A Prescription for Independent ED Groups: Partner with your Hospital C-suite

Business Challenge

Partnering with your hospital can be an elusive goal without a deeper understanding of how your emergency group can impact the hospital’s bottom line. But, how do you identify the root cause of pain points and then operationalize a collaborative strategy?

Intelligent Practice Solutions

To help guide our clients, Brault provides assistance from our full suite of Intelligent Practice Solutions.

Establish an Ongoing Dialogue

On a recent client visit, Brault requested a joint meeting with our client and their hospital’s CEO and CFO. This emergency group had just starting billing separately from the hospital within the last year, so we knew this was a prime opportunity for us to understand how the change may have impacted their years’ long partnership. It only took one simple question for the hospital to get the conversation going:

  • Are you experiencing many denials due to final diagnoses coming in from the ED?

    Admittedly, this was a loaded question because we already knew that they were experiencing this. We had already caught this correlation trend in our own data. But, the fact that we proactively brought this to their attention was the real value add – we not only identified an issue that hadn’t been recognized, we also came to them with solutions to address the issue head on.

    An example we offered was: a patient that comes in for chest pain and it turns out to be acid reflux. In this scenario, if GERD was the final diagnosis, then the incident is likely to be classified as a non-qualifying event. In the future, this issue can be solved by adding both “GERD” and “chest pain” to the final diagnosis documentation.

    But more importantly, from an operations standpoint, we recommended an ongoing feedback – where the ED group (and Brault) could access the history of hospital denials in order to develop tracking mechanisms, trainings programs, and interventions with groups or individual providers.

Always Keep Your Eyes and Ears Open

On another client visit, while we were walking in for our meeting, we happened to notice a section of the ED waiting room that had been designated “Orders Pending.” This seemingly trivial observance actually had deep implications, which led to an important question:

  • How many denials are you seeing due to incomplete orders that are set entries, but do not have completed physician orders?

    In this particular ED, they had been using protocol-driven lab orders for certain patients in the ED Triage area. When patients came in with something like a sore throat, nurses would start running a strep screen with the understanding that a physician would later review and sign the order. But, because of a lack of bed capacity, patients would get sent back into the waiting room until the physician was able to see them.

    In this ED, though, patients were more likely to walk out after their lab than wait to be seen by a doctor. So, without physician orders, the lab work became unbillable. And, despite being an ED of only 16,000 annual visits, the financial impact of their walkouts was calculated at more than $80,000/month.


    The question sparked a lot of conversation. And, from that, came operational changes – including a new process where physicians could see patients in the waiting room and a separate “pending orders” area to discourage patient walkouts.

Consider a Clinical Decision Unit (CDU)

On a separate occasion, we again met with leadership teams from both the ED group and hospital. But, this time, the conversation led to a different question:

  • How many admissions are you seeing from the ED, where the Two-Midnight rule isn’t being met?

    The conversation was quite insightful and, ultimately, the two teams decided that establishing a Clinical Decision Unit was the best path forward. The CDU would include case managers to determine whether patients had met the admissions criteria to be admitted upstairs or instead remain in the observation unit for what would be considered an outpatient treatment.

    By creating a CDU, the physician group was actually going to play a key role in helping the hospital avoid short-term admission penalties – while the physician group benefited from additional revenue capture due to the new service line. The result was a win-win.

Proper Documentation Can Have Downstream Effects

On yet another client visit, we asked:

  • Do you know how documentation from the ED might be impacting the hospital’s bottom line?

    After some conversation, we learned that the admitting hospitalists were not documenting certain co-morbidities.

    So, the emergency physicians agreed that they would identify patients who could be described as having sepsis or, when altered mental status, patients who could properly be described as having “encephalopathy.”

    These severity indicators could be documented by the treating emergency physician, which would then allow the hospital to improve their DRG assignments. These severity indicators would also help trigger the hospitalists to document these findings and address them in their records as well – therefore improving care while also improving revenue by several hundred-thousands of dollars per year.

Bottom Line: Always Keep Adding Value

To bulletproof your contract, emergency physician groups need to find ways to show value to their partner hospital in ways that drive revenue and reduce cost. A valuable partnership only exists when one party can create value for the other in a way that can’t be found elsewhere. Brault works with client practices to identify specific ways that they can create this value on an ongoing basis.


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