Background and challenge

When medical procedures are conducted, a variety of medical supplies are utilized, often warranting a material allowance. Proper reporting of these materials is essential to ensure accurate reimbursement. However, manual or scanning-based registration of these materials is prone to errors, leading to missed reimbursements.

To mitigate such losses, hospital pharmacists conduct regular manual audits of files. During these audits, they search for indications of specific material usage in medical records. If a pharmacist finds sufficient evidence for material reimbursement, they can register it accordingly, triggering correct invoicing.

However, these manual file audits are time-consuming and require the expertise of a hospital pharmacist, a valuable and costly resource. With CTcue's automation capabilities, these audits can be streamlined. By automating this process, we can prevent revenue loss and free up the pharmacist's time for other essential tasks.

Approach and results

To streamline the automation of retrieving missed material allowances, CTcue can be leveraged. CTcue is a Natural Language Processing (NLP) tool designed to extract information from both structured and unstructured data within the EMR.

In this specific scenario, our focus will be on the RIZIV procedure '589186 - Percutaneous insertion under control by medical imaging of endovascular catheters,' involving a thrombectomy with a stent retriever. This procedure qualifies for two material allowances, namely RIZIV code 182136-182140 and RIZIV code 182151-182162. Using CTcue queries, we will identify patients who underwent RIZIV procedure 589186 but are missing one or both material allowances. Subsequently, we will analyze radiology reports for mentions of stent retrievers, solitaires, or thrombectomy procedures.

The query was constructed using the following components:

• Patients with a recorded RIZIV code 589186
• Missing one or two material compensations
• Reference to a stent retriever, solitaire, or thrombectomy in a radiology report coinciding with the RIZIV 589186 registration date.

The outcome is a pseudonymized patient list consolidating all necessary validation information into a single table. This streamlined format facilitates the identification of cases where material fees have been overlooked. Traditionally, manual file audits were exclusive to hospital pharmacists due to the therapeutic relationship with patients. However, with CTcue generating pseudonymized lists, administrative staff can now perform these checks. Upon completion of the audit, a colleague with appropriate access privileges can 'unblind' the selected patients and rectify any invoicing discrepancies.

The CTcue system not only optimizes the efficiency of hospital pharmacists by automating the process but also enables more frequent checks to be conducted. The primary limitation for oversight is the lag time associated with the billing cycle. Typically, billing data becomes accessible two to three months post-service delivery. Once the billing data for a particular month is finalized and integrated into the Forcea HealthReport data warehouse, it becomes instantly accessible within CTcue, allowing for the execution of the control query.

Conclusion

Leveraging CTcue for identifying missed material compensations offers numerous benefits to hospitals. Firstly, it enables hospitals to pinpoint and rectify any overlooked material reimbursements. In the previously mentioned scenario, hospitals successfully recouped up to €70,000 in missed material allowances associated with RIZIV procedure 589186.

Additionally, CTcue streamlines the process of recovering missed material compensations through automation, leading to a quicker and more efficient data review. By pseudonymizing patient data, the revision task can now be performed by administrative personnel rather than hospital pharmacists, saving up to 0.2 FTE of a hospital pharmacist's time.

Lastly, the implementation of CTcue enables hospitals to execute the query more frequently. Previously, the assessment for missed material allowances occurred annually, but with the current query, this frequency can be substantially increased. This proactive approach facilitates the early detection and recovery of financial losses.

In the preceding example, we concentrated on material allowances associated with RIZIV procedure 589186. However, similar checks can be extended to various other procedures that currently necessitate manual file audits to address missed material allowances. Broadening the scope of the CTcue query to encompass additional procedures has the potential to enhance the financial benefits for the hospital.

If you are interested in initiating this process or have any inquiries, please feel free to reach out to linda.ludikhuyze@iqvia.com for further information.