Quantitative Analysis of BJC Health System Managed Care Contract Reimbursement for Major Joint and Limb Reattachment Procedures of the Lower Extremities (DRG 209)

摘要

Healthcare organizations are currently losing millions of dollars each year because of errors in billing processes. Many problems arise due to a lack of information, about and comprehension of; managed care contracts, terms, and requirements. As managed care continues to penetrate healthcare markets, these problems are likely to magnify. Given that BJC Health System's survival is dependent upon managed care revenue, and the negotiated contract language is structured to maximize return, it is imperative BJC faculties bill for all reimbursable items allowable in their managed care contracts. However, there is suspicion among BJC Managed Care Executives that BJC facilities may not be accurately billing for all reimbursable items, specifically prosthetics and implants devices The purpose of this study is to examine internal processes culminating in the patient's bill to determine if BJC is properly billing for prosthetics and implants. This study focuses on DRG 209 cases (Total Hip Replacement, Partial Hip Replacement, and Total Knee Replacement procedures) as a potential area of lost revenue. Overall, 8.6% ($202,000) of all charges for total knee and hip prosthetic and implant devices are not captured on bills being sent to managed care plans. Therefore, BJC is not capturing all possible revenue.