ACCOUNT REVENUE FY2021
Abstract
The following is the Account Revenue Report review for year-ending FY2021 for UMMC hospitals. In this fictitious analysis we will examine the Account Revenue FY2021 to analyze what pertinent issues are affecting UMMS especially in relation to Denied Amounts. The excel document called “UMMC $”, has copious amount of data. My work as the Data Analyst is to go through the data to determine what information will help us draw significant conclusions and what actions UMMC will have to take to help deal with pertinent issues in the FY2022. The most immediate issue facing the institution is the significant amount of Denied Amount that patients and payors are not paying after treatment. This report aims to ensure that UMMC achieves its objective of improving Maryland’s State of Care while at the same time generating sufficient income to meet its obligations.
Data Cleaning & Preparation
To make the data set work I had to prepare the data. I took the following actions.
1) Removed blanks in Column A under Facility by unselecting blanks in the Filter box (Total Records is 9725)
2) Created new Column called Received Amount (Column I) this is the difference between (Amount Charged — Denied Amount)
3) Inserted zero where there was no Denied amount instead of having a blank cell
4) Converted dates Admission dates and Discharge dates into mm/dd/yyyy format
5) In CPT Codes column where there was no CPT Code hence a blank cell, I added N/A
6) Denial Reason Code column where there was none, I imputed None
7) After the data had been cleaned it was renamed RRAS FY21 Account Balance Memo Exercise EDITED (copy attached in the email)
8) Aligned the data set to make it easier to read and work. Some of the data in the Columns were Aligned to the Right, others were Aligned to the Left and finally others were Middle Aligned.
9) Noted that the Admission Date and the Discharge Date were on this same day in most of the records. But this did not affect my analysis of the data set.
Finally, I created Tables and Charts both in Excel and in Tableau please see the link below to access the Tableau page.
https://public.tableau.com/app/profile/kiio.mutua/viz/ACCOUNTREVENUE2021BOOKONE/Dashboard1
https://public.tableau.com/app/profile/kiio.mutua/viz/ACCOUNTREVENUE2021BOOKONE/Dashboard2
Impact Statement
University of Maryland Medical System (UMMS) continues to exceed expectations as the leading Health Care provider in the State of Maryland. With over 13 hospitals, 29,000 employees and 4,600 affiliated physicians and more than 150 locations UMMS works hard to ensure a Better State of Care in Maryland.
Healthcare professionals understand that many in the communities will visit medical centers especially the Emergency Room due to the Pandemic. As a result, the hospitals have seen a rise in hospitalizations in the FY2021 as Coronavirus variants continue to ravage the US and the world as well. The main issue to be addressed in this data set is the amount of Denied Charges that were not paid after services were rendered, The Data Set RRAS FY21 Account Balance Memo Exercise EDITED will help us better identify what type of hospital charges that were not received from the payors and which type of Payors these were.
From Table 1 below, Total Charges for the FY2021 was $41,188,372 while the Denied Amount was $1,572,681 so UMMS was able to Receive $39,615,691
Table 1 (FY2021) (Millions)
Total Charges $ 41,188,372
Total Denied Amount $ 1,572,681
Total Received Amount $ 39,615,691
The good news is that the Denied Amount represents 3.81% of the Total Charges Received. Despite this, it still represents a significant amount totaling over $1.5 Million that was denied. From the data Emergency Room visits represents a significant amount of these denied amounts with two codes 50- 50 Non — Cvd — Not deemed Medical Necessity $ 424,605 and 40- 40 Chgs Don’t Quality for Er/Urgent Care $270,896 accounted for almost 44.22 % of the Total Denied Amount (Table 2). From this we can infer, patients will have to be educated that their primary care doctors can provide the same care as the ER personnel especially in non-emergency situations.
The Top 10 Denial Reason Codes are the following as shown in Table 2 below:
Table 2 Denial Reason Codes (FY2021) Amount (Thousands)
50–50 Non — Cvd — Not deemed Medical Necessity $ 424,605
40–40 Chgs Don’t Quality for Er/Urgent Care $ 270,896
96–96 Non-Covered Charges $181,456
A1-A1 Claim/Svc Denied $125,009
16–16 Lacks Info Needed for Adjudication $ 103,050
62–62 Denied /Reduced, PreCert/Auth Absent /Ex $ 77,211
252–252 Attach/Doc Req $66,949
78–78 Non- Covd Days/Room Charge Adjustment $61,698
109–109 Not Covd by Payor $ 43,660
97–97 PMT — Incl PMT for office $ 40,989
Medicare had the highest Denial Amount based on Primary Financial Class at $719,362 and was closely followed by Medicaid $704,721 (Table 3 & Chart 1 below ). Looking at the Emergency Room visit and the Denials from Medicare and Medicaid it seems like those patients with these two types of insurance as their only Primary insurances visited the ER the most. Either these patients are over 65 years old, the poor or children who cannot afford to private insurance and therefore do not have a primary care physician.
Table 3 Primary Financials Class
Primary Financial Class Sum of Denied Amt
Blue Cross $1270.15
Commercial $33829.62
Medicaid MCO $704426.6
Medicare $719361.68
Medicare Replacement Plan $95542.97
Military $18249.87
Grand Total $1572680.89
Chart 1 Primary Financial Class & Denied Amount
Outpatient Services of different forms (Observation, Outpatient Ambulatory Surgery and Outpatient Extended Recovery) were some of the highest revenue streams so UMMS should device mechanisms to move patients from Emergency Room visits towards outpatient visits as much as possible. This will result in increasing the revenue stream for UMMS while at the same time reducing the amount of Denied payments.
Chart 2 Primary Insurance Plan & Denied Amount
Recommendations
1 Reduce Emergency Room Visits which in turn reduces Denied Amounts at the end of FY2022
2 Encourage patients to use Outpatient(Observation, Outpatient Ambulatory Surgery and Outpatient Extended Recovery) services which will increase revenue to the institution.
3 Find out why most of the Denied Amounts arise from Not Deemed medically necessary and Charges do not qualify for Emergency or Urgent Care.
4 Find out whether Emergency room visits are caused by Social Determinants of health such as poverty, poor diet, and lack of preventive care.
Conclusions
In this fictitious dataset we examined the Account Revenue FY2021 to analyze what pertinent issues are affecting UMMS especially in relation to Denied Amounts.
1. We see that most of the Denied Amounts come from Medicare and Medicaid MCO respectively.
2. We see that Emergency Room visits represents a significant amount of these denied amounts with two codes 50- 50 Non — Cvd — Not deemed Medical Necessity $ 424,605 and 40- 40 Chgs Don’t Quality for Er/Urgent Care $270,896 accounted for 44.22 % of the Total Denied Amount.
3. Finally, we saw the impact of Emergency Room visit and its relation to denial amount and based on this we can safely say that there is a direct correlation between Emergency Room visits and Denied Amounts.
Please note that these findings here are purely observational and are not based on any real dataset out there.
