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PubMed2001

What if pediatric residents could bill for their outpatient services?

OBJECTIVE: We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics. METHODS: Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology. RESULTS: A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 +/- 0.01 and 0.81 +/- 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively. CONCLUSION: When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.

Accounting↗
PubMed2001

[An individual based analysis of medical expenses of outpatient services for the elderly at one health insurance society in Fukuoka Prefecture. Focus on multiple or redundant consultations].

PURPOSE: To ascertain way to reduce medical expenses of the elderly, we analyzed old outpatients' receipts covered by the Health and Medical Services Law for the Aged at one health insurance society in Fukuoka prefecture. In addition, an attempt was made to find better ways to share medical information and construct a system of receipt analysis. SUBJECTS AND METHODS: We used 312 receipts for 179 old outpatients in July in 1997. The number of prescriptions was internalized into the number of outpatients' receipt. We classified the patients as "multiple" who consulted several clinics a month and as "redundant" who consulted several clinics for the same diseases. RESULTS AND CONCLUSION: 1) The expenses of outpatients accounted for about 1/3 of the total. Average values for patients were 78.3 years old of age, 7.7 diseases, 1.5 pharmacies, 1.7 clinics, 7 consulting days, and the medical expenses of 40,482 yen per month. 2) The rate of multiple including redundant consultations was 49.7% and that for those that were redundant was 9.5%. Redundant consultations increased as the number of consultation clinics increased. 3) Factors considered to increase medical expenses were the number of diseases, the consulting days, and the number of consultation/prescription organizations. Multiple and redundant consultations amounting to half of the whole fulfilled all of these criteria. 4) The average medical expense for non-multiple and non-redundant patients was 28,314 yen, as compared with 52,786 yen for multiple and redundant and 64,306 yen for redundant cases. If there were no multiple consultations, thirty percent of the expenses could be avoided and if there were no redundant consultations, the reduction might be 6%, although more detailed clinical records are necessary for firm conclusions. To reduce excess expenditure, instructions for patients having home doctors and passing through introductions are important. 5) Regarding the expense of medical services, medication was accounted for 39.2% as the greatest outlay. Cautions for suitable use of drugs are required for multiple and redundant patients, because they tend to visit many pharmacies. Considering the rate rise of separation of pharmacy and clinic, fixing of field division of work and the sharing of medical information are inadequate. For example, introduction of an IC card system might be very useful to facilitate the development of community-based medical information system. 6) It is strongly suggested that a computerized information system with a standardized format should be developed on the initiative of a national organization such as the National Federation of Health Insurance Societies.

Aged↗
PubMed1996

A network approach to outpatient service delivery systems: resources flow and system influence.

OBJECTIVE: The study tests a path model for the effects on organizational influence of an organization's centrality in four resource exchange networks in order to gain insight into the network relations that may affect coordination and effectiveness of outpatient health and mental health service systems. DATA SOURCES: Primary data are used from face-to-face interviews with the directors of every organization in the predefined service systems in three urbanized counties in Oregon. Each system consisted of 19 to 20 organizations. Data were collected during 1986 and 1987. STUDY DESIGN: The path model contains five variables: the major dependent variable is attributed organizational influence; the independent variables are three sets of primary resource exchanges: funds allocation, client referrals, and client inflow. An intervening variable of general network contacts, as an informational resource, is modeled as an outcome of the three primary resource exchanges, as well as one of the predictors of influence. DATA COLLECTION: Organizations were identified as system members through a modified snowball sampling procedure. Measures of organizational influence and centrality in each of the exchange networks were derived from interviews with all directors about their interactions with each organization in the system. Multiple regression analysis was used to test the path model. PRINCIPAL FINDINGS: The most important resource in predicting centrality in a general contact network is centrality in a client referral network, while contacts and funds allocation centrality are significant predictors of organizational influence. CONCLUSIONS: The organization with the greatest influence within the system (because of its ability to allocate funds) may not be the organization that takes the largest role in terms of coordinating routine contacts (because of its ability to refer clients). This disjuncture may signal a weakness in the coordination network and system effectiveness, since the more influential organization may not be the most knowledgeable one in terms of the needs of the system.

Ambulatory Care↗