October 31, 2019

Has your EHR “ghosted” your revenue?: A scary Halloween Revenue Integrity tale

Gretchen Case

Most providers, hospitals, systems, and physician practices have long implemented Electronic Health Records (EHRs). In conjunction with myriad clinical modules, revenue cycle modules have also been installed covering patient access, charging, coding, and billing. But many feel that EHRs have ‘ghosted’ the middle of the revenue cycle for things like chargemasters and charge capture for all intents and purposes.

There are many stories in the provider world like “Just like a magic act, the new module made NDCs ‘completely disappear’ from claims!”, or “We just couldn’t find our contrast charges, after multiple interventions by IT, they found them in a pharmacy technicians in-basket list, but he no longer worked at he hospital, and hadn’t for several months.”

While those stories may not occur every day, the more common charge related errors can be even scarier – stagnant charge review workqueues, $0.00 charge lines, charge missing revenue code, and everyone’s favorite ‘unassigned cost-center.’

Now more than ever, a pristine CDM is no longer the gold standard of a solid revenue integrity program, because it doesn’t matter how pristine it is if it isn’t integrated into the clinical modules.

Moreover, what once was under the ‘control’ of RI, things like pricing and HCPCs codes for supplies and drugs, now ‘reside’ in these clinical modules, which are usually maintained by IT professionals who wouldn’t really know a HCPCs if they tripped over one. While the decision-making may still be a function of RI, the execution is in an entirely different arena. And RI professionals often have a distant connection to these financial and code components of these clinical modules.

As a result, many RI professionals aren’t very comfortable with the current state of affairs. Nowhere was this more acutely captured than in a recent study issued by the Advisory Board, “Deconstructing Revenue Integrity, Building an Efficient and Effective Information Chain to Ensure Payment Accuracy,” September, 2019. The AB conducted numerous interviews with their provider members to arrive at the following findings.

EHRs are widely used for charge capture, but few report satisfactions with current state

84% Of health care organizations rely at least partly on their EHR systems for charge capture
50% Of health care organizations use it exclusively as their charge capture solution
10% Of health care organizations would recommend their current charge capture solution

That’s a pretty shocking statistic -that means 90% would NOT recommend their current ‘electronic/automatic’ charge capture process.

Based on provider enquiries, The Advisory Board report also gave a list of nine top operational demands that negatively impact the RI function and a corresponding list of potential solutions.

Table 1:

Operational demands negatively impact information chain for Revenue Integrity Corresponding Nine Imperative for an Efficient and Effective Information Chain
1.     Lack of oversight and inflexible program structure 1.     Establish flexible oversite
2.     Gaps left by IT interoperability 2.     Fill in the charge capture gaps with IT support
3.     Haphazard, scattershot performance monitoring 3.     Use ROI as the ultimate performance metric
4.     Deprioritized CDM and contracting strategy 4.     Ensure a strong foundation through CDM and contracting
5.     No regulatory monitoring or anticipation of potential changes 5.     Monitor regulatory landscape for potential chain disruptors
6.     Resources not distributed according to level of revenue risk 6.     Increase scrutiny in areas of high revenue risk
7.     Inappropriate staff assigned to tasks 7.     Craft a compelling career opportunity
8.     Documentation efforts duplicative, diminishing of CDI 8.     Engage with, but don’t corrupt, CDI
9.     Clinicians struggle with timely, efficient charge drop 9.     Make charge drop easy for clinicians

Further recent research on the topic, published via PR newswire,

Key findings include:

Charge capture is critical for success but is not a frequent agenda item


  • Over three-quarters (78%) of respondents characterize charge capture as “essential” to their organization’s success. Twenty-one percent characterize it as useful, and 1 percent say it’s optional.
  • Despite this, leadership teams at 40 percent of organizations talk about charge capture once a month or less. One-third (32%) discuss it weekly, while 18 percent discuss it twice a month, 8 percent discuss it daily, and 2 percent never discuss it.
EHR solutions are the default, and they are not well-liked


  • Most healthcare organizations (84%), rely at least partly on their EMR/EHR systems for charge capture. Half (50%) use it exclusively as their charge capture solution.
  • Just over a quarter (28%) use electronic, standalone solutions as part of their charge capture mix, while 27% use paper charge capture.
  • When asked how likely they are to recommend their current charge capture solution, using the Net Promoter Score methodology, only 10 percent of respondents are promoters.
  • More than half (52%) are detractors.

These two reports echo what I’ve heard many times over – “we got the system in, but we don’t really like it.” And we’re beginning to observe providers, weary from the war, and with ever increasing cost-reduction demands, are beginning to turn to external vendors for help and purchased services or technologies.

But let’s take a brief ‘Wilshire pause’ and ponder the bigger question – What is so Wrong? And do we really need to turn to an external solution, or should we lean in? Or lean on, or sit on, or whatever it takes to get what we bought into in the first place – integrated clinical and financial modules working together to achieve best practice – a reality.

From experience we can tell you it is possible. And that you can even see early returns and quick wins. With the advent of integrated EHRs, RI work fundamentally changed. However, not many of the workflows have yet to catch up. It will take a change in traditional RI philosophies and scope of practice to be successful in the new world. Following I provide some thoughts on some of the AB findings that I believe pose ROI opportunities and prevent revenue leakage.

Operational demands negatively impact information chain for Revenue Integrity Corresponding Nine Imperative for an Efficient and Effective Information Chain
1.     Lack of oversight and inflexible program structure 1.     Establish flexible oversite

Is the technology too hard to understand? Or is it that we haven’t devoted the time to understand it?

I think this issue speaks to the complexities of performing RI work in an integrated system. Gone are the days of CDM work being done by one team in one ‘section’ of a patient accounting system.

NDC gone missing? It’s in there, trust me. There’s just some setting that is off that is preventing it from making it to your claim. (Fun fact: did you know that there are over 125 data elements per medication record?!).

RI teams need to set up regular meetings with both IT and clinical partners to discuss the financial functionality of clinical modules. RI teams can be dispersed across service lines and their related modules.

These RI workgroups as I’ve called them – and implemented them across the country – are regularly scheduled meetings, led by RI. Any constituent can bring forward an issue to the meeting and it will be documented and managed until completion. A big ‘win’ from implementing these workgroups is that it alleviates the burden of managing issues via email and leads to better staff satisfaction.

Convene “Workgroups” to leverage functionality

Examples of work done in a RI workgroup:

  • Charge trigger functionality – get in there and demand to understand how charges are triggered. (Additionally, there is a lot of information available online for training RI staff on these kinds of topics).
  • What changes with a system upgrade, what new functionality might exist? (use your bells and whistles)
  • Explain back-end billing and denial edits and issues and ask for input from these teams
  • What charges are on preference lists that are tied to charges – this is usually a big revenue find. Charges are there in the CDM but the build in the system is not.
  • IT teams work regularly with clinicians for system optimization. It is a very fair ask for the same attention to the financial, components of the modules in coordination with RI teams.
  • Focus on understanding how dynamic pricing works for things like drugs and implants?
  • Set testing standards that could impact charges or codes. (i.e. patient class changes, payer changes, etc.)
  • Leverage linked charges – ex. If a supply item is used 100% of the time when a procedure is done, link it to the procedure charge and ensure 100% capture and 1 less step for charging.
3.     Haphazard, scattershot performance monitoring 3.     Use ROI as the ultimate performance metric

Know Your Vital Statistics & Prove Your Net Contribution

RI teams should be diving deep into data that shows the amount of revenue and the number of transactions coming from each clinical module or ancillary charging application. That is how you create a plan of intervention and/or monitoring.

For example, in a hospital, lab modules, send over 50% of the total number of all charge transactions but only 15% of the revenue. Conversely, OR modules send fewest charges but greatest revenue. Pharmacy is the gorilla which post a super high number of transactions and revenue. These are all very easily identifiable points of data that can inform RI projects.

Revenue Integrity programs have many iterations in the provider world. “If you’ve seen one RI program, you’ve seen ONE RI program” as the saying goes. And true to most RI programs, they struggle to show their contribution to the bottom line. It is entirely possibleto establish a gross and net contribution factor based on the work of these programs.

It requires some thoughtful engagement with finance and IT to assess:

  • Average rates of reimbursement – overall and/or service line specific
  • Charge audit program returns
  • Process improvement program returns – ex. adding charges on preference lists, improving charge capture from 20 to 90%
  • Code based reimbursement program returns
7.     Inappropriate staff assigned to tasks 7.     Craft a compelling career opportunity

Leverage expertise not Roles & Departments

Many providers get stuck trying to make current workflows and department structures fit the new EHR world. Conversely, Wilshire suggests you take that expertise, like coders for example, and let the new workflows dictate where that talent is used. That may mean some coders switch to working in a RI department versus Health Information Management. Many RI programs have certified coders on their teams that work various billing edits and can focus on code-based reimbursement as well.

One major trend we’ve observed due to the lack of knowledge and/or confidence in charge capture in an EHR environment, has been a return to 100% manual charge capture by HIM coding staff.

It is understandable that given the rates of dissatisfaction, many organizations feel the need to revert to this practice. But there is an alternative. One that not only improves revenue recognition but also cuts costs and leads to greater worker satisfaction.

One client, a large academic medical center, was manually posting all cardiac cath lab charges – procedures, supplies and implants. It is a complicated area to code and generates high revenue. It took over 5 FTE highly credentialed coders to perform this task. The following change was implemented.

Charges were allowed to post from the clinical module. The accounts were easily caught in a charge review workqueue for review the next day by a coder. It was found that changes were only required on 10-15% of accounts. So, by using the system to do the initial charge capture, and positioning the coder to act as reviewer, the department cost was cut by 80% and revenue increased anywhere from 3-10%.   Compliant, fast and accurate.

There are many opportunities out there for this kind of system/workflow optimization with cost savings.


If we think back to our pause, to consider the question, “what is so wrong” with charge capture in an EHR world, perhaps the answer is that it’s not so wrong as much as it is, different. And when EHR’s were first implemented the focus was on the clinical build as opposed to the financial and therefore we’re living in a system that seems to have a ghost inside at times that mysteriously produces charges! The good news is that the ‘ghost in the machine’ is a friendly ghost – a Casper of Revenue if you will! Wilshire is ready to help you demystify the system and optimize the revenue cycle and financial components of your EHR!

Happy Halloween!

Gretchen Case

Managing Partner

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