Correcting the Cashflow Crisis: Avoiding EMR Implementation Fallout

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Correcting the Cashflow Crisis: Avoiding EMR Implementation Fallout
July 2, 2019

EMR implementations are an intense undertaking.

With thousands of challenges during an EMR project, the implementation team and all departments must work diligently to understand how the new system will impact the organization.

Project steps occur in order—Contracting and Setup, Current State vs Future State Analysis, Design, Build, Testing, Training and, finally, Activation. There is a keen focus on ensuring the system is safe for patients and that clinician workflow is smooth. Usually, the hospital is breathing a big sigh of relief just days after Activation.

Unfortunately, while all of these key components are taking place, there is often a looming crisis growing in the background…and it’s about to surface in the billing department when least expected.

A common scenario begins weeks after Go Live when the number of bills generated by the new system is far fewer than expected. Eyes hone in on the billing department—why can’t they get bills out the door? What’s wrong with the software?!

Another week or two passes and the realization hits home: HIM is having trouble coding charts. Pressure gets applied to resolve the situation, but HIM is also struggling to figure out the problem. Everyone begins to assume it is a software issue and the vendor is quickly pulled in. Days and weeks pass by, and too few bills continue to go out the door.

Cashflow suddenly becomes a major problem.    

Does this sound familiar? We’d venture to say it does.

The internet is full of scenarios where hospitals and vendors are caught up in courthouse battles surrounding revenue disputes. Finger-pointing, contractual threats, and financial devastation are, unfortunately, an all-too-common reality.

As we examine these scenarios, we are forced to ask, what really happened? What was the cause and, more importantly, what is the cure?

It doesn’t take long to realize that billing issues are rarely just “billing” issues. They begin in a variety of places; typically while the patient is still in the hospital. Multiple events prevent charts from being thoroughly or accurately completed, which creates a snowball effect until the sheer volume overwhelms an entire HIM department.

While addressing the reality of these common pitfalls, it’s important to identify the problems that impact both HIM and Patient Accounting, thereby preventing the generation of clean bills. A few of those problems are:

  • -Scheduling, registration, and service dates may be set incorrectly during a new implementation, causing critical inconsistencies.
  • -Patient types become confusing to registration staff or system triggers alter a patient type, resulting in the system recognizing an error.
  • -New workflows result in confusion over documentation and the signing of orders.
  • -Registration staff selects incorrect insurances within the unfamiliar new system.
  • -Incorrect charges may exist in the CDM, creating values that are too high or too low.
  • -Charges not posting from foreign interfaces begin causing delays.
  • -Departments lack a clear process for reviewing and verifying daily charges.
  • -Physicians are unfamiliar or non-compliant with tools for diagnosis coding.
  • -Clinical staff, unaccustomed to documenting and charging for daily items and activities, fail to correctly use the system.
  • -Staff is unfamiliar with appropriate Revenue Cycle Reports available to assist with charges and coding.
  • -Patient Accounting staff is unable to identify workflow issues within the clinical staff that may be contributing to chart issues.

As one might imagine, the business team recognizes that hundreds, if not thousands, of charts, are being held for a myriad of reasons. HIM is not equipped to resolve the clinical workflows that might be contributing to these problems. Days are spent trying to resolve a single chart’s issues while the bigger picture is ignored.

However, there is good news: Fortunately, there are a number of things you can do to prevent your hospital from EMR revenue collapse.

Here are some critical steps we encourage our clients to follow:

  • -Ensure your team has very strong Patient Accounting and HIM analysts in place who will drive for early chart testing. They should demand small charts be completed early with a few procedures to validate the payor, charging and completion aspects—eventually testing every chart and charge scenario.
  • -Designate a Charge Analyst who will understand how charges are generated for every department. He or she must then validate that proper charging is occurring throughout the organization using every manner, well before any formal testing begins.
  • -Your interface team must be aware of the importance of having data passing early so all the fields necessary for charging, completion, and billing are going to the right places.
  • -Registration must be trained extensively so they clearly understand any patient type changes, how to assign the correct insurances and guarantors, and how to change the information in a patient’s demographics or insurance records when the time comes.
  • -You must understand what reports will be used to monitor charging and coding while making sure your staff knows how to interpret issues and address them early.
  • -Assign someone to monitor error queues which, all too often, go untended following a Go Live.
  • -Develop teams to conduct Financial Audits and Chart Audits immediately after Go Live. These audits can identify problems early on, saving money and complication later.
  • -Ensure you have multiple workflow experts who can be called in to pinpoint confusion creating chart issues; resolve the confusion with modified workflows and immediate retraining.
  • -Test the entire revenue cycle process rigorously. Don’t allow a vendor to cut your billing testing short simply because they only allow 5 days per testing round. Work hard to set up billing scripts that ensure charging and charting are being completed to your satisfaction, even if your testing occurs outside the normal testing phase.
  • -Ensure that the Revenue Cycle and Clinical teams work together when creating integration test scripts so that expected outcomes are clearly defined.
  • -Be aware that it’s human nature for HIM and billing clerks to gravitate towards work that’s comfortable. They might spend time working down charts and accounts from the old system and get a late start on immersing themselves in the new system.

Whatever you do, don’t give up.

In the event, you aren’t able to fully avoid the issues presented above and you find yourself with a billing and cashflow crisis, there is a way to resolve your issues in a logical manner.

Before throwing in the towel, we recommend following these additional steps:

  • Recognize that this problem is indeed a project in and of itself and that it will require a Resolution Team to resolve it.
  • -Assign a Revenue Cycle expert as a Project Manager to lead the Resolution Team.
  • -Bring together representatives from Registration, Nursing, Physician, Workflow, HIM, Billing, and any ancillaries that seem to have significant charging or coding issues.
  • -Get an immediate handle on what reports and metrics you’ll focus on to monitor progress.
  • -Focus on categorizing the problems—how many charts/bills are being held due to date issues, how many are due to charging issues, etc.
  • -Look at high dollar accounts, but also focus on payors that have the shortest claim denial terms (i.e., focus on those that only give you 90 days to submit versus those that give you 6 months).
  • -Attack each problem based on category. Look at charts that have incorrect account types or insurance information. For example, have Registration and your Workflow expert review chart issues with account type issues and identify what caused them in the first place.
  • -Resolve the workflow and training issues and ensure no new issues are created in this area while you work to correct each discrepancy one by one. Move on to the next category, enlist the correct people, follow the workflow, identify what’s causing the problem, and then resolve.

By following these steps you will equip yourself to handle each problem category, correct your workflow, and retrain. It won’t be easy, but you’ll start to see the battle tilt in your favor.

If you find you need additional help, please don’t hesitate to reach out to us at

We have experts who can lead the effort to pull you out of trouble. When it comes to successful EMR implementation, every day counts. Don’t take the risk of falling behind even one of them.

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