Germany’s Berliner DRK-Kliniken refine financial strategies in light of DRG legislation on hospital reimbursement

DRK-Kliniken, Berlin, Germany New IT solutions from ORBIS™ help DRK-Kliniken in Berlin manage problem payments

One of the key principles guiding German hospitals since the introduction of the country’s DRG legislation, which governs the way that hospital reimbursement is calculated, is: "If it's not documented, it can't be invoiced." It’s also far from being the case that payment is received from public or private medical insurance for everything that’s invoiced. Increasing numbers of cases are being received by medical insurance companies, and clarifying them can become increasingly time-consuming for both hospitals and the insurance company. Professional support from modern hospital IT systems can be of significant assistance, as the example of the DRK-Kliniken in Berlin shows.

The DRK-Kliniken consists of three hospitals and a care home, along with supporting central service departments. Since 1997, the ORBIS Hospital Information System (HIS) from GWI (a subsidiary of Agfa) has been used in the organization and optimization of processes in management, invoicing, medicine and care. The software is used at all three sites. In use are functionalities for materials planning and accounts, as well as ward workstations and medical documentation, among others. The DRK-Kliniken also plans to purchase ORBIS modules for pharmacy and lab.

Healthcare delivery in Berlin

In the German capital, things tend to work a little differently than in the rest of Germany, and this applies in particular to healthcare. The overstretched cost situation and competitive pressure between the various institutions is especially noticeable in Berlin. No surprise, then, that the number of Medical Service enquiries from medical insurance companies received by local hospitals is especially high and far above the national German average. One thing is clear: Berlin will not remain an exception for much longer, and this simply indicates a trend which will quickly spread to the rest of the country.

For the DRK-Kliniken, the growing workload over the past few years with respect to payment verification and the resulting rejected invoices has become considerable. An initial IT support tool (Excel) for problem case management was implemented as early as 1996, at the same time as the setup of a professional medical controlling department. However, the ever-increasing number of enquiries necessitated the development of a more powerful, made-to-measure instrument: a clearing tool based on Access. With ongoing efforts to further optimize processes across workgroups, however, it was becoming clear that a technology-based implementation to manage enquiries, integrated into the HIS, was what was really required.

This need, along with an existing relationship with GWI, made the DRK-Kliniken an ideal partner in the development of a specialized workstation for communication with the Health Service departments of medical insurance agencies. The resulting ORBIS MDK monitor software application is now the only product on the market of this nature that has more than successfully passed its baptism of fire in Berlin.

Many problems – one solution

The initial requirements for the development of the software solution were clear: more efficient case management. The authority of the MDK software to check medical documents was expanded considerably with the introduction of the DRG system. Recurring issues are well known to the staff who manage problem case management in hospitals. The reality is that virtually every case can become a potential "problem case", whether arising from general facts in an inpatient admission or if the correctness of the medical documentation, the primary and secondary inappropriate occupation or formal requirements of the invoicing department by the hospitals are later questioned. In other words, the provision of services and the supporting documentation do not necessarily secure the profit.

At DRK-Kliniken, the amount of work for medical controlling alone ran to 1,800 cases checked in 2002 with approximately 10,000 items of correspondence exchanged. This basically shows that out of 50,000 cases, every third treatment case was causing a problem at any given time that year. It just wasn't possible to handle this number of inconsistencies with an in-house clearing tool and a lack of tie-in to important elements of the problem case management system, such as checking payments received, an overview of the status of complaint processes and a simple functionality for re-submission.

After analyzing the communication paths in problem cases, it was determined that a new organization was required, in addition to taking all of these elements into account. As a result, problem case management is now the central point for problem management at DRK-Kliniken. Based on this assumption, the hospital's internal departments (FIBU-PDM-MedCon-FA ) and external departments (legal department, welfare tribunal, insurance companies, MDK) coordinated the correspondence. For the requirements for medical statements, the route via medical controlling and specialist medical departments was selected.

In problem case management, the MDK monitor application fulfils the following functions and more:

Integration of scanned, external paper correspondence
Creation of one process per problem case, via which the entire correspondence history provides information
Specification of standard letters
Creation of reports
Appending of existing documents to the correspondence
Technical support of filing requirements, forwarding with request for position statements and automatic reminders (re-submission function)
Simple filtering by outstanding payments per cost object

The MDK monitor permits various types of analysis, from overall evaluation to individual cases, and the graphical representation of the results for reports and direct editing in the real-time HIS database without complex importing and exporting of data. All communication, including contact persons and handling and payment status, is displayed at a glance.

The digital availability of external correspondence in particular offers considerable advantages for the medical center in its daily tasks. In spite of paragraph 301 of the DRG legislation, a large proportion of the correspondence with the insurance companies is still conveyed via traditional postal services. Documents such as reports and assessments are also received by the hospital in paper form only. The processing of problem cases by the relevant doctors frequently takes place when they are on call, when the postal services and administrative offices are closed, and hence when the paper-based files are not readily available. Electronic communication within the medical center therefore simplifies and speeds up the processing of these cases considerably, and also helps to increase the center's profits.

The satisfaction levels of the departments and staff are correspondingly high, and the objective - professional technical support of problem case management and workflow support in collaboration with the workgroups involved - has now been achieved.

It is not just internal communication which becomes much more efficient; correspondence with hospitals is also made much easier. If the watchword in past years has been "the more, the better" - in other words, complete documentation as far as possible, and equally comprehensive correspondence - in light of the increased number of cases now present, what's now required are short and concise analyses, and with the relevant standard templates these can be created easily. At the same time, the system provides the opportunity for individual case handling and analysis of more complex cases where appropriate.

Satisfaction levels high

Following the implementation of the MDK software tool, it has become clear that the requirements of the DRK-Kliniken have been met in the best possible way. The satisfaction levels of the departments and staff are correspondingly high, and the objective - professional technical support of problem case management and workflow support in collaboration with the workgroups involved - has now been achieved.

The simple implementation process and the use of the solution on existing standard PCs has also proved to be a significant advantage. The amount of work required has been noticeably reduced, for example because internal queries as to the processing status of cases and double information entries no longer arise - a considerable time-saving for all parties involved.