of Outpatient Elective Surgery for the Privately Insured

OBJECTIVE

To examine temporal trends of OOP expenses, total payments, facility fees, and professional fees for outpatient surgery.

SUMMARY BACKGROUND DATA

Approximately 48 million outpatient surgeries are performed annually with a limited financial understanding of these procedures. High OOP expenses may influence treatment decisions, delay care, and cause financial burden for patients.

METHODS

We conducted a retrospective cohort study of patients with employer-sponsored insurance undergoing common outpatient surgical procedures (cholecystectomy, cataract surgery, meniscectomy, muscle/tendon procedures, and joint procedures) from 2011 to 2017. Total payments for surgical encounters paid by the insurer/employer and patient OOP expenses were calculated. We used multivariable linear regression to predict total payments and OOP expenses, with costs adjusted to the 2017 US dollar.

RESULTS

We evaluated 5,261,295 outpatient surgeries (2011-2017). Total payments increased by 29%, with a 53% increase in facility fees and no change in professional fees. OOP expenses grew by 50%. After controlling for procedure type, procedures performed in ambulatory surgery centers conferred an additional $2019 in predicted total payments (95%CI:$2002-$2036) and $324 in OOP expenses (95%CI:$319-$328) compared to predicted cost for office-based procedures. Hospital-based procedures cost an additional $2649 in predicted total payments (95%CI:$2632-$2667) and $302 in predicted OOP expenses (95%CI:$297-$306) compared to office procedures.

CONCLUSION

Increases in outpatient surgery total payments were driven primarily by facility fees and OOP expenses. OOP expenses are rising faster than total payments, highlighting the transition of costs to patients. Healthcare cost reduction policies should consider the largest areas of spending growth such as facility fees and OOP expenses to minimize the financial burden placed on patients.