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Hospital Reimbursement 101: Help your docs answer every query


Hospital reimbursement starts with physician documentation. Physician documentation must be complete, accurate and precise to support optimal reimbursement and accurate quality reporting.

Increasingly, hospitals are funding clinical documentation improvement (CDI) programs and dedicated staff to educate physicians on the specificity needed for proper reimbursement and quality reporting. The primary tool used by CDI specialists and hospital coders to clarify physician documentation is the physician query. Physicians are typically queried about their documentation by email, fax, phone or in-person and asked to update the chart or respond on the query form.

Physician queries provide significant financial impact for hospitals. Artifact Health’s research found that 63% of physician query responses have a positive financial impact on the inpatient record. Each response with positive financial impact increases reimbursement by $5,000 on average. This means that every unanswered physician query reduces the hospital’s potential reimbursement by an average of $3,150. For a 1,200 bed hospital with 50,000 inpatient admissions per year querying on 15% of admissions, the difference between a physician query response rate of 60% and 100% is $9.5 million dollars.

Under enormous financial pressures already, hospitals cannot afford to leave $9.5 million dollars on the table because they fail to engage physicians in the query process. Exacerbating the situation, queries are expected to surge by year’s end with the government-mandated transition to ICD-10. The predicted 10-fold increase in query volume will account for even greater losses as hospitals tax already inefficient query processes.

There is no greater opportunity to maximize hospital reimbursement than to immediately improve physician response rates to documentation-related queries.