Reimbursement Risks: Patient Identity Errors Cost Hospitals Billions

April 1, 2021
April 1, 2021

This blog post is based on a recent webinar featuring Susan Gurzynski-Wells, Senior Product Manager, who specializes in coding and revenue cycle management at HealthStream.

When you think about optimizing reimbursement, you’ll notice that many problems are outside of your direct control. Experts at the American College of Healthcare Executives say the three top problems are timeliness of Medicaid reimbursements, bad debt, and Medicare reimbursement. Unfortunately, hospitals and physicians don't have much control over these issues. So where can you find the low-hanging fruit, the areas within your control?

The $8 Billion Question

Do you have patient matching errors? The RAND Corporation says 14 to 20% of medical records have identity errors, racking up an annual estimated cost of eight billion dollars nationally. Mismatched patient identifiers result in costly denials and unpaid cost of care. These also link to catastrophic adverse medical deaths, medication errors, and unnecessary procedures. Successful enterprise integrity management helps to identify and avoid these errors.

Overlaps, Overlays, and Duplicate or Incorrect Patient Identifiers

The Journal of AHIMA says one in ten patients have multiple medical record numbers. Overlays occur when two or more patients’ data is combined into a single record. Approximately 2% of master patient index (MPI) errors are overlays. Overlaps occur when a patient is seen at two or more facilities within a health system and his records are maintained separately by each facility. In multi-entity systems, the occurrence of these overlaps can be as high as 40%.

Duplicate and incorrect patient identifiers also lead to reimbursement losses, compromised data integrity, increased administrative waste, staff ineffectiveness, and increased liability. Most important, they can lead to poor quality of care and diminished patient safety. 

Addressing Patient Matching and Identification Issues

AHIMA recommends creating an enterprise identity management strategy to address these issues. This requires governance policies and procedures across the organization. As you push for data integrity, you must provide regular staff training to ensure they understand the importance of compliance.

From registration to billing, it's estimated that upwards of 250 people in an organization process and treat each patient. Most errors related to mismatched patient identifiers and duplicate medical record numbers happen within the Patient Access department. Problems sometimes occur when registration is decentralized and registrars report to different individuals within the same organization. The people registering patients in a lab or physical therapy department have other responsibilities besides registration. They may not understand the consequences of mismatched patient identifiers due to the fact that they may not receive regular training. These staff members, like others in the organization, must be trained to understand that their activities and actions can affect the revenue cycle through its entirety.

The usual causes of errors are entry errors, unfamiliar name structures, adding or deleting a middle initial, unfamiliar foreign names, and ID and insurance cards shared by multiple people. We depend on technology to solve the problem, but we still need to educate healthcare professionals about critical thinking, best practices, and how to avoid and recognize identity mistakes.

“Every patient deserves the best trained workforce.” We accomplish this by hiring well, onboarding well, and continuing to professionally develop our teams, resulting in reduced turnover, increased employee satisfaction, and increased patient satisfaction.

Watch the full Webinar. Learn more about our revenue cycle solutions.