Case Study: To Query or Not to Query… that is NOT the Question
Continual increases in billing and payor requirements are driving unprecedented demands for detailed documentation. Many organizations are becoming more attuned to the potential tension created between providers and coding, CDI, quality, and reimbursement staffs.
Often times, inefficient or miss-managed query programs increase that tension and become non-productive. Across healthcare, the majority of hospitals or healthcare systems have incorporated query programs; however in many cases they are driven solely from a compliance perspective.
To query or not to query; that is NOT the question. We’ve prepared a case study using data gathered over the past couple of years, in order to reach an undeniable conclusion: it’s not about the why, it’s about the how.
Our approach: Leadership should utilize query programs driven by analytics, as an opportunity for significant revenue creation while maintaining compliance standards. Throughout this article we will review a case study ranging from July 2016 – June 2018.
During the case study we assumed the following metrics:
- Subjects (3): 120 bed hospital, 465 bed hospital and a 3459 bed healthcare system
- Year 1 – Query program management without a data analytics program
- Year 2 – Query program management with a data analytics program
Our hypothesis: The case study hypotheses were that as a result of implementing a data analytics program, hospitals realize the following statements:
- Decrease in Missed Revenue
- e. Revenue not captured due to poor program structure, poor query form design, insufficient documentation, non-compliant provider responses or no response from providers
- Increase in Bottom Line Revenue
- Decrease in Query Response Time
- Resulting in decreases in hospital DNFB as queried charts can be dropped sooner
- Highlight Education Opportunities regarding non-compliance for providers
The case study results directly correlated with implementing data analytics were as follows:
- Decreased the amount of missed revenue related to insufficient documentation or unanswered queries
Example 120 Bed Hospital: In year 1 (July 2016 – June 2017), there was a missed opportunity to collect $67,201.18 due to unanswered or undetermined queries. By implementing a data analytics program in year 2 (July 2017 – June 2018), the 120 bed hospital collected an additional $46,610.40 (a 69% increase) in revenue that may have otherwise been missed.
- Increased the amount of bottom line revenue generated through the query program
Example 465 Bed Hospital: In year 1 (July 2016 – June 2017) utilizing a compliant query process, the query program generated $1,078,142.41 in bottom line revenue. By implementing the data analytics program in year 2 (July 2017 – June 2018), the 465 bed hospital collected an additional $1,422,299.93 (a 132% increase) which totaled $2,500,442.34 in bottom line revenue.
- Decreased the provider response time to outstanding queries
As part of this process we developed a “Query Aging Report” that was provided to hospital supervisors weekly. This report outlined and prioritized all outstanding queries and allowed the hospital supervisors to provide FOCUSED query follow up and closure of queries with final coding completed. By prioritizing which queries needed to be addressed this assisted the hospital in:
- Addressing issues prior to final coding and dropping claims resulting in less payor rejections and claims re-submittals
- Assistance in avoidance of triggering red flags for regulatory audits due to too many resubmittals
- Addressing provider query response times which in turn reduces hold times for final coding which ultimately positively affected their DNFB
- Highlighted education opportunities regarding non-compliance for providers
Over the course of year 2 (July 2017 – June 2018), using data analytics we identified providers that did not respond to the query(ies) at least 50% of the time.
For example, the 3459 bed healthcare system identified their top 177 non-compliant providers who on average were not answering 72% of their queries. Providing additional education to these providers will assist the hospital or healthcare system to lessen non-compliant provider impact on missed revenue, to increase compliance and to add to the bottom line.
Additional Benefits Realized
- Identified top queried DRG, DX, Physicians (Leverage for Educational Opportunities)
- Identified query forms that were not comprehensive as well as not up to current guidelines
- Increased the amount of answered queries / Decreased the amount of canceled / unanswered queries
Provider Specific Benefits
- Positively affected provider and reimbursement staff relations
- Provider can focus only on “true” outstanding queries and avoid frustrating re-work
- Place importance on response turnaround time when notified
Staff Specific Benefits
- Identified coders who may need additional clinical education regarding specific DRGs
- Identified coders who are querying less than their colleagues
- Identified coders who are querying significantly more than their colleagues
Our conclusions: The key factors to success in our case study, and what we believe to be true for “efficiently run query programs” are:
- Program Driven by Data Analytics
- Dedicated Project Manager (either on Client or Vendor side)
- Frequent communication / touch point discussions
- 15-30 minute touch point calls weekly
- Query aging reports – Weekly report(s) sent to hospital supervisors to provide follow up so they may work with their staff to resolve outstanding queries so coding can be finalized
The benefits resulting from implementing an efficiently managed query program driven by data analytics are visibly captured in our day-to-day operations with the partners we serve, as well as throughout this case study.
From relationship management to revenue management our experience has proven that efficiently run query programs supported and driven by niche data analytics will be a valuable asset to your organization, both in revenue generation as well as coding and documentation compliance. Throughout our experience we have seen how valuable data can be when developing programs or initiatives. Equally as important is that the data is retrieved and analyzed by a partner that knows what to look for.