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Case Study
Fixing Unexpected Medical Coding Pattern Protects Revenue
“Working together with the Change Healthcare coding and compliance task force has enabled us to create a truly collaborative model…It will help us reduce and mitigate risk while ensuring the ongoing financial success of our practices.”
-Lamont Louis,
MBA Vice President Employed Physician Network Pocono Medical Center
Customer
Employed Physician Network of Pocono Medical Center Monroe County, Pennsylvania
Challenge
Turnover in certified coders as well as physician coding inconsistency and coding discrepancies
Products
Coding and Compliance Advocate
Results
- Reduce and mitigate risk
- Ensure ongoing financial success of physician practices
The Customer:
Employed Physician Network of Pocono Medical Center, the sole community hospital serving Monroe County, Pennsylvania, with 175 physicians across 27 specialties.
The Challenge: Turnover in Certified Coders and Inconsistent Coding
After a review of the management services organization (MSO) operations as a whole, Lamont Louis, MBA, Vice President of the Employed Physician Network for Pocono Medical Center, identified some inconsistent coding patterns. Concurrently, while working with his MSO leadership team, Louis learned that maintaining coding consistency over time had become a challenge for the organization, with the turnover of coders averaging one per year in a department of only 4.5 full-time employees.
Louis then reached out to Change Healthcare to perform an objective assessment of the Employed Physician Network’s coding processes and accuracy. The assessment revealed a significant issue. Over the preceding four years, a significant percentage of all physician documentation was incorrectly coded compared to medical documentation, and compared to the codes that coders from Change Healthcare would have assigned for the same conditions and procedures.
“This assessment provided a factual outcome by an external credible resource, and the outcome was concerning,” states Louis.
The Solution: A Comprehensive Medical Coding Audit and Education Program
Without hesitation, Louis escalated the priority of his medical coding and audit improvements. Partnering with Change Healthcare, Pocono Medical Center was able to accelerate the development and execution of a three-year medical coding and compliance initiative, which incorporates:
- A full, baseline assessment of internal coding efficiency and accuracy
- Creation of a third-party coding audit program in partnership with Change Healthcare, consisting of:
- Quarterly coding assessments, including review of random samples
- Quarterly training for all physicians, starting with a baseline training session to ensure knowledge of current compliance rules and documentation guidelines
- Quarterly certification of physician coding accuracy fall below established quality and accuracy benchmarks
- Healthcare compliance training for internal coding leaders, who will then utilize the Change Healthcare platform to train new providers as part of their onboarding process, thus maintaining a high level of educational consistency across the organization
- Periodic reassessment of medical coding accuracy, efficiency, and productivity to inform updates to the program for continued improvements
The Results: Continuous Medical Coding Accuracy
Louis explains that his 25 years of experience in working with large, integrated healthcare systems provided valuable knowledge regarding the critical importance of coding compliance and accuracy. “We take medical coding and healthcare compliance seriously because these issues present significant risk to the health system,” he states. “It’s a big deal.”
“People in accountability roles can easily overlook these potential risks if they’re merely not paying attention. Inaccurate coding can provide risk to the organization, and undercoding can leave money on the table, which could have been realized in revenues by both the hospital and its physician network.”
Louis maintains that coding is never just one person’s, or even one department’s, responsibility. “There must be accountability at every level. Health systems and medical practices trust coders to assist physicians. However, physicians equally share the responsibility too.”
Cindy Cain, Director of Consulting with Change Healthcare, worked closely with Louis to develop and implement Pocono Medical Center’s program and agrees that medical coding and healthcare compliance must remain as a top-of-mind issue for revenue cycle leaders. “If hospitals and health systems aren’t continually asking themselves key questions about their documentation, they could be putting themselves at risk for reduced revenues at best, and devastating financial impact at worst,” she says.
If the answer to any of these questions is “I don’t know” or “no,” then the time has come to take control and take action to make improvements.
Coding and Compliance Advocate
To learn how our Coding and Compliance Advocate solution suite can help, contact us at changehealthcare.com/solutions/revenue-cycle-management/revenue-integrity/coding-quality-audit-services.
