The team was established and began having weekly meetings in May 2012. The first aim statement was as follows: "Develop an enhanced and efficient patient process that will maximize revenue by November 2012." The team plotted the current patient flow process on a flowchart. Evidently, the patient flow process was too large of an endeavor to complete with one QI project. The aim statement was narrowed down to only the billing process by stating, "Narrow aged accounts of more than 120 days by 40% by November 2012." As the team worked through the many reporting issues from the electronic billing system, it further narrowed the scope of the aim to state, "Increase revenue from billable health services in behavioral health and Patriot Place School-Based Health Center (SBHC) by 10% by November 2012." The reason for this revision is that the denied claims report was so extensive that staff felt the need to focus on two departments.
The initiative was chosen to reduce the burden on the county for the provision of health services. The charter statement reads, "We want to improve the revenue system for Madison County Health Department in order to provide public health programs and services to our community with the least burden to our taxpayers."
The team implemented this project through a series of Plan, Do, Check, Act (PDCA) cycles that attempted to provide solutions. As the PDCA cycles were successful or if staff identified further issues in the course of the cycles, they either implemented a standard procedure or went back to the evaluation phase to identify and investigate the issues discovered. This process was repeated many times; issues emerged frequently. Ultimately, the QI project addressed the problem by identifying gaps on reporting, accelerating the denied claims re-billing process, and increasing revenue as a result.
PDCA 1: Assigned one staff member to follow up on denied claims. This cycle produced positive results, although the team noted that singling out one staff member for one duty would not be sustainable.
PDCA 2: Developed a checklist for scheduling and registration staff to obtain all the necessary information from patients to ensure proper billing. This checklist was successful and continues to be used.
PDCA 3: Developed a monthly monitor of claims activity with specific action required by the administrative supervisor. This process continues to be used.
PDCA 3: Reassigned duties to remove anything not related to billing from the staff who are focused on billing. The health department continues to use this model, although shifting work has been difficult.
Methods of evaluation:
The team used data from billing and finance applications to evaluate progress. Although the team has realized an increase in revenue in the identified departments, it is unable to positively identify whether the increase in revenue was a result of increased encounters or of a resolution in the denied claims and aging accounts process. One major barrier is the inadequate state billing system and unreliable reporting of this system.
In the process of researching an EHR application for purchase, the team is able to articulate reporting needs to ensure that when a new system is implemented, staff will be able to better control statistical reporting. During the QI process, one of the two billing personnel resigned, and the health department recruited and hired a new staff member with billing experience. The value of this experience is already evident.
The team was able to implement a standard procedure of pulling reports of aged accounts and investigating those denials, which is going well. The team is committed to embark on a patient flow and provider encounter QI project and to continue to work on the billing QI until completion.
The health department learned the following lessons during the QI initiative: (1) staff should have engaged in a broader QI training before starting the team and project; (2) staff did not know the limitations of the reports (data) available, and this was a constant barrier, although those lessons were applied to further develop the project; (3) staff now fully understand the importance of data-driven projects; (4) staff were able, through this project, to reinforce a patient service value: one that enlightened staff about treatment of patients regardless of their ability to pay; (5) staff recognize their limitations in statistical analysis and will develop a plan to fill that gap; and (6) partnering with Hot Springs Health Program was valuable because of the expertise their staff demonstrate with patient flow and billing effectively. They afforded the Madison County Health Department staff the benefit of that expertise by sending a representative to the meetings and providing valuable options to consider.