2 Hospital Cost Accounting Flow Overview Overhead Centers: Expenses & Offsetting Revenues Service Items Patient Encounters Patient Care Departments: Direct and Indirect Expenses Service lines Physicians Payors Overhead allocation statistics Service Item standards & volume Department- level costing Patient Care Departments without HPM Service Items stop here To accomplish this, a number of HPM application programs are used.
3 Glossary of Terms Department = Cost Center Service Item=charge item or CDM item, something you billed a patient for SIM=Service Item Master = CDM (Charge Description Master) Patient Care Departments: provide patient services (AKA Direct Departments) –Three Types of Patient Care Departments Billed and in HPM: Billing data is in HPM Billed and NOT in HPM: Patients are billed by a system not feeding HPM (e.g. home health) Unbilled: Patient are not billed for services (e.g. outreach programs) Overhead Departments: support other departments, do not provide services directly to patients (AKA Indirect Departments) Studied Service Items: Have a standard Unstudied Service Items: Do not have a standard Partially Studied Service Items: Some components for a service item have a standard and others do not Miscellaneous service item: a service item for which the price is assigned at the time the charge is assigned to the patient (AKA variable charge item, catch-all charge item)
4 Contents: HPM Costing Applications List 1.Integrate data - import statistics for overhead allocation 2.Data set manager - deleting data to recost the datasets 3.Worksheet - to gather and audit data 4.Enter components, allocation relationship 5.GL account to component mappings – chart of accounts editor 6.GL Remap - transform GL data 7.Edit GL Allocation structure – add new department 8.Create Components – make cost components from GL data 9.Run GL Allocation - allocate overhead 10.Service Item Remap - move service items to new department 11.Create Service Item Volume and Price - activity basis for costing 12.Revise Service Item Standards 13.Service Item Allocation Mapping – which standard to use 14.Service Item Allocation – calculate cost per service item 15.Summarized Component Mapping – rollup cost for encounter reporting 16.Encounter Costing – apply service item cost to patients 17.Implant costs in data extension 18.Worksheets for Analysis of cost and margins
5 Data preparation applications: 1, 2, 3 1.Integrate data - import statistics for overhead allocation 2.Data set manager - deleting data before costing 3.Worksheet - to gather and audit data This guide will give cursory treatment to these applications, as they are core HPM applications you are already familiar with.
6 1. Integrate data Purposes: Integrate GL data –Use your usual approach Integrate statistics –Square footage:__________________ –Equipment Depreciation: CAstatEQDEPR.txt derived from Excel sheet supplied by fixed asset system Integrate cost standards –For importing supply costs and other standards from outside HPM – more on this later Integrate Implant Extension data –More on this later
7 A Word on Preparing Depreciation Statistics See “Deprec by Dept Roger.xls” Tabs from right to left transform the data – read notes on each tab
8 2. Data Set Manager Used to copy datasets and clear datasets as called for in the costing checklist Caution: At no point do we delete an entire dataset. Doing so will remove all references to the dataset in Worksheets, which you would then need to add. Caution: Deleting the service item components will also delete the service item standards. Be sure your standards are backed up periodically in a copy of the dataset, or using the Worksheet “Extract Standards”. This option should not be needed, since starting over with an empty dataset, all service item data is deleted anyway.
9 3. Worksheet Numerous worksheets exist in the Costing library, 2008 folder for various purposes throughout the process: –Worksheet for figuring out benefits percentage –Worksheets for determining implants adjustment –Worksheets for auditing –Worksheets for using the costing data in margin and cost analysis What we need before we do anything else: Worksheets for determining new departments and accounts and new service items
10 3. Worksheets for New Departments and New Accounts “0000 New Depts”: Generate, open and sort the worksheet to identify the new departments. Make a list of the new departments Follow the “New Department Flowchart” (next slide) “0000 New Accts”: Open and sort the report to identify the new accounts from last time. Make a list of the new accounts Follow the “New Account Flowchart” (slide after next)
11 New department flow Patient Service? 1) Make it a direct department. 2) Give it OH allocation statistics and overrides (see OH Allocation editor) 3) Create SI volume, prices 4) Create service Item standards 5) Add to remap “2009 Cost remap 01 Labor Fix/Var” Chgs in Pat Acct? 1)Make it a direct dept if you want it to get overhead. It will have no SI volume, and so “dead-ends” 2) Give it OH allocation statistics and overrides 3) Add to remap “2009 Cost remap 01 Labor Fix/Var” Patient Service means that patient services are provided. Usually this means we bill patients for the services, though sometimes the billing data is not in HPM or the services are not billed for. In this case the department “dead-ends”. Overhead departments support Patient Service Departments. Overhead? yes No no yes reevaluate 1)Allocation Area Editor: Add to existing overhead area, or Create new overhead area 2)Add OH allocation statistics/overrides 3)Edit remap “2009 Cost Remap 03 Components” to add to overhead component New Dept
12 New account flow Labor or Benefit? 1) Add to remap “2009 Cost remap 01 Labor Fix/Var” 2) Edit Worksheet "Benefits as % Salaries" 3) Edit remap “2009 Cost Remap 02 Benefits 1) Edit remap “2009 Cost Remap 03 Components” add it to an existing GL component Non-Labor? yes no yes reevaluate 1)Add to “2009 Cost Remap 04 Revenue” New Account Revenue? no yes Part of Offset? no ignore yes
13 Locating the “Set Up Costing Process” Menu
14 Relating the costing setup menu to applications list , “Service Item Remap” is not on this menu because not all hospitals will use it.
15 4: Component Editor a) Enter components (do not use) b) Relate direct, indirect and credit c) Select standard to use d) Exceptions to standard to use e) Enter summarized components f) Map to summarized components (will be covered in point 15) Right-click on the table name Not about our costing process: Flexed Budget Mapping: CCA Charge Weight Mapping Note: You should not alter this data without consulting Roger
16 4a: Enter components This screen is where components are set up. Once they are set up, no changes should be needed. Changing this information should be considered and planned very carefully so as to not nullify prior costing work. Note: You should not alter this data without consulting Roger
17 4b: Relate direct, indirect, credit This screen is where a relationship is made so that each direct component has a matching indirect and credit component. Again, once this information is set, it should not be changed without careful consideration and planning. Note: You should not alter this data without consulting Roger
18 4c: Select standard for components This screen is where each component is assigned to use a standard for allocation to the service item. Again, once this information is set, it should not be changed without careful consideration and planning. Note: You should not alter this data without consulting Roger
19 A word about studied/unstudied/partially studied Studied means that a service item standard is aSampleable Unstudied means no standard is aSampleable. Price or even allocation are your choices Partially studied: some procedures have standards, others do not Partially studied: If a service item appears with no standard, the system will use the price of the item to determine a standard: –Standards of studied/ charges of studied x price of unstudied = unstudied standard We are making everything studied to avoid using this.
20 4e: Enter summarized components This screen is where summarized component names are entered. There is room for 40 total, with 5 reserved as system standard. We are using 36. Again, once this information is set, it should not be changed without careful consideration and planning. These will be used later in 15, “Summarized Component Mappings” Note: You should not alter this data without consulting Roger
21 5. Account to Component Mappings Option in the Chart of Accounts Editor These are already set up for you and should not need to change unless you add or change a cost component Any new GL accounts are mapped to an existing GL component using GL remap: –“2009 Cost Remap 03 Components” If you feel a need to make changes here, please consult Roger first. The following slides show how these mappings were made.
22 Choosing “Define Account to Component Mappings” brings up Chart of Accounts Editor
23 Select the account to map and move it to the selected accounts list.
24 On the Option menu, choose “Component Mapping”
25 The screen switches to component assignment mode. Choosing the List button lets you see all aSampleable components to map to. No changes should be needed to these mappings – the real mappings work is being done in remap “2009 Cost Remap 03 Components”
26 A word on why the real component mapping work is done in GL remap Changing account to component mappings in the Chart of Accounts is slow because every database uses the same chart of accounts If you try to print the account to component mappings in the chart, you can only access 250 accounts at one time, and the format of the output is not user friendly The user dialog for adding or changing mappings in the chart editor is not user friendly. Note: The “Missing Account to Component Mappings” audit report on HPM is of no use with this approach – use Worksheet “0003 New Remaps Comparison” to identify any missing mappings Note: we still use GL Account to Component Mappings – but it is just a formality, a one-to-one from GL components to cost components (e.g. account DVL goes to component DVL)
27 6. GL Remap About Remaps: Moves and transforms data Similar to double entry accounting: one entry to move or credit a value, another to offset or debit the original value When you assign, GL Remap “remembers” the settings for the next time. You should not change the Assign settings, as they will produce wrong results if you do. The assign settings for each remap are in the Excel process checklist.
28 6: Remap Example – First Remap Each row is a rule. Input accounts are converted to the output account. The first rule first moves all data from the input dataset into the output set. Assign lets you choose an input and output dataset.
29 6: Remap Notes Remember to look at and use the notes feature to document changes. Click on this icon to access notes.
30 6: Remap Assign The input and output datasets are always different in this process. Processing options for each are listed in the Excel checklist. You should not change these options – they will be retained for future assign jobs.
31 Remaps in the Sample Process CA Remap 00 moves all exc b/d CA Remap 01 fixed variable labor CA Remap 02 allocate benefits CA Remap 03 make gl components CA Remap 04 Revenue CA Remap 05 Statistics CA Remap 06 Dept Moves See “Sample Cost Development Checklist.xls” for full instructions on the options used when running each one.
32 7: Edit Allocation Structure You will use this if you are adding a new department or refining your overhead allocation structure or statistics.
33 Allocation Structure and Statistics
34 Existing structure can be changed, reordered. MUST HIT ACCEPT AFTER CHANGES! Then save.
35 1st option: Automated stats have some limited use, mainly Total Expense. (We are not populating the others options shown.)
36 Data selection of statistics for an overhead area. 2nd option: use data selection to reference statistics you have built into the dataset. See next slide for format of stats input file.
37 Allocation Structure and Statistics 3 rd Option: Overrides gives you a convenient way to put a statistic in for each department in one place. Can be used with automated or selection.
38 Recap on Statistics: Automated mainly for total expense Selection for statistics that you have put in the dataset Override by itself, with zeros for all departments except the ones you want to give a number Override with ZEROSTAT let’s you plug in only numbers you want Override with other selected stats lets you exclude some departments by entering zero in the override
39 Sample Statistics Input File This is the standard GL periodic data format for integration. GLREAL~department code~filler~account code~filler~data type~entity~filler~filler~filler~pd1 value~pd2 value and so on
40 8: Create Component Data Choose dataset Choose time period Reverse signs makes positive revenue into negative expense Limit processing to 100% makes sure that overlapping rules do not duplicate cost Should require 2 to 3 minutes. You can detach or stay attached. This step must be done after the allocation structure is complete, with all departments accounted for, or it will fail.
41 Create Component Audit Logs Note the location and name, open file with WordPad
42 9: GL Allocation Choose dataset Choose timeframe Run it for all components Store statistics Store credit values Use single stepdown Takes a minimum of 16 minutes, so detach. When you look at job record later in job viewer, right click on job to see log files. For more detail see “Sample HPM Cost Allocation.ppt”
43 A Word On GL Allocation Options Single vs Simultaneous: Single is the standard Medicare cost report method. Simultaneous is required by the Canadian government for its hospitals. It passes more overhead between overhead areas before passing it to patient care areas. Store credit and statistic values so that audit worksheets can be used later to illustrate how the allocation worked. If you are costing part of the year, you MUST control the time frame in running GL Allocation and in audit worksheets or you will not get the intended results.
44 GL Allocation Audit Log File 1 Note the location and name, open file with WordPad. First file is smaller, contains useful summary data.
45 GL Allocation Audit Log File 2 Note the location and name, open file with WordPad. Second file is larger, contains detail about allocation – at the end, it indicates if it failed and clues as to why.
46 GL Allocation Audit Worksheets Several examples are on the slides that follow.
47 Audit Worksheet “0005 GL Allocation Results” shows direct, allocated and credit values, proof of balancing
48 Audit Worksheet “0006 Audit Ovh Ratios Patient Care Areas” shows overhead burden by patient care area.
49 Audit Worksheet “0008 Allocation By Source Area” illustrates the step down from each overhead area to each area
50 10: Service Item Remap Nursery has charges, but no GL cost (it’s all booked in Labor and Delivery) Must move Nursery charges to Labor and Delivery to match with cost. After every encounter data update, must run the SI Remap to move the Nursery charges to Labor and Delivery for each database updated. After this is done, for costing must create SI volume and price from the encounter datasets. The next four slides show how SI Remap works.
51 Finding Service Item Remap on the “Editors” Menu
52 Open the SI Remap called “Remap Nursery to Labor and Delivery”
53 Use the File/Apply option to apply the SI Remap to your datasets.
54 Choose the datasets you have updated and select “Encounter Data.” Run detached as processing takes a minimum of 10 minutes per dataset. Do this after each update.
55 11: Create Service Item Volume and Price Price and volume, along with standards, are used to develop cost per service item We load our price and volume from the patient datasets.
56 11: Create Service Item Volume and Price Develop from encounter datasets Choose 2 datasets to pick up all activity posted in a time period. Use average price calculation Insert/Update records Use date of service and choose time frame to match the GL data Convert all patient types to “Other” Mark new as “studied”.
57 A Word about “Create Service Item Volume and Price” Options Why two encounter datasets? –Charge activity for FY2008 can be found in the 2007 encounter data; patients admitted in 2007 but staying in hospital into 2008 have charges in Patient Types in Costing: –HPM ws designed to allow different standards for the same service item, depending on the patient type it was provided for –The additional level of detail is usually more than a hospital starting is cost accounting is prepared to use –Therefore, we default all patient types in costing to “Other” so that single patient type is used for all patients. Price Calculation: –Choice is average YTD or periodic. Periodic calculates each month individually. YTD works better because it smoothes out spikes in volume and price increases All versus Accumulated Units: –In nursing units that distinguish accumulated units versus other units, would allow you to use only the accumulated unit service item volume (usually patient days and observation hours). We use all units in the department which also picks up many chargeable supplies
Revising Standards Several options: a) Built in tool for revising standards: okay for cost acountant, but not for managers b) Worksheet: good for managers and cost accountant, but must pre-integrate values so fields can be editted c) Integrate using standard file layout: for cost accountant only, useful for: Move standards from one dataset to another Pre-integrate default values for use in model Worksheet Integrate standards developed elsewhere Bottom Line: Likely to be a combination of all these methods
59 12a. Using the Service Item Standards Editor Choose dept and patient type “Other” to see standards
60 12b. Using Worksheet to Revise Standards Copy existing standards dataset Create new volume and price from new time period Run a worksheet to find new service items Run MS/Access tool to create new service item standards for new service items Standards should be set to.001 to indicate the new service items (see next slide on importing standards) Generate model worksheet for entry by managers Use distribution list to distribute to managers Following slides illustrate distribution and consolidation
61 Select the worksheet you want to distribute
62 Then choose the menu option Applications/Teamware/Distribute
63 Next choose the distribution list you want to use.
64 From the menu choose Options. You may then choose to distribute, consolidate or use the distribution list editor. Here we choose Consolidate…
65 …The distribution list is displayed, where you can see the status of when users sent their results back (“submitted”). You may view the worksheet and either hit “consolidate” or “refuse”. Consolidate puts the results back into the master worksheet. Refuse sends the worksheet back to the manager for further work.
66 As you consolidate worksheets the “Date Consolidated” column fills in.
67 Once the worksheet is sufficiently consolidated, you may commit its contents back to the original dataset with the menu option Data/Commit.
68 12c. Integrate Standards From Other Sources Uses: –Pre-load standards for entry (you cannot edit null/empty values using worksheet – must load a value first) –Load standards developed elsewhere –Load chargeable supply or pharmacy supply cost by service item –Moving all standards from one dataset to another Method: –Text file in correct format or Export from HPM Worksheet (see below) –Import to Access Tool: “Yardley HPM Standards Formatter” –Export text file –Integrate file to desired dataset
69 To extract standards from a dataset Build, open and export this worksheet to a tab delimited text file.
70 “Yardley HPM Standards Formatter” Built using Microsoft Access database Import this file or any other in the same file format to table “Importfile” The queries in the database will format the data for integration to HPM Important: Any values (zero or greater) supplied in this file will overwrite values already in the target dataset. Null values in this file will not replace the values in the target dataset. The most recent integration file was called “CAsistds txt”, found in the source directory
71 You will clear and then load the Importfile table with your data, then go to the queries tab..
72 Run the last query and your data will be formatted. Export this data to a file on the HPM Source directory, then integrate it (see next slide).
73 Data integrator process for standards Choose process definition “CA RVU Import and make sure the target dataset is correct. Check the audit to ensure success.
Service Item Allocation Mapping Lets you choose the standard that will be used for each component It is possible to make exceptions by department which are called overrides We illustrate how in the following slides
75 Service Item Allocation Mapping lets you pick which standard is use to allocate each component,
76 In this case, DVL is being allocated with the standard we have loaded for DVL. Other labor components will also use DVL.
77 In this example, it looks like the default way of allocating DVS is using price of each service item, but DVS also has an override…
78 By choosing Options and “Service Item Allocation Overrides” you come to the overrides screen…
79 …and here, for DVS we can see that the DVS standard is specified for use in specific department. All others would then use price. This is the only override we are using for now.
Service Item Allocation Use these options each time you run SI allocation
81 A Word on SI Allocation Options We store YTD and periodic values, though our main purpose is YTD values (we may want to try our periodic values at some point for some reason, and it costs nothing extra to include it here). You MUST remember to use the date cut off for the last month in your GL dataset. The report may be helpful in identifying a problem in the process – we don’t generally look at the report unless there is a problem This job only takes a few minutes to run
82 15: Map to summarized components Summarized components are used in encounter reporting. We are using 37 of 40 aSampleable groupings. Note: You can change this data after careful consideration
83 Worksheet to audit summarized component mappings These mappings should rarely change If you change these mappings, encounter cost worksheets will be affected and will need to be rerun You should run this audit worksheet to cross-foot every component and grouping See next slide
84 “0047 Encounter Component Costs” Examine this worksheet to be sure the components are falling into the summary groups you intended.
Encounter Costing Choose your encounter and unit cost datasets Usually you are costing the whole dataset, so no encounter selection needed. Unit cost source is YTD Open Period Cost Source is YTD allocated values Last closed period is last GL period that was costed MUST detach as it will take 25 minutes at the least and tie up the datasets Note: the option “Include out of date encounters only” should be set and saved before subsequent encounter updates (see next page)
86 More on Encounter Costing The option “Include out of date encounters only” should be set (checked off) and parameters saved before subsequent encounter updates (see next page) This will cause each encounter that is added or changed to be costed during the integration process. Options “Actual Payment as Cost” and “Add Supply Cost” depend on having this data in the encounter record. This does not occur in our data, so the options are unused. Open period cost source: If GL and costing are complete through September, and the encounter data has patients through October, October is an open period. To cost these cases we use YTD allocated values.
Implant Costs in Data Extension Background: Miscellaneous service item ( ) was used for approximately 2.6 million of over 6 million in implant costs in 2008, with a range per item of 0 to $14,000 Using this data as is, HPM would develop an average cost and apply it to all patients, grossly overstating and understating individual patients.
88 There are several approaches to handling this: 1)Custom interface program from McKesson to break out ranges of charge values –Makes new charge codes to replace old code –Would have to reload history for these patients –Have to process with each subsequent update 2)Change charge capture in STAR to include better detail –Will not correct prior history –Strongly recommend for going forward 3)Include invoice cost or a reasonable approximation for each patient –Most control for Sample using a data extension –Easy and aSampleable –You MUST include this field when reporting encounter cost –Must remove this cost from implant to be allocated using a remap –This is the approach we have adopted for now 17. Implant Costs in Data Extension - continued
89 Using an Encounter Data Extension Setting up the extension To Stage or Not to Stage Integrating staged data Merging staged data Using the data in Worksheet
90 Setting Up The Extension Data Integration/Data Model Extensibility Choose staged or not staged (see next slide for more) Choose field names and data types System returns the format that the file for integration must have MUST got to security next and enable modify access for your account and view access for other accounts for the extension
91 Setting up the data extension (1) Your extension is already set up, you do not need to make a new one or modify the existing. This just shows how it was done.
92 Extensions are set up in the data model where appropriate, this one is in the encounter section. Setting up the data extension (2)
93 Setting up the data extension (3) When you make an extension template you get to choose if a staging area will be used. If it is, a box pops up to ask how it will link to the patient record. See more on staging on the next slide.
94 To Stage or Not To Stage Two approaches to loading an extension: 1)You have the encounter key aSampleable and can put it on each record The encounter key is complex, consisting of multiple elements, including patient name Using this method, you can integrate directly to the extension 2)You have the patient billing number on each record, but not the whole encounter key You first integrate to the staging area Then you merge the staged data with the dataset We used #2 because it is easier to obtain the patient billing number in the data you want to load.
95 Options here allow you to create a new extension, and once created, to “build” it, essentially publishing it in the data model. Setting up the data extension (4)
96 One of the options on the prior screen is “Layout Report” which tells you exactly how to format the file for the data. Setting up the data extension (5)
97 Actual file for integration This file uses “Layout Report” specifications from prior screen. The file for 2008 is complete, unless we make a better version with invoice cost. For 2009, we should rebuild this file year-to-date with each update. You must be vigilant to make sure this data is complete as patients are added to the dataset. The next slides depict how the values were arrived at in this file.
98 Preparing the miscellaneous implant patient file (1) Use implant.xls to determine the cost for each patient using the markup of charges tab.
99 Preparing the miscellaneous implant patient file (2) The tab “Simple HPM Load” creates the file format needed in column e.
100 Recap on the implant extension: For 2008, the data has been loaded based on the markup and patient charges –Need to monitor to make sure future updates to 2008 do not change the million –Could make it more accurate by replacing the values with invoice costs For 2009, if the charge mechanism is now splitting out several ranges of miscellaneous code, we could use those –Need to see when it began and how much it covers –Should probably continue to populate the extension with invoice for the most accurate implant cost
101 Add access in security You must give yourself and others access to the extension before you do anything else. You will not be able to integrate until you do.
102 When you open the process, you can see the target is the staging area for the extension we built. Setting up the integration process
103 Merge Staging Area Data If you picked “Integrate to the staging area” as an option, you have one more step after integration of the data You need to merge the data with one or more datasets. This makes the association to each patient record using the linking field you specified. Following slides depict how this is done
104 Merging Staged Area Data: Choose on menu
105 Merging Staged Data: Choose staging area and dataset(s). Okay button will detach automatically.
106 Merging Staged Data: From job menu, right click on job to read logs files
107 Merging Staged Data: From job menu, right click on job to read logs files
108 Merging Staged Data: Locating the data extension in Worksheet Editor
109 Merging Staged Data: Seeing the results in Worksheet
110 Merging Staged Data: Seeing the results in Worksheet – drill to encounter
111 Other Notes on Using The Extended Implant Data If reporting with department drill level, qualify column for the implant extension so that it is limited to the surgery department (6211) so that it does not pop up in others. DO NOT FORGET to build this element into all P&Ls and cost analyses, otherwise you are understating the cost.
112 Using the Data: Worksheets for Cost and Margin Analysis 0050 Encounter Component Costs by Dept 0332 Service Line Margins Template Specialty DVI REMEMBER: To get full cost in a worksheet, you MUST include the extended data to pick up the full cost of implants. The extended data is NOT in any of the summarized cost components!
Encounter Component Costs by Dept
Service Line Margins Template Specialty DVI
115 Reconciliation Worksheet More on reconciliation on next slide
116 Reconciliation Worksheet Notes During and after each update, this Excel sheet should be completed It gives a summary for users of the cost information of what is in the cost data It serves as a proof that the cost information relates to the financial statements
117 Questions or Corrections? Roger would like to maintain a current copy of this file with you. If you need changes made, or have made changes, please let him know. Office: Fax: