Within revenue cycle management, billing is an important activity for physicians with financial implications across remuneration models. We assessed the self-reported billing confidence of residents and attending physicians practicing at an academic family health team in a single payer setting.
All residents and attending physicians working or who had worked at the team were invited to complete a 20-question electronic survey on their exposure to billing education and their self-reported confidence with various billing activities.
Twenty-five percent (n=40) of eligible physicians completed the survey. There were statistically significant differences between attending and resident physicians’ billing experience (median 117.5 vs. 7.5 months). Analysis of free text comments revealed the positive impact of early billing exposure and opportunities for longitudinal feedback.
Despite the small sample size, findings suggest that early exposure of family medicine residents to billing with standardized training contributes to a more positive experience during residency.
Keywords: family medicine, physicians, billing, competency based medical education
Revenue cycle management is a critical process for healthcare organizations encompassing pre-encounter (e.g., appointment scheduling), intra-encounter (e.g., patient registration, physician billing), and post-encounter (e.g., coding, claims review, and insurance follow-up) steps. In addition to serving as a mechanism for remuneration, physician billing yields important diagnostic information used in practice-level panel management and quality improvement. While physician billing of the encounter represents one component of revenue cycle management, recent work has demonstrated that more than 30 percent of the total processing cost for an encounter bill is for physician time. Moreover, nearly 25 percent of the total processing time of a single bill has been attributed to physicians. This time adds to the already significant time spent in the electronic medical record (EMR), which has been shown to be associated with health-related stress and burnout.
Given this context, physician billing performance is critical, yet challenges remain. Previous studies conducted in family medicine (FM) practices found that when independent auditors retrospectively reviewed provider code selection, they agreed with the selection 15.2 percent to 29.2 percent of the time. Upcoding and unbundling are also problematic, with one study showing that internal medicine residents overbilled nearly 20 percent of encounters. Such discordances cost physician practices substantial revenue and may also increase the risk of potential legal action.
Despite being an important practice management skill and critical across remuneration models, literature across specialties has demonstrated that many residents and attending physicians feel inadequately prepared to handle billing within their practice. Moreover, current literature comprises studies examining billing performance or knowledge within multi-payer environments with little known about the experiences of FM resident or attending physicians working in an academic setting in a single-payer system.
The objective of our exploratory study was to assess the impact of existing billing education on self-reported billing confidence of resident and attending family physicians to guide future quality improvement work in this area. We conducted a survey-based study at an academic FM residency program. We hypothesized that attending physicians would have greater confidence with billing and with identifying billing errors when compared to resident physicians. However, we anticipated that resident physicians would have developed moderate confidence with these activities through the billing curriculum.
This was a single-centre, cross-sectional survey-based study conducted between December 13, 2019, and February 21, 2020. The study received local research ethics board approval (FMED-6723-19).
Participants and Data Collection
Our study was conducted in the setting of an academic FM residency program in Ontario, Canada. All current postgraduate year 1 (PGY1) or year 2 (PGY2) residents and attending physicians (including faculty and locums) for the 2019-2020 academic year working at the largest site of an academic family health team were eligible for inclusion in this study. This site is funded through a family health organization (FHO) model, where faculty physicians are compensated through capitation payments but also receive fee-for-service payments. Physicians working at other sites were not eligible to participate due to their exposure to different billing education. All potential participants who met the inclusion criteria were invited to complete a 20-question electronic survey (see Appendix 1) designed in Qualtrics.
Resident physicians receive education on billing and are required to bill as part of their daily practice. Resident billing education comprises seminars that are concentrated during the first month of training, while attending physicians participate in a billing orientation prior to beginning their work. Both groups receive billing “tips and tricks” that are circulated periodically throughout the year.
Data were extracted using Microsoft Excel. Likert-scale responses were separated from open-ended feedback. One case was removed from the dataset due to a significant number of missing values (60 percent of the survey questions were not completed by the resident physician). Likert responses were converted into a numerical scale, categorized into two groups (resident and attending physicians), and quantitatively compared using a combination of descriptive statistics and non-normal analyses of variance in IBM SPSS Statistics 23.
Free text responses were aggregated by question. Two authors independently analyzed them using a line-by-line approach and then performed a secondary analysis of codes to identify themes. A third author not involved in the original analysis then reviewed and discussed interpretations to resolve discrepancies during this process.
Fifty-five PGY1, 25 faculty physicians, and 25 locum physicians worked at the academic family health team at the time of survey completion; 55 PGY2 FM residents had worked at the site the year prior. Twenty residents and 20 attending physicians completed the survey in its entirety, representing an overall response rate of 25 percent. Attending physicians had a median billing experience of 117.5 months (IQR = 74.75-285.00), while resident respondents had a median billing experience of 7.5 months (IQR = 6.00-12.00), a statistically significant difference (U=0.0, p<0.001). There was no difference in attending and resident physicians’ perspective on the importance of residents learning to bill (U=190.000, p=0.553). Aside from a significant difference between attending physicians’ confidence (median = 3.00, IQR 3.00-4.00) in identifying common billing errors compared to residents (median = 2.50, IQR 2.00-3.00) [U=124.000, p=0.029], no other statistically significant differences were noted (Table 1).
Our qualitative analysis revealed that residents and attending physicians found orientation and early exposure to billing as well as ad hoc sessions throughout the year helpful and useful.
“I think the lectures were a good start. Then being thrown into it in clinic, with guidance from preceptors. They made themselves available to answer any questions and give guidance along the way.” (Resident)
“As a faculty, it is my impression that it is important for the residents to actually attempt billing, rather than just hearing about it in the abstract, particularly if faculty take the time to inform about any billing done incorrectly.” (Attending Physician)
In contrast to these strengths, residents and attending physicians reported a lack of confidence with more complex codes. They reported that various billing codes (especially more complex ones or those related to specific procedures or situations outside of the family health team) were still unclear and confusing to them.
“How do I combine codes? How do I code for procedures?” (Resident)
“There are so many codes that I don’t know how to use and want to use. AHC, out of basket counselling/education codes/diabetes codes. House calls are very complicated.” (Attending Physician)
In this context, both surveyed residents and attending physicians desired more feedback and longitudinal training.
“[I would like to] have preceptors review billing and give feedback just like they do for clinical work.” (Resident)
“[I would like] more review. I review the residents’ billing, but no one is helping me with mine.” (Attending Physician)
“More frequent, brief reviews on billing would be better than one or two heavy sessions at the beginning. Questions arise during the year and refreshers would build on knowledge.” (Resident)
“I would like to have a 10- or 15-minute short refresher once a month at rounds.” (Attending Physician)
To our knowledge, this study is the first to explore the perspectives of resident and attending family physicians on billing education and their confidence with key billing activities at a large academic family health team in a single payer setting. Consistent with previous work in other disciplines, our results revealed that more than 90 percent of surveyed residents and physicians strongly agreed that it is important for residents to learn how to bill. Responses to open-ended questions revealed that most residents and attending physicians had a positive experience with being introduced to billing and acknowledged common strengths in terms of early standardized education.
However, low levels of confidence suggest that education alone is insufficient. While mentorship by more senior family physicians may facilitate comfort with billing, our work surprisingly demonstrated no significant differences between surveyed residents and attending physicians’ confidence in ability to bill appropriately, teaching others to bill appropriately, or being able to find answers to billing questions. These findings suggest that FM residency training programs should consider the feasibility of implementing longitudinal feedback on billing performance by non-physician revenue cycle experts to foster continuous improvement. In addition to providing feedback, experts could use these opportunities to provide updates on evaluation and management services, share reminders regarding unbundling and upcoding, and help physicians appropriately navigate EMR-based coding modules and documentation.
Although education is important, its impact on billing performance may be limited. Previous work has demonstrated that coding accuracy did not significantly improve following introduction of a billing curriculum. Furthermore, selection of diagnostic and billing codes by physicians represents one component of the revenue cycle process with many opportunities for improvement. As such, improving performance should consider broad quality improvement strategies. The use of forcing functions and automation, including predictive algorithms for medical billing, could be used to address challenging areas, including complex coding of visits and billing optimization. Similarly, reminders and checklists integrated in the EMR at the point of care could help physicians ensure that encounters are appropriately coded to avoid errors and insurance review. The impact of these interventions should be explored in future studies.
There are several reasons to interpret our results with caution. Although we strived to reach all residents and attending physicians at the family health team and provide sufficient time to respond, our response rate was low. In addition to potentially introducing selection bias, the small sample size makes it difficult to detect meaningful differences in participant responses.
Our survey was also focused on physicians’ self-reported confidence and did not specifically delve into physicians’ knowledge or practices around visit coding or their perspectives on revenue cycle management. Our study was also conducted at a single academic family health team where billing abilities may differ from community-based physicians. Consequently, our results may not be generalizable to other FM settings.
Conclusions and Future Work
Our work highlights the importance of providing residents and attending physicians with some billing education as part of broader practice management curricula. However, low levels of confidence with billing remain, necessitating multi-modal approaches to improve billing comfort and performance. Future efforts should address the limitations of our study and continue to support resident and attending family physicians in developing greater confidence with billing.
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Conflicts of Interest
Dr. Rajaram co-founded and runs an early-stage, pre-commercial start-up, 12676362 Canada Inc, doing business as Caddie Health. Caddie Health has developed AI-powered software to reduce the administrative burden of physicians. He owns an equity stake in the company and receives compensation for part-time work. The research presented in this submission was completed before the formation of the company and was not funded.
This research did not receive grants for from any funding agency in the public, commercial or not-for-profit sectors.