Brad Turpen, Practice Manager, Idaho Pulmonary Associates

Idaho Pulmonary Associates is a physician-owned private practice that is now part of a not-for-profit health system. Brad Turpen, Practice Manager at Idaho Pulmonary, regularly evaluates revenue cycle efficiency at his practice. His analyses were showing annual growth in average days in Accounts Receivable (AR), and revenue lost to timely filing denials. A manual audit revealed that they were missing inpatient hospital charges. Implementing a charge capture solution should help mitigate these issues, but they already had one in place. Brad recognized an opportunity for improvement; revamping the charge capture process could compress the billing cycle and have a positive impact on their bottom line.  

Every business needs to be paid for their goods and services, but that transaction is rarely immediate or guaranteed in the healthcare industry. Patients do not pay for the majority of the care they receive according to Centers for Medicare & Medicaid Services (CMS). Doctors and hospitals provide care in return for an insurance company’s promise of future payment. They may never get paid; if too much time has elapsed since services were rendered, payers reserve the right to deny payment entirely.  

In addition to an exploding offer of reimbursement, payers seem to use any technicality they can find to reject claims. Rejected claims require additional attention and need to be resubmitted to collect revenue. Resources are finite, so a business office will prioritize newer claims. They are easier to work and yield more reimbursement per hour spent on collections. In an environment where insurance denials are commonplace, every inefficiency in the work flow limits the resources available to work difficult claims and can result in lost revenue.  

Reducing days in AR is of interest to any business because the faster services are converted to cash, the sooner that cash can be reinvested to generate more business. Even if monies owed to a business will be paid eventually, longer collection cycles equate to lost opportunity. Even worse, outstanding revenue for a medical practice often becomes worthless if it ages beyond a certain point. Average days in AR is not just a measure of cash flow efficiency for a medical practice like Idaho Pulmonary; decreasing the time needed to obtain reimbursement can be the difference between being paid for services rendered and permanently missing out on revenue.  

“In a small business, cash is king. We can look busy on paper, but if we don’t actually collect the cash, we won’t have the money to pay our bills, employees, or our doctors,” Brad said. According to CMS statistics, the operating cost per FTE physician has been steadily rising over the last decade while revenue has remained relatively flat. With each passing year, practices like Idaho Pulmonary must become more efficient to stay in business.

“At minimum expense, you need to maximize the revenue you can capture. The number one job of an administrator is to run a profitable business. Patient care is clearly a priority, but you lose the ability to care for patients entirely if you go out of business,” Brad said.

The Challenge:

“We had a charge capture system that was working, but we could see that it wasn’t great,” said Brad. “Because of the nature of our practice, our doctors were coding critical care and high level hospital visits more heavily than other doctors in the area. This put us on Medicare’s radar, and they would refuse to process our claims until we produced a paper copy of the doctor’s note.” Idaho Pulmonary lacked the transparency needed to effectively manage Medicare's specific billing requirements. Initial critical care visits can be billed once per 24 hour period of care. Each additional time increment of critical care provided during the following 24 hours changes the coding necessary for a clean claim submission. This becomes confounded at a practice like Idaho Pulmonary because it is common for multiple doctors to see the same patient during a 24 hour period.  

“For certain types of liability insurance, there is a finite amount of reimbursement that will be paid out on a first come first served basis,” Brad said. “The hospital does not release their paper charts until after the patient is discharged, but they can submit their own claims almost immediately. By the time we had the documentation needed to bill these claims, the funds would be maxed out and we wouldn't get reimbursed for the care our doctors provided.”  

To transmit charge information, providers had to plug in their devices at the office during business hours. The manual synchronization lasted 30 minutes, often failing before completion. Sometimes doctors didn't have the opportunity to synchronize for a week or more. This time delay between services being rendered and charges coming through the door could result in lost revenue and made it especially difficult to coordinate critical care billing. It was impossible to be certain that all of Idaho Pulmonary's critical care charges for a 24 hour period made it to the bill before claim submission.  

Their old charge capture solution was not an effective rounding tool. The application they were using could not communicate between devices, so each physician stood on their own island of information. Idaho Pulmonary’s doctors would come on to new rotations at different locations weekly, and had to rebuild the rounding list each time. They had to enter demographic information for every patient seen during a rotation, even for patients seen on a previous rotation. The information they rounded with was static, and they did not have access to historical charges entered by other physicians. To preserve continuity of care, doctors spent time contacting each other or sifting through patient charts.  

“We ask so much of our doctors, and to waste even a minute of their time is not fair to them. After evaluating our situation, we knew that we could give them hours of their lives back. This also represented an opportunity to generate additional revenue because the doctors could use that time to perform additional procedures or provide medical director services,” Brad said.  

Improving the charge capture and billing process would not just reduce average days in AR. It would enable a reallocation of resources at the business office, and allow physicians to utilize their time more effectively.

The Charge Capture Solution:

“Idaho Pulmonary was just beginning to explore how newer technology could be used to benefit our practice, and we knew too much money was being written off to timely filing denials. We did an evaluation of price and quality to figure out a value, and assigned dollar amounts to what we thought could be gained from a new charge capture solution,” Brad said.  

At the time, Idaho Pulmonary was evaluating practice management and EMR systems. The vendor they selected assured them that a charge capture solution would be part of the system.  

“We wrote into our contract that they would deliver this capability by a certain time, and the charge capture solution they sent us was horribly inadequate,” said Brad. Since they were not going to get the solution they needed from their EMR vendor, they went to the market and started doing research.  

They narrowed down the decision to two competing vendors and performed a detailed comparison of their offerings. pMD seemed to offer a better experience for physicians, but it was also the more expensive option – at least on paper. The most expensive charge capture solution isn't necessarily the one with the highest price. The most expensive solution is a product that doctors don’t like and avoid using. The entire investment has the potential to fail if doctors aren’t happy with it. Brad and his team decided to put both solutions in physician hands and use that as the litmus test.  

Rudy Kreiter, Project Manager at Idaho Pulmonary, led this initiative. "As the project manager, I coordinated a side-by-side comparison of pMD and another charge capture solution. The doctors loved pMD -they didn't want to give their devices back at the end of the trial! Needless to say, we chose pMD, and we've been extremely happy with it ever since," said Rudy.  

‍Ease of Use - pMD built its software for each mobile platform with existing design conventions in mind so that using it would feel familiar for any person already using an iPhone or Android device. The development team at pMD is obsessed with minimizing steps and creating a polished, intuitive user experience. Physicians can use devices they are already comfortable with, and most can enter charges into pMD within minutes of picking it up. Diagnosis and procedure lists are customized for each practice, and instant text searching makes it easy for providers to input charges with a high level of specificity within seconds. Because pMD is a native application, it does not rely on an Internet connection to function. Physicians can use it anywhere, even without data signal, and information is automatically shared when they step back into data service.  

‍Real-Time Transparency - pMD creates a highly transparent flow of real-time information by storing data in a secure central database that any authorized user at the practice can access at any time. The active patient census list is dynamic; physicians can see patients appear as new consults are added by other providers or office staff. pMD's ability to interface with other software systems makes it possible for patient information to be available in pMD as soon as they are registered for care at the facility. Office staff can see what is happening within minutes of services being rendered. Doctors can follow behind their partners throughout the day and know which patients have been seen and which patients still need to be seen. Sign-off notes can be input securely into pMD and accessed by other providers when needed. pMD is powerful in a team environment like Idaho Pulmonary's because the information is there when it’s needed and always fresh.  

‍pMD in the Business Office - With pMD, providers never have to think about synchronization or plugging in their mobile devices to send charges. The billing staff receives information in an easy to read format, and they can securely communicate with physicians within the application. Doctors can submit charges remotely via their mobile device with a couple of clicks, and office staff can send changes back to providers for approval within minutes. Work flow in the business office is more consistent; instead of productivity ebbing and flowing as providers submit charges en masse, office staff can bill charges as they occur. The billing staff at Idaho Pulmonary now sees critical care visits immediately and can start collecting hospital documentation as soon as possible.  

‍Missing Charges - In addition to charge capture, rounding, and scheduling, pMD is a powerful auditing tool. pMD’s Gap Checker report identifies missing charges at the click of a button. The billing office can quickly identify patients with scheduled appointments lacking visit charges, patients missing a rounding visit, and patients with duplicate rounding visits on a single date. pMD can also generate detailed visit history reports by provider, by patient, or for specific types of charges in usable and easy to read formats. When they were assessing mobile charge capture solutions, Idaho Pulmonary performed a time intensive audit for missing charges. Instead of spending many hours on a manual audit, Idaho Pulmonary can run this report and immediately identify problems.  

‍Always Supported - Idaho Pulmonary has implemented various medical software solutions, and there are other vendors that offer 24/7 support. Oftentimes, vendors fulfill that promise by outsourcing support to people that are difficult to communicate with and don't understand the product very well. Issues typically have to navigate through many frustrating layers of bureaucracy before they are resolved. pMD support is an integral part of the job for every pMD employee, and is not outsourced.  

“We’ve been incredibly happy with pMD support. With one phone call, you’re going to get somebody that is able to fix the problem right then and there, regardless of the hour. The support is a big competitive advantage for pMD; to put it frankly, they have exceeded our expectations,” said Brad.

The Results:

Providers -“The doctors say that they are now significantly more efficient and don’t have to waste a bunch of time re-entering information. We’ve heard loud and clear that everybody is very happy with pMD,” Brad said.  

‍Missing Charges – After their initial audit, it was estimated that Idaho Pulmonary was missing almost $60k in hospital inpatient charges annually before pMD. Brad is confident that these missing charges are now easily visible and no longer falling through the cracks.  

“Before we had the additional transparency from pMD, we weren’t sure what was going on. Instead of banging our heads against a wall harder and harder to make things better, we know where to attack. The resources we spent hunting for missing charges, which the Gap Checker does automatically, are freed up for insurance recovery work,” said Brad.  

Days in Accounts Receivable -After one year with pMD, Idaho Pulmonary Associates witnessed a 43% reduction of days in AR. Brad's team is now able to successfully collect revenue that was previously being written off to timely filing denials.  

Percent of AR Over 120 Days – Before using pMD, 23% of Idaho Pulmonary's AR was aged over 120 days. Only 15% of Idaho Pulmonary's AR was aged over 120 days after the first year of using pMD. Outstanding Revenue – Idaho Pulmonary Associates wanted to reduce their outstanding revenue in accounts receivable. The year after pMD was implemented, Idaho Pulmonary’s outstanding revenue had dropped by 44% while maintaining a 93% net collections rate.  

“As a practice manager, you expect a certain amount of struggle anytime you implement something new. We were ready for that struggle, but we didn't experience it. The numbers speak for themselves, but it was the exceptional customer service that blew our minds. pMD delivered everything that was promised and more. These guys are amazing,” said Brad.  

Idaho Pulmonary had specific goals in mind when they moved to a new charge capture solution, and the results exceeded their expectations. pMD had an immediate and noticeable impact on the bottom line at Idaho Pulmonary, and allowed providers, staff, and administrators to share that feeling of success.  

“We frequently look at key performance indicator reports with our entire team, and we know that pMD made a difference. It was pretty motivating to paint the goal line and see us move forward together,” said Brad.  

To learn more about pMD, contact us.