Every business knows that billing delays cause payment delays. Besides the obvious impact, health centers must consider something more: Delays in your billing department create clinical quality measure (CQM) problems. Azara has recently seen an escalation in the misunderstood relationship between billing and quality measures. In this week’s blog, I'll explain how they’re related, and why the relationship matters.
At the fundamental level, the relationship between billing and CQMs boils down to which patients should be included within a measure. Most measures have denominator criteria that select or limit patients to those that had a “qualifying” visit at the center during the past year.
Since most of our customers use E&M billing codes to identify qualifying visits, coding and billing is directly tied to measures. This method is preferred by both our customers and the National Quality Forum (NQF) because of the accuracy and flexibility it provides. However, the unforeseen consequence of using these billing codes to identify qualifying visits is that the submission of charges typically lags behind the visit, so encounters may not be identified as “qualifying” for some time.
On average, our customers create charges 11 days after a visit[1], while DRVS measures are recalculated for at least 15 days after any reporting period has ended. This extra recalculation time accounts for delays in data entry and assures that the typical lag in charge creation and other post visit documentation of activities does not have any meaningful impact on measure calculations.
Let’s highlight an example:
- Jane Doe visits a community health center (CHC) on Nov. 22, 2015, for her annual check-up
- DRVS receives the encounter record for Jane Doe on Nov. 23
- The CHC bills Jane Doe’s insurance a 99213 on Dec. 2 for her visit
- DRVS receives the charge record for Jane Doe on Dec. 3
Will Jane Doe be included in measures denominators for the November 2015 period? Yes, she will, because her qualifying charge arrived well within the time range for measure recalculation (15 days after a period ends). This example represents the situation at 77 percent of our client health centers.
But what about the other 23 percent – the ones, who, on average, create charges for a visit 15 days or more after the visit? When the billing delay is this significant, several charges will be created after the period in which the measure has stopped recalculating. This means that the patient will not be counted for the period.
Here’s an example:
- Jane Doe visits a CHC on Nov. 22, 2015, for her annual check-up
- DRVS receives the encounter record on Nov. 23
- The CHC bills Jane Doe’s insurance a 99213 on Dec. 18 for her visit
- DRVS receives the charge record on Dec. 19
Will this patient be included in measures denominators for the November 2015 period? No, because the charges that qualify her for the measure weren’t created until after the measures for that period stopped reprocessing (on the 15th of the following month).
With this in mind, you can understand why delayed billing, on a large scale, can significantly affect measure results. Now sometimes, delays in billing are unavoidable, such as in the case of long-term episodic care. For example, a first-trimester prenatal visit cannot be billed for utill the OB episode has been completed, so charges for that visit may have a delay of up to 270 days. If enough patients’ charges are created after the period has stopped recalculating, reported measure denominators could be much lower than actual results. Beyond just inaccuracies caused by a deflated denominator, there is another potential financial pitfall from delayed billing: shared savings and pay-per-performance programs. With many clinical quality programs pay for specific results on a per-patient basis, having too few patients represented in your measures could affect the magnitude of the incentive dollars your center qualifies for.
Any health center CEO or CFO will tell you their cash flow and financial stability depends on timely, accurate billing. Azara’s message: The same timeliness can impact your clinical quality results and any additional payments tied to your performance.
Sam Bar is an implementation specialist at Azara Healthcare.
[1] When looking at the difference between the “create date” and “date of service” of charges in the DRVS Warehouse during 2015 after accounting for bad data