Don't Let DNFB Cripple Hospital Cash Flow

Healthcare leaders who know their financial data points understand there's one business metric that should never be on the upswing: discharged not final billed (DNFB). If an organization's bills don't leave the front door, its cash flow and opportunities to earn interest certainly will.

The C-Suite must set acceptable DNFB standards that are consistent in their measurement and organizational-specific issues, says Lou Ann Weidemann, MS, RHIA, CPEHR, FAHIMA, director of HIM Solutions at the American Health Information Management Association (AHIMA) in Chicago.

What can make DNFB rise?

• Lack of qualified coders.
• Bills held up during pre-bill audit reviews.
• Poor internal review systems between the departments that code records and the clinicians who complete pathology and operative reports.

Most organizations set a three-day threshold for accounts, she says, meaning that accounts that are not coded or dropped within three days of discharge appear on the DNFB. Other organizations choose to keep the DNFB at a percentage of overall revenue (e.g. 2%) as their measurement. 

"Choose the measure that best fits the organization and stick with it," Weidemann says.

Urge collaboration
"Also, develop a collaborative team within the organization that includes representatives from HIM, coding, quality assurance, and others that meets on a regular basis to discuss ongoing issues. In the beginning, this group may meet weekly, and then taper off to a monthly meeting once improvement is seen. In the end, assign the responsibility of the DNFB monitoring to one individual and ensure that they have the tools and resources to review the report, identify process issues, and make corrections."

In most situations, the CEO or CFO has the HIM director deliver the DNFB rates, Weidemann says. It may differ; for instance, at an integrated delivery system or those in which the coding professionals do not report to the HIM director.

Ultimately, the HIM director should lead the effort to improve DNFB rates and should work with representatives from across many groups:  business office, coding, chargemaster, admitting, case management or utilization review, quality management, and HIM. 

"The HIM director should know on a daily basis what the DNFB is, the expected coder productivity, reason for large dollar amounts on the DNFB, etc., and be able to answer questions to the C-Suite," Weidemann adds.

Successfully monitoring and controlling DNFB lies within understanding its cause, says Darice M. Grzybowski, MA, RHIA, FAHIMA, founder and president of HIMentors, LLC, in Westchester, IL.

A HIM department may struggle with getting records coded, Grzybowski says, while other times it may attempt to code the medical record, but find that key information such as a pathology report or dictated operative report is missing.

Success keys
"In some cases, the record is outstanding due to other reasons, such as a problem with a duplicate account number, or there is a question regarding a charge error," Grzybowski adds. "Whatever the reason, it should be classified in a category and not lumped together for one sum number. The HIM department should work in conjunction with the business office to agree on a method of classifying, tracking, and reporting this data on a regular basis to the C-Suite."

How else can healthcare leaders ensure their DNFB rates improve? Gryzbowski says leaders can start by:

• Investing in an HIM operational assessment to identify causes of DNFB and possible solutions
• Putting an ongoing tracking mechanism in place to monitor DNFB
• Ensuring the Patient Financial Services (PFS) department and HIM teams agree how DNFB will be defined and measured
• Enforcing record-completion policies
• Ensuring that deficiency analysis takes place before coding (within the first 24 hours post discharge) to identify missing data earlier in the lifecycle of record processing, and to improve coder productivity to avoid them spending time searching for missing information

"Those facilities that have undergone a thorough HIM and Revenue Cycle operational assessment can identify the areas that need improvement," Gryzbowski adds. "And by implementing various changes in process, adjusting staffing, or providing better analytical tracking of the DNFB, problems can be avoided with the proper solutions."

Staffing and technology
Be aware that a shortage of qualified, credentialed, and experienced coders can make your organization's DNFB rise. A lack of an adequate staff working seven days a week in the scanning, analysis, and coding areas could mean higher rates, Gryzbowski warns. 

"ICD-10 may make that shortage more severe and have a detrimental effect on DNFB," she says. "Electronic health records and a good electronic document management system that makes physician completion of record deficiencies easier to manage actually helps improved and decrease the DNFB rate."

Even when your organization is doing well preparing for audits like the CMS Recovery Audit Program, you may be hurting your DNFB.

"Some organizations are choosing to pre-bill review these types of accounts as a precautionary measure which leaves it on the report longer," Weidemann says. "External audits often post big risks for an organization, and no organization can afford to pay back audits for multiple accounts. Some organizations are choosing to be proactive in their audit activities and mitigate their risk by placing accounts on ‘hold' in order to review the documentation and code assignment internally before the account is dropped."