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Tightening up counting and coding

Emma Wilkinson asks three experts about how best to go about validating your data

Emma Wilkinson asks three experts about how best to go about validating your data

It is clear the NHS must tighten its belt over the next few years. Facing a budget cut of a predicted £15bn over five years may seem an incredibly bleak prospect but it is clear there are efficiency savings to be made. Tackling poor data, tightening up coding and challenging acute trusts over discrepancies in work being claimed for could produce savings of 5-10%, maybe even 20% in some areas. Here, three leading professionals explain how they are using data validation tools – with varying degrees of success…

Dr Gurkirit Kalkat - Barking & Dagenham Quality Care Health Consortium of 24 practices

What we did

In the first year of PBC we were told we should be validating data. We started trying to do so with some basic information but found it very difficult to look through reams and reams of data that we were sent from the PCT. That led us to look for another, easier way to check the information that was coming from the acute trust.

How we did it

Eventually we decided to work with a firm called JSL Consulting, who looked at our situation and advised us on possible coding pitfalls.

After discussions on how we could do monthly crosschecks on the coding we were getting from the acute trust, JSL developed software to make the crosschecks easier.

Every month we select a different set of codes and we ask practices to drill down into information and verify that it is correct. Then we send our queries back to the PCT who will challenge the acute trust.

We paid an overall consultancy fee but similar software would cost £5-10,000.

What we uncovered

Several problems were thrown up. One was incorrect patients – a patient who is not yours – and another thing was where patients are admitted for particular diseases but are incorrectly coded for surgical procedures.

I had a patient who had surgery for abdominal aortic aneurysm, which costs £4-5,000. The patient went into hospital but they couldn't operate. He was called back the next week but the same thing happened. He finally had the procedure but when we looked at the codes we had been charged three times for the same operation – these are the sorts of things we pick up.

We have focused on areas such as excessive length of stay and we initially focused on COPD because we found there were a lot of admissions in that area.

What happened next

We've been doing this for two years now and in the first year we made challenges of £250,000 and we got back £120,000.

It has been useful – the only problem we have had is when you challenge the acute trust they are a little bit behind, so for them to agree with our queries can take a while.

We are still doing the monthly validation. The acute trust had not been through this before. Now that we're asking questions, they are taking steps to try and improve the quality of the coding in the first place.

Top tips

If anyone is looking at validation, the first thing is GPs and practice managers need training to understand HRG codes.

You need to start looking at the easy wins – patients who are not yours, patients with costs exceeding £4,000, excessive lengths of stay and short-stay admissions in A&E. Once you have done that, you can go onto looking at specific disease areas.

You might then find there is a particular disease area where problems stand out – for example, we had a lot of COPD admissions so we decided to look at respiratory admissions as a whole.

How successful you will be at realising the savings you have found is down to the relationship the PCT has with the acute trust. If the PCT is more forceful you will see more results.

Dr Ian Goodman - Hillingdon PBC cluster of 49 practices

What we did

I was quite surprised to find that most, if not all, PCTs were paying trusts without really checking what they were paying for. You or I wouldn't dream of running our household budgets in the way the PCTs run theirs. So we got a piece of software from IQ called Budget Manager, which is basically an accounting programme and checks what is being billed for is what is being done and persuaded our PCT that it was worth using. We paid for the software licence through the PBC budget. We've been using it for almost two years.

How we did it

When a patient gets referred a parallel database is set up. So the practice enters onto the software that patient X has been sent to the skin clinic. Then, when the patient has been seen at the hospital and the clinic sends a letter to the practice, this is also entered into the IQ Budget Manager. The software suggests an HRG code to use.

At the end of the quarter the providers all send their invoices to the PCT based on their SUS data, which is in turn forwarded on to the practices. They look at their referral 'ledger' and can see which discrepancies have occurred – for example, whether the patient is actually one of theirs and the correct codes have been used.

What we uncovered

The main problem we have found is that a huge number of discharge letters just don't arrive at the GP surgery – up to 40% that are being billed for. That means practices don't have the information on what's being treated. We have a service level agreement on discharge letters but it's just not being followed.

Second we found we were being billed for patients who weren't ours – and in some cases weren't even the PCT's.

Then there are the discrepancies between what's being billed for – what the hospital says it has done, and what's actually being done. The discrepancy can be about 5-10%, which can run into hundreds of thousands of pounds – possibly even millions.

On unscheduled admissions I think at least 5% of the budget could be challenged successfully. Every quarter we are coming up with a discrepancy of more than £1m and most of this is failed notification of discharges.

What happened next

The PCT has only put in challenges for several thousand pounds so far but that is still ongoing.

There is a big issue that when we find these discrepancies, the PCT needs to take that data to hospitals and challenge them, but that's not being done.

It is a disappointment to me that they're not doing this. It's not about money, it's about patient care. For example, I had a patient in this morning who said his wife was having chemotherapy so I looked in her notes and there's nothing in there about a cancer diagnosis. This software provides the evidence that such things are happening.

I do think the PCT is too quick to pay these bills without checking them rigorously.

From the hospital's point of view, the better they code, the more income they get back – so they are starting to think more about the way they code.

Top tips

For those looking to do a similar exercise, an easy win would be with outpatient letters and hospital discharge letters.

PCTs are not getting enough support from the SHA – ours seem to not want to have trusts being confrontational with each other, so I think SHA support is important.

There are very many areas where the PCT could challenge hospitals but they themselves go for the quick wins so that's worth focusing on initially.

Christine O'Connor - Chief executive of Catch On Group

What we did

We have been working with PBC groups for about three or four years with some work on data validation. The area where we did most work on this was Warrington, although North Lincolnshire has also done some work using our approach. The PCT generally pays for the service.

How we did it

We use SUS data as a foundation and we download that for a given period of time – which tends to be quarterly – and we agree areas that need to be looked at, say admissions for less than a day's stay. We have a set of questions and we analyse the answers and we can say whether it was the right patient, whether there was a discharge procedure and so on. That goes to the PCT – it's up to them to challenge the acute trust and you have to give the acute trust a chance to rectify it. It took 18 months for us to get Warrington to challenge but when they did it was successful.

What we uncovered

In Warrington we found things such as patients allocated to the wrong doctor, or issues with short stays in hospital.

Over a number of quarters we probably identified in the region of £2m excess.

What happened next

The fifth time the PCT was presented with quarterly data for hundreds of thousands of pounds, it challenged the acute trust and got about £120,000 back. If you multiply that by another four quarters, you're talking about a lot of money.

We have worked on similar projects with other PCTs but there are issues about realising those savings and that's ongoing. Still, for the acute trusts it does focus them on improving their coding skills.

The problem we have in general is that PCTs struggle to manage their providers. Acute trusts are business-savvy and PCTs are not – you have very high-level strategic thinkers dealing with a low level of management. The PCTs are out of their depth and it is the system that is at fault.

Top tips

I would recommend carrying out data validation as it opens your eyes to what's going on in the system. Data validation is not rocket science and it's easy to find savings. If you've never done it before, the easy areas to look at relate to A&E looking at things such as pregnant mothers who go with pains, are admitted for 20 minutes for a scan and then they go home.

Don't do too much at once. And you need to agree with your PCT beforehand that if you find discrepancies, the PCT will do something with that information.

Is data validation worth it? Is data validation worth it?

NAPC chair Dr Johnny Marshall genuinely believes that data validation is a valuable exercise.
‘We shouldn't be paying for things that aren't being done,' he says.But he warns that if done properly it can be like ‘opening Pandora's box' as, when challenged on one thing, the acute trust can then use more sophisticated coding to generate income in another area.There is also the massive problem of PCTs being unwilling to challenge.‘Data validation can make a big difference in terms of redesign. Even if the PCT doesn't challenge, you will end up with better data. But if you want freed-up resources you will have to have a PCT that challenges.‘It is a big issue and I wonder if SHAs need to get on top of this and ensure information is correct in the first place.'

PBC Masterclass

PBC Masterclass: Regional events

What: These regional PBC events are designed to equip you with the sophisticated skills needed to overcome barriers and push on towards PBC success.

When: 10 individual events running from October 2009 to January 2010

Where: 10 different regions throughout England. Each event has been tailored to address the learning priorities highlighted by practice-based commissioners in that area.

Next steps: Find out more and book

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