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.

Evaluating the Clinical Utility and Cost of Imaging Strategies in Adults with Newly Diagnosed Primary Intradural Spinal Tumors.

OBJECTIVE: In patients with new primary intradural spinal tumors, the best screening strategy for additional central nervous system (CNS) lesions is unclear. The goal of this study was to document the rate of additional CNS tumors in these patients. METHODS: Adults with primary intradural spinal tumors were retrospectively reviewed. Imaging strategy at diagnosis was classified as focused spine (cervical, thoracic, or lumbar), total spine, or complete neuraxis (brain and total spine). Tumor pathology, genetic syndromes, and presence of additional CNS lesions at diagnosis or follow-up were collected. RESULTS: The study comprised 319 patients with mean age of 51 years and mean follow-up of 41 months. In 151 patients with focused spine imaging, 3 (2.0%) were found to have new lesions with 2 (1.4%) requiring treatment. In 35 patients with total spine imaging, there were no additional lesions. In 133 patients with complete neuraxis imaging, 4 (3.0%) were found to have new lesions with 2 (1.5%) requiring treatment. There was no difference in the identification of new lesions (P = 0.542) or new lesions requiring treatment (P = 0.772) across imaging strategies. Among patients without genetic syndromes, rates of new lesions requiring treatment were 1.4% for focused spine, 0% for total spine, and 2.2% for complete neuraxis (P = 0.683). There were no cases of delayed identification causing risk to life or neurological function. Complete neuraxis imaging carried an increased charge of $4420 per patient. CONCLUSIONS: Among patients without an underlying genetic syndrome, the likelihood of identifying additional CNS lesions requiring treatment is low. In appropriate cases, focused spine imaging may be a more cost-effective strategy.

Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians.

When physicians whom patients do not choose and cannot avoid can bill out of network for care delivered within in-network hospitals, it exposes patients to financial risk and undercuts the functioning of health care markets. Using data for 2015 from a large commercial insurer, we found that at in-network hospitals, 11.8 percent of anesthesiology care, 12.3 percent of care involving a pathologist, 5.6 percent of claims for radiologists, and 11.3 percent of cases involving an assistant surgeon were billed out of network. The ability to bill out of network allows these specialists to negotiate artificially high in-network rates. Out-of-network billing is more prevalent at hospitals in concentrated hospital and insurance markets and at for-profit hospitals. Our estimates show that if these specialists were not able to bill out of network, it would lower physician payments for privately insured patients by 13.4 percent and reduce health care spending for people with employer-sponsored insurance by 3.4 percent (approximately $40 billion annually).

Economic factors converge: force hospitals to review pricing strategies.

The US hospital service price structures are complex and tend to be significantly higher than the actual cost to provide the service. Health care consumers have been given more authority to drive health care decisions. Transparency in health care is forcing hospitals to critically review and substantiate service prices. It is vital that US hospitals review their pricing strategies in order to continue as strong leaders in the health care market.

Accuracy of administrative billing codes to detect urinary tract infection hospitalizations.

BACKGROUND: Hospital billing data are frequently used for quality measures and research, but the accuracy of the use of discharge codes to identify urinary tract infections (UTIs) is unknown. OBJECTIVE: To determine the accuracy of International Classification of Diseases, 9th revision (ICD-9) discharge codes to identify children hospitalized with UTIs. METHODS: This multicenter study conducted in 5 children's hospitals included children aged 3 days to 18 years who had been admitted to the hospital, undergone a urinalysis or urine culture, and discharged from the hospital. Data were obtained from the pediatric health information system database and medical record review. With the use of 2 gold-standard methods, the positive predictive value (PPV) was calculated for individual and combined UTI codes and for common UTI identification strategies. PPV was measured for all groupings for which the UTI code was the principal discharge diagnosis. RESULTS: There were 833 patients in the study. The PPV was 50.3% with the use of the gold standard of laboratory-confirmed UTIs but increased to 85% with provider confirmation. Restriction of the study cohort to patients with a principle diagnosis of UTI improved the PPV for laboratory-confirmed UTI (61.2%) and provider-confirmed UTI (93.2%), as well as the ability to benchmark performance. Other common identification strategies did not markedly affect the PPV. CONCLUSIONS: ICD-9 codes can be used to identify patients with UTIs but are most accurate when UTI is the principal discharge diagnosis. The identification strategies reported in this study can be used to improve the accuracy and applicability of benchmarking measures.

A better way to measure volume--and benchmark costs.

Equivalent patient units is a more reliable measure of a hospital's patient volume than adjusted discharges or adjusted patient days because it better accounts for both inpatient and outpatient volumes. Three elements are required to calculate equivalent patient units: equivalent discharges, equivalent visits, and the payment ratio. All of these elements are available through publicly available data, making it possible for hospitals to immediately adopt this new metric and, thereby, better understand their potential for savings.

Do declining private insurance coverage rates influence pediatric hospital charging practices?

OBJECTIVE: To analyze trends in primary payer composition for pediatric hospitalizations and insurance coverage rates from 2000 to 2006 and possible effects on hospital charging practices. DESIGN: We documented national trends in hospital charge-to-cost ratios and primary payer mixes for pediatric discharges from 2000 to 2006 using the Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID). We then performed regression analyses at the hospital level to analyze associations between pediatric insurance coverage rates and hospital charge-to-cost ratios. RESULTS: We found pediatric inpatient charge-to-cost ratios increased dramatically during study period. Charge-to-cost ratios were higher for hospitals located in states with either higher uninsurance rates or a public-private coverage mix that was skewed towards public coverage. CONCLUSIONS: This study provides evidence of both important changes in pediatric health insurance distribution in the United States and hospital charging practices.

Hospital emergency department visits attributed to pulpal and periapical disease in the United States in 2006.

BACKGROUND: Relatively localized conditions such as infection of the pulp or periapical tissues if left untreated could spread and require hospital care. The objectives of this study were to assess the prevalence of such hospital-based emergency department (ED) visits, to quantify hospital charges associated with those visits, and to identify characteristics of those members of the population who are likely to make such visits. METHODS: The experimental design of this study involves the use of The Nationwide Emergency Department Sample for the year 2006. All discharges with a primary diagnosis code for pulpal and periapical diseases (International Classification of Disease, Clinical Modification [ICD-9-CM] code of 522) were selected for analysis. All estimates were projected to national levels using the discharge weight variables. RESULTS: In the United States, during the year 2006, a total of 403,149 ED visits had a primary diagnosis code for pulp and periapical diseases. The average patient age was 32.9 years. The mean hospital charge for ED visits was $480, and the total charges for all the ED visits in the United States was $163,692,957. Among the ED visits, 5,721 were admitted to the same hospital for inpatient care. The mean length of stay after hospitalization was 2.95 days. The uninsured (39.92%) constituted the largest proportion of all ED visits. CONCLUSIONS: This study identifies high-risk groups that are likely to present to hospital-based EDs for the treatment of pulp and periapical diseases. This highlights the need for significant resources to treat such patients in a hospital care setting.

The devil is in the details: maximizing revenue for daily trauma care.

BACKGROUND: Falling reimbursement rates for trauma care demand a concerted effort of charge capture for the fiscal survival of trauma surgeons. We compared current procedure terminology code distribution and billing patterns for Subsequent Hospital Care (SHC) before and after the institution of standardized documentation. METHODS: Standardized SHC progress notes were created. The note was formulated with an emphasis on efficiency and accuracy. Documentation was completed by residents in conjunction with attendings following standard guidelines of linkage. Year-to-year patient volume, length of stay (LOS), injury severity, bills submitted, coding of service, work relative value units (wRVUs), revenue stream, and collection rate were compared with and without standardized documentation. RESULTS: A 394% average revenue increase was observed with the standardization of SHC documentation. Submitted charges more than doubled in the first year despite a 14% reduction in admissions and no change in length of stay. Significant increases in level II and level III billing and billing volume (P < .05) were sustainable year to year and resulted in an average per patient admission SHC income increase from $91.85 to $362.31. CONCLUSIONS: Use of a standardized daily progress note dramatically increases the accuracy of coding and associated billing of subsequent hospital care for trauma services.