The Automated Interface of PROFEE Billing
Updated: Oct 18, 2021
I hate paper. You can ask anyone who has ever worked with me. If you hand me a piece of paper it is either going to be scanned in immediately, or just forgotten about for weeks to months. This is why I think I am always striving for that perfectly automated interface.
Obviously the most automated feed-based version of any hospital system would be:
ADT via HL7 – Patient demographics and insurance.
DFT via HL7 – Charges (if providers drop initial charges).
MDM via HL7 – Digital Medical Record (MR)
Daily Unit Census Log – For full reconciliation.
EHR Access – Read and print to PDF functionality. With access (if available) to system-based inboxes to communicate deficiencies to providers.
If you asked me 5 years ago what any of these were, what they stood for, how they impacted revenue cycle, I would have blankly stared at you. I think I get it now, at least I have done enough integrations to know where each piece applies and I definitely know what happens if I do not get one of these things built right.
Manual Pull from Health System/Facility System(s)
Scheduled Push from Health System/Facility
ADT (Patient Demographics and Insurance, GT)
Look up in EHR/EMR
Flat File (txt/tif) - 1x daily cut of info via SFTP
ADT data via HL7
EMR/EHR MR (Provider documentation)
Direct Coding from EHR/EMR
Downtime/ Paper Charts
PDF MR transmitted via SFTP
MDM data via HL7
Charge Entry (1st pass coding)
Charge entry into PM system from EHR
Charges pulled from system
Charge Interface report
DFT data via HL7
1. Admit Discharge Transfer (ADT) – Patient demographics and insurance
This HL7 feed of A04 and A08-type event messages, with PID and PV1 segments and fields, contain all those vital patient demographics that allow external users to create shell accounts for patient coding and billing. It is a portion we are reliant on the facility registration team to get as accurate as possible on the first touch.
Insider tip: Build a relationship with a facility contact that has connection/oversight of the patient access/registration/patient financial service areas. For the ProFee spaces where group billing is external to the health system, the downstream impacts compound. Bad addresses, incorrect or missing insurance, patient call routing for facility vs ProFee services, or minor accounts without a guarantor. These can all be cleaned up on the back end, but without working with the health system, you are only clearing the symptoms of lagging AR. You never are fixing the root issues unless you go work where it started. Sometimes this is people training, sometimes it is process, and yes, sometimes it is technology and you need to re-program the ADT feed.
2. Detailed Financial Transactions (DFT) – Account/Encounter Charges
Charge entry. This segment of automation is not standard across all professional billing. Rather, it is dependent on the workflow of the providers in relation to their RCM vendor. The easiest way to explain this is the generic question of, “Do the providers code/drop their own charges?” If the answer is yes, the this is where the DFT feed from a health system comes into play.
This HL7 feed contains the charges that are entered traditionally by a performing provider. If you are a provider group separate from the health system, there may be some fine tuning to ensure the charges do not route into any internal facility charge processor. Also, even if a provider is dropping their own charges, in the form of CPT codes, it is likely that the RCM vendor will need to do a pass across the coding to ensure codes are appropriate for billing. This is especially true if you have multiple providers caring for a patient over and extend period of time, often having patient encounters on the same day.
3. Medical Document Management (MDM) – Digital Medical Record (MR)
I wish I had understood digital record transmission earlier in my career. I was making everything too difficult until someone came along and said there is a better way to transmit patient documentation.
If you know anything about provider care vs provider documentation, you know that they are not always in sync. Some providers are amazing at getting their documentation in within a day or two of their patient care, others it can take weeks. And here you have a opportunity to help that feedback loop by using technology.
The MDM is my first option. It breaks down the sections of an already digital medical record and transmits them allowing for a rebuilding of the record on the vendor side. Where an MDM feed is not available, the other option is an Observation Result (ORU) feed. Like the MDM, it transmits multiple components of a medical record. Each methods will work if you have a team that understand the components and triggers of each message. The best part is when the updated documentation comes over automatically; say goodbye to manual processing of deficiencies that you find with PDF versions of MRs.
4. Daily Unit Census Log – Patient list for a particular Date of Service (DOS)
Feeds are great...up to a point. HL7 interfaces allow timely, continuous, automated information transfer. These feeds are only good longer term, if they accurate. Enter the Daily Census Log! There is a single file that contains a single day service with a high level set of data points for a particular unit. Layman's terms: a list of all patients connected to a particular unit/service line for a single day. It is a little gray so an example may help.
Example: The Emergency Department (ED)
I need a list of every patient that was registered in an ED status as indicated by the facility EHR system on a given calendar day. I need them if they registered online and did not show. I need them if they were a direct transfer that came through the ED, or a Labor and Delivery patient that arrived by EMS. I need the patients that were errors, AMA, LWBS, transfers, discharges, admits, all of them.
This list (usually a daily txt or tif file) is my source of truth. I can use it to check against the various HL7 feeds to indicate total volume vs true billable volume.
5. EHR Access – Read and print to PDF functionality.
Medical record is not a new term. However, the complex layers of an electronic medical record is not always as easily defined. At a high level, the medical record should be the entire record of all direct and indirect care of a patient. The medical record can be the entire history of all visits ever rendered at a particular health system, or it can be a sub-selection of by a type of service, or for a unique service date.
For ProFee billing, it is challenging to define the medical record. As the variances of hours to days to months for an encounter by a particular provider or provider group can be variable depending on the service(s). There are also dependencies on the facility for the segmentation of this data, and/or just getting access to the system. I cannot tell you how many times over the course of my career I have used that system access to perform audits, research for complaints, or sample accounts that for whatever reason are causing downstream workflow errors.
Now there are probably other methods of information transmissions that I am missing here. Probably, some that would greatly increase the throughput of the patients accounts and record, but at least being familiar with these is a good place to start. The only other obstacle is understanding the facility system's capabilities or limitations to meet these feed needs.