Empowering employees to maximize revenue.

Reimbursement and costs are really controlled by line staff, not management -- and this facility has put that lesson to work

Maximizing revenue is critically important for our two long-term care operations at St. Barnabas Health System. Both St. Barnabas Nursing Home and Valencia Woods Nursing Center average a 95% census of Medicare and Medicaid patients -- 10% above the national average and 50% above the mix required for non-profit status. Obviously, for St. Barnabas to maintain its charitable mission, we must carefully manage our billing and actual acquisition of funds.

A recent study we performed indicated that, just to comply with Medicare and Medicaid regulations, 30 of St. Bamabas Nursing Home's caregivers spend 10,260 hours a year completing at least 167,879 forms at a cost of $825,467. In the face of such a mountain of government paperwork, we find ourselves challenged to maintain a high quality of care while remaining financially stable.

To meet that challenge, we try to employ the tactics of big business, i.e., we empower our people. To some, St. Barnabas may seem big, with its 276-acre campus, 249 long-term-care beds, outpatient clinic, retirement community and charitable foundation. We encourage employees to think even bigger, and then empower them to act on those thoughts. Nowhere has that empowerment yielded more dramatic results than in the area of billing and collections.

AnticiPAYtion

Nurse managers start to develop a plan for full payment even before treatment begins. They start by gleaning as much information as possible from admissions applications and contacting referring hospitals for additional facts. Because admission is often within one day of initial inquiry, the nurse managers must move quickly to gather information and deliver it to the accounting department. Then they work with accountants to create a proforma for the particular resident -- a plan with goals and steps to achieve it --, to start implementing it, and to raise red flags for potential problems that may get in the way of achieving maximum reimbursement for each resident's anticipated treatment.

This level of cooperation in working for maximum reimbursement continues throughout a patient's stay. It is not uncommon to see nurses conferring at a computer with accounting clerks and accountants, identifying and defining billable procedures and services.

"Nursing is so close to accounting because we stretch ourselves to provide services," says Linda Morgan, Director of Case Management and the Registered Nurse Assessment Coordinator for St. Barnabas Nursing Home. "We look for every avenue and really try to do what is best for the patient and for St. Barnabas."

Morgan took the initiative to create "niche marketing" for St. Barnabas. "We profile the ideal patient for St. Barnabas, based on our charitable mission, patient census needs, and type of insurance." After completing that profile she gives it to the admissions director and says, "When you see this type of patient, let's get going right away." That approach lets us speed up the process of admission for these particular residents and strengthen's our efforts to maximize reimbursement.

Meeting of the Minds

Valencia Woods' Director of Nursing Charlene Kline reports that her August, 1994 revenue is up 43% over August of '93. She attributes that increase to intense examination of patient status focusing on rehabilitation options. Simply put, the more rehab, the more reimbursement.

"Meet, meet, meet," says Kline, who regularly convenes with doctors, physical, speech, and occupational therapists, nurses, and accountants to review the status of at least 55 patients each month. One recent result of this constant sharing of information was the adding of a revenue source by pinpointing and reversing a delay in physical therapy for a hip fracture patient. The patient's care plan for developing ADLs and transfer skills through physical and occupational therapy came to a halt when he contracted pneumonia. After 30 days of inactive rehab, the reimbursement team evaluated his recuperation, saw a green light for more therapy, secured the physician's order for it, and improved the patient's health by getting rehab started again.

Checks and Balances

"My nurses know I'm looking over their shoulders," explains Morgan. "I review supplies daily, and may come fight up to a nurse and ask, for example, why a 4 x 4 bandage was used. We enforce all the way down the line the message that, if we save until needed and then charge for each supply item, we'll generate more revenue and, in turn, have more money for supplies."

Morgan reviews "supplies-used" lists through daily tracking forms and monthly compilations. She'll often take a question directly to the nurses' station, seeking their rationale for inventory use. This is not busywork: The hands-on caregivers are the ones, not upper management, who control expenses, in her view.

Donna Huselton, Valencia Woods Medical Coordinator, rations pencils and tablets to the nursing staff, advising those who are "running out" to hold on until next month. She catches feedback for her "extremism," but holds fast to her conviction that every dollar adds up. "By conserving in this way, we may save only $20 per month, but over the course of several years, the numbers become significant," she says.

On the other hand, nurses do advocate spending one dollar to make ten. Huselton hopes to recoup losses that Valencia Woods incurred last year when there was a high occurrence of pneumonia. She calculated that treating pneumonia cost $201.51 per resident in non-reimbursable antibiotic therapy and Duoderm utilization. This year eligible patients are receiving Pneumovac, a vaccine that costs $12.50 per shot and is reimbursable.

Ancillary Billing

Perhaps the most difficult and challenging area of reimbursement management lies in ancillary services. With our recent increase in subacute care patients, St. Barnabas Nursing Home's Director of Nursing, Ellen Bertolino, uses both clinical experience and financial management expertise to control expense while not jeopardizing patient care.

In the 172-bed facility, she and her staff monitor and submit claims for an average of 35 catheters, 17 enteral feedings, 10 wound-care dressings, and four ostomies each month. Medicare Part A may cover these and other ancillary treatments for a limited time, but most private insurers do not. Meanwhile, to achieve Medicare Part B or Medicaid coverage, the paper justification required is all but insurmountable.

There was one case in which Bertolino spent years appealing to Medicare to reimburse St. Barnabas for one cerebral palsy patient's enteral feedings. She spent hours with physiology books in an effort to describe the patients physical condition, often taking the texts home for further research. Finally, after weeks of hard work and consulting with a gastroenterologist, she succeeding in convincing the Pennsylvania Department of Public Welfare that the patient's tube feedings were necessary; she was able to document that the cerebral palsy had curved the patient's esophagus, interrupting food digestion and causing gastric ulcers.

This approval necessitated submitting at least 30 forms after three months, nine months, 15 months, and annually thereafter. Even with approval of this ancillary service, the process of maintaining payment for it remains exhausting and requires cooperation among unit nurses, accountants and supervisors. It is, however, getting done.

St. Barnabas does incur non-reimbursable expenses, but these losses are calculated, not nasty surprises. If, for example, a patient requires intermittent catheterization every shift, but Medicare pays for only a permanent catheter once a month, the patient gets the intermittent catheterization. On the other hand, Bertolino readily admits that she and fellow nurses sometimes adamantly point out to physicians the benefits of services and "sell" physicians on providing them, thus making them reimbursable.

Fight, Fight, Fight

Extreme precaution is taken to assure that billing documentation is correct and denials are few. Our nurses and accountants continually consult with reimbursement specialists for new strategies and developments. Occasionally, however, they still will have a claim denied. Morgan, in her role as Registered Nurse Assessment Coordinator (RNAC), submits and resubmits claims in a battle to get what she believes is deserved.

For this reason, the RNAC has become an integral part of our long-term-care management team. The RNAC is responsible for overseeing and developing a plan of care for each patient. Information to accomplish this task is gathered from the five-page MDS and review of a resident's chart. These plans of care are reviewed at least quarterly to maintain adequate documentation. When a claim is denied, the RNAC takes the lead in fighting for the reimbursement.

That fight has often taken Morgan to the Allegheny County Courthouse. In one instance, her diligence led to St. Barnabas being awarded tens of thousands of dollars for services rendered in 1991 by its former rehabilitation provider. Though the process took years, it was worth every minute, she says. Such hard-fought battles produce results in many ways. Because we were able to obtain reimbursement that was justified, our two long-term care facilities were able to provide more than $2 million in free medical care last year alone.

Whether it is rationing pads and pencils or responding to new technological developments, what we at St. Barnabas Health System are trying to do is lower costs and increase our yield so that we can provide better care to our patients. The better we can keep track of what we do and how we do it, the more accurate our billings will be, and the greater will be our percent of reimbursement. Someday, I expect, we will have our supplies and services bar coded and a bar code reader accessable at every nurses' station, perhaps even at bedside. Our caregivers will then be able to scan into our computers every supply used and service rendered at the very moment it occurs. That is the kind of record keeping that is needed for a nursing home's best chance at maximizing its reimbursement.

Before and after that time arrives, though, it will still be the commitment of employees who have been empowered to find and implement improved caregiving that will make or break an operation.

And that is up to management, i.e., empower people for success, and then get out of the way, letting them do their best to achieve it.

William V. Day, Ed.D, has been President of St. Barnabas Health System in Gibsonia Pennsylvania for 27 years. He is a Fellow of and a Regional Governor for the American College of Health Care Administrators. Under his direction, St. Barnabas has grown from a 63-bed nursing home to the largest health care concern of its kind in Pennsylvania.