Revenue Cycle Strategist

Transcription

1 Insights and actions for successful results April 2010 Revenue Cycle Strategist Benchmark Reporting: Transforming Data into Results By Brent Grimes Using benchmark data to develop a systemwide revenue cycle scorecard has helped INTEGRIS Health decrease net days in A/R from 78 days to 42 days. INSIDE THIS ISSUE Strategies to Improve Self-Pay Collections 4 Using the Audit Process as a Revenue Generator 5 Many healthcare providers find benchmarking to be a difficult, though rewarding, task. The amount of data and standards needed to gauge revenue cycle performance is overwhelming. The leaders of INTEGRIS Health undertook the daunting task of systemwide benchmarking in Based in Oklahoma City, Okla., and consisting of 14 hospitals across the state, INTEGRIS is the largest not-for-profit health system in Oklahoma. The task yielded improvements in benchmarking and reporting that helped the system develop streamlined, consistent reporting for revenue cycle information throughout the system. The scorecards have helped INTEGRIS Sponsored by increase net revenue percent over the past six years. The scorecard has become a living document for INTEGRIS Health. As healthcare changes, the scorecard must be flexible with the ability to adapt to the ever-changing request environment. Issues Discovered After conducting a review of all of the current reports and matrix used by the system s various facilities, it was discovered the facilities were inconsistent in how they formulated data and reported the data back to management. Reporting was further complicated by the use of various information systems throughout the system. Using Software to Spot Underpayments 6 How Much of Your Receivables Do You Control? Medicare Cost Report Results Median Values 8 WEB EXTRA! 3 Common Pitfalls in Acquiring Physician Practices at COMING IN MAY Learn how to optimize the elusive last 10 percent of your revenue cycle in the next issue of Revenue Cycle Strategist! NEW HFMA RESOURCE Strategies for Effective Self-Pay Management, billing/ htm

2 The scorecard has become a living document for INTEGRIS Health. A decision was made to form one scorecard that each facility would report on. This scorecard would become the master document used to grade the health of the revenue cycle at each facility. Challenges Faced One of the first challenges faced was deciding what data and benchmarks were to be represented to reflect the health of the revenue integrity. The revenue integrity concept was created by the System Vice President Greg Meyers. Revenue integrity is a comprehensive process that allows INTEGRIS Health to improve patient satisfaction and physician relations, while ensuring compliance and the maximization of revenue capture at every step in order to guarantee optimum and timely reimbursement for the services we provide. Robert Fromberg Editor-in-Chief Carole Bolster Senior Editor Amy D. Larsen Production Revenue Cycle Strategist is published 10 times a year (plus an 11th issue in 2009) by the Healthcare Financial Management Association, Two Westbrook Corporate Center, Suite 700, Westchester, IL Presorted standard postage paid in Chicago, IL Healthcare Financial Management Association. Volume 7, Number 3 Subscriptions are $110 for HFMA members and $165 for other individuals and organizations. Subscribe online at or call HFMA, ext 2. To order reprints, call HFMA, ext To submit an article, contact Carole Bolster at cbolster@hfma.org. Revenue Cycle Strategist is indexed with Hospital and Health Administration Index and the HealthSTAR database. Material published in Revenue Cycle Strategist is provided solely for the information and education of its readers. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions in Revenue Cycle Strategist articles and columns are those of the authors and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear in such articles or columns do not constitute endorsements by HFMA. ISSN Revenue integrity touches every aspect of the hospital, from the time a patient is referred to service until the patient s financial responsibility is satisfied. As a result, each patient encounter leads to considerable data to consider. Another challenge faced was ensuring we had apples-to-apples comparison of data. An example of this was looking at cost-to-collect ratios. One facility may have a hospital-based business office, while another rented space off site for its business office. Others had on-site IT staff who worked for revenue integrity, and others had none. The size of the facility also affected the data set. A large facility may have data elements that it finds vital, but those same data elements may not apply to a critical access facility. The amount of time needed to work on the collection of data was another factor to consider. All of the directors responsible for the collection of data are working managers. They were not able to spend an enormous amount of time collecting data. The data selected for the scorecard had to be easily accessible to pull through canned reports and simple data collection. Targets were based on several variables. Information was pulled from HARA, HFMA, and other facilities. After these data were collected, benchmarks were set based on the availability of data and the results that were expected. As all healthcare leaders know, implementing reporting changes is challenging and hard for some to understand. Staff education as to why the changes are being made and the benefits of the changes can go a long way to having a compliant team. Developing the Scorecard Six major areas of revenue integrity were identified as being critical to the success of INTEGRIS Health: revenue outcomes, registration and preservice coordination, health information services, case management, contracting and revenue recovery, and patient account services. Revenue outcomes. Revenue outcomes consists of eight overall data sets used to measure the facilities month. Areas reported on are cash collections as a percentage of net revenue, cash collections, net revenue, gross revenue, net revenue as a percentage of gross revenue, gross accounts receivable (A/R), net A/R, and net days in A/R. These eight items represent the sum of the entire different department overall efforts in revenue integrity. Registration and preservice coordination. Registration and preservice coordination reports on three main goals: registration accuracy, point-of-service cash collected, and point-of-service cash collected as a percentage of net revenue. These areas were selected as having the most impact to the registration piece of revenue integrity and items all facilities could report on. Health information services. Health information services decided on one main data set to report on: discharged not final billed. The team is currently reviewing addition items as the Recovery Audit Contractors reviews begin, with possible negative impact on an organization. Case management. Case management is a team of nurses who work with our physicians, patients, and insurance companies. This team reports on two goals: indexed length of stay and percentage of Medicare reviews conducted each month. Case management had remained one of our most hidden and 2 April 2010 Revenue Cycle Strategist

3 under-recognized areas of the revenue cycle. By educating revenue cycle staff and bringing this group into the revenue integrity team, we have achieved significant savings for our organization and better outcomes to our patients with better understanding of both financial and clinical outcomes. Contracting and revenue recovery. Contracting and revenue recovery has eight goals: denial appeals overturn rate, Continued on page 4 Revenue Integrity Scorecard Area Target Jan-10 Feb-10 Revenue Outcomes Cash Collections as % of Net Revenue ( 60 day prior) 100% 0.00% 0.00% Cash Collections - $0 $0 Net Revenue - $0 $0 Gross Revenue $0 $0 Net Revenue as % of Gross Revenue 0.00% 0.00% Gross Accounts Receivables (A/R) - $0 $0 Net A/R - $0 $0 Net Days in A/R ( Exhaustion Method) (Hospital) < Registration and Preservice Coordination Registration accuracy > 98% 0.00% 0.00% POS Cash Collected as $ of Cash Goal $0 $0 POS Cash Collected as % of Net Revenue 1.50% 0.00% 0.00% Health Information Services Discharged Not Final Billed ( DNFB - days of avg daily gross pt rev) < Number of Queries 0 0 Number of Query Responses 0 0 Financial Impact of Queries $0 $0 Percentage of Query Responses 80% 0.00% 0.00% Case Management Indexed Length of Stay < Medicare Reviews 100% 0.00% 0.00% Contracting and Revenue Recovery Denial Appeals Overturn % Rate 0.00% 0.00% Total Recovery $0 $0 Total Recovery vs. % of Total Identified 0.00% 0.00% Denial as % of Total Net A/R < 1.5% 0.00% 0.00% Denials $ Recovered as a % of Total $ Identified >50% 0.00% 0.00% Underpayments as a % of Total Net A/R < 2% 0.00% 0.00% Underpayment $ Recovered as a % of Total $ Identified >50% 0.00% 0.00% Total $ Nonrecoverable for All Precert Denials $0 $0 Patient Account Services Medicare Aging > 60 days < 10% 0.00% 0.00% Medicaid Aging > 90 days < 15% 0.00% 0.00% Insurance Aging > 90 days < 15% 0.00% 0.00% Medicare Risk F/C 'J&R' ONLY > 90 days < 15% 0.00% 0.00% Self-Pay Aging F/C 'S' ONLY >120 days < 15% 0.00% 0.00% Self-Pay Aging F/C 'K&L' ONLY >120 days <75% 0.00% 0.00% Bad Debt as % of Gross Revenue 3.18% 0.00% 0.00% Charity as % of Gross Revenue No TARGET 0.00% 0.00% Patient Responsibility Recoveries (A/R) > 15% 0.00% 0.00% Patient Responsibility Recoveries (Bad Debt) > 7% 0.00% 0.00% Medicare Payer Mix % 0.00% 0.00% Commercial Payer Mix % 0.00% 0.00% Medicaid Payer Mix % 0.00% 0.00% Self-Pay Mix % 0.00% 0.00% Managed Care Payer Mix % 0.00% 0.00% 0.00% 0.00% April

4 Collections total dollars recovered, total recovery versus percentage identified, denials as percentage of total net A/R, denials recovered as percentage of total dollars identified, underpayments as a percentage of total net A/R, underpayment dollars recovered as a percentage of total dollars identified, and total dollars nonrecoverable for all precertified denials. The contracting and revenue recovery team has proved to be a tremendous asset to our revenue integrity team. By using metrics and reporting tools, this team was able to recover an additional $18 million for the INTEGRIS system. Patient account services. The final group in the scorecard report is patient account services. This team reports monthly on aging in Medicare, Medicaid, insurance, and self-pay accounts. The areas of bad debt and charity are also reported monthly. The central business office also works patient responsibility for A/R and bad debt, both of which are reported on a monthly basis. Finally, this team keeps track of the payer mix of each of the facilities to track and trend the different financial classes. Holding Leaders Accountable The leaders of each team are required to fill out performance reports whenever an item on the scorecard does not meet the minimum standard. These reports have become just as important and critical to the organization as the scorecard itself. The performance reports were created to address four critical questions when a goal is not meeting the standard: > Which goal has not been met? > What action steps will be taken to achieve goal? > Which team member is responsible for achieving the goal? > What is the time frame for achieving the standard? The scorecard has evolved from being an excellent executive report to being a great educational tool for the entire staff. This strategy has been highly successful in communicating the day-to-day goals and strategies of the teams to upper management. Benefits of Scorecards Numerous benefits have been discovered with the use of scorecards. One of the greatest benefits is the sense of camaraderie and healthy competition among the facilities. The facilities have become quite competitive and strive to win awards and recognition in the highest cash collections, best DNFB, lowest days in A/R, and other categories. At the end of the year, INTEGRIS holds a revenue integrity consortium. Facilities receive awards and recognition for being best of the best. The sharing of how objectives and goals have been achieved also provides a great learning opportunity during this meeting. The scorecard has evolved from being an excellent executive report to being a great educational tool for the entire staff. INTEGRIS has shown a net revenue increase of 24 percent and an increase in cash collections of percent. Benchmarking and scorecards are vital tools for the success of INTEGRIS. They have become tools that tell us not just the past, but also where we are going. Brent Grimes is administrative director of patient account services, INTEGRIS Health, Oklahoma City, Okla., and a member of HFMA s Oklahoma Chapter (Brent.Grimes@Integris-Health.com). Strategies to Improve Self-Pay Collections Hospitals today increasingly struggle to collect outstanding receivables from patients. Effective management of patient payment is becoming a top priority for hospitals primarily due to two factors: growth in patient financial responsibility and effects on the organization s revenue cycle. The cost of collecting on open patient accounts significantly affects the bottom line. Hospitals generally will send three to four bills to patients before payment is fully collected. As tough economic times heighten pressures on financial performance, hospitals need increased focus on improving revenue cycle efficiencies and the collection of every dollar appropriately due. From a few simple steps to comprehensive plans, a variety of strategies can help patients understand their financial responsibility and improve the organization s self-pay performance: > Make self-pay an organizational priority. > Improve front-end training. > Set collection goals and reward achievement. > Enhance screening for government program eligibility. > Improve financial counseling services. > Expand payment opportunities. > Provide prompt-pay discounts. > Keep the individual in mind. > Set policies that support some form of up-front payment for elective services. > Prioritize back-end collections. Developing strategies to set expectations and effectively collect patient payment isn't easy. However, the challenge is one that must be addressed. Growth in out-of-pocket expense represents a real threat to hospital margins. As financial pressures continue to build and bad debt becomes harder to simply write off, those hospitals best positioned for financial success will have solid self-pay management processes in place. Excerpted from Strategies for Effective Self-Pay Management, HFMA, 2010 ( revenue/billing/ htm). 4 April 2010 Revenue Cycle Strategist

5 Revenue Assurance By Samuel A. Donio, Jr., and Adam Abramowitz Using the Audit Process as a Revenue Generator Preparing for integrity program audits can open up opportunities for increased revenue. In most areas of the country, the Recovery Audit Contractors (RACs) have started to send additional documentation requests (ADRs) to acutecare hospitals. Many hospitals have been preparing for this event by forming interdisciplinary RAC teams to address RAC-related concerns and to determine how best to respond to these requests. These efforts have often focused on a work flow perspective purchasing tracking software and establishing the division of labor for RAC activity with the hospitals resigned to the inevitability of Medicare paybacks during the multiyear RAC period. Although this reactive approach has helped hospitals improve documentation gathering, establish tracking protocols, and prepare for the document chase, the approach has rarely addressed the core issues leading to payment recoupment. More progressive hospitals know they cannot eliminate all RAC exposure. The objective should not be to merely manage the RAC process, but to mitigate RAC risk. These proactive hospitals are reviewing their data through a focused approach aimed at making the necessary process improvements in documentation and education that will prevent perpetual recoupments from becoming a fait accompli. Furthermore, the most proactive hospitals have realized a significant benefit from this approach: Improving clinical documentation results in increased overall reimbursement. Although the RACs have focused primarily on Medicare overpayments (95 percent during the RAC demonstration project), smart hospitals and health systems have seen that the incomplete clinical documentation that led to recoupment also has led to significant underpayments. Case Study: A Risk Review with Benefits A RAC assessment was performed on an urban 566-bed tertiary care teaching hospital with more than 30,000 annual inpatient admissions. Using the hospital s detailed patient billing data coupled with focused patient-level data analytics, specific cases were identified where potential over/underpayments could exist due to inpatient coding issues. A review of 100 of these specific cases not only validated the documentation for the high-risk cases, but also identified 17 accounts that, upon review of all of the available documentation, could be rebilled at a higher diagnosis-related group (DRG) level. The hospital then rebilled these cases and earned a net revenue improvement of more than $95,000. In addition, the review effort provided the hospital with the insight to implement a process improvement task force charged with fine-tuning documentation through physician education efforts. The early results of these initiatives have already resulted in fewer cases at risk for RAC recoupment, and the hospital is not leaving dollars on the table. Follow-up reviews of the remaining accounts identified have yielded similar results. A Universe of Opportunities After summarizing more than 150 hospital-specific RAC reviews performed across the country using focused patient-level data analytics, we have found that for every three accounts that are at risk for RAC recoupment, one account is underpaid. The average recoupment account has an at-risk value of approximately $4,800 (the result of the DRG being changed to a lowerweight DRG), while the average underpaid account has a value of $4,600 (the result of the DRG being changed to a higher-weight DRG). For most of the at-risk accounts, a documentation-improvement effort will mitigate the risk while ensuring proper payment levels for the underpaid accounts. Thus, a focused effort, looking at specific at-risk accounts, not only significantly reduces potential liability, but also significantly improves payment. The Real RAC Response: Improve Of course, the RACs are only the beginning of several government integrity programs aimed at recovering money from providers. The Medicaid Improvement Contractors (MICs) have already started in a few states, and the Medicare Administrative Contractors (MACs) are aggressively attacking specific target issues. In addition, the Zone Program Integrity Contracts (ZPICs) will be focusing on additional Medicare Part A issues, home health cases, hospice patients, Part B, durable medical equipment, prosthetics, orthotics supplies, Part C (managed care), and Part D (Medicare prescription drug and Medicare and Medicaid data matching). The only way hospitals can effectively respond to the coming storm is to focus their efforts on improvement. Providers should analyze their data and realize which types of issues (e.g., shortstay admissions, three-day transfer to skilled nursing facilities, inpatient coding) are most in need of urgent attention. Hospitals then need to implement a systematic approach to improving performance by tightening up processes, instituting consistent internal audits, reviewing records, providing additional education, and monitoring improvement. Samuel A. Donio, Jr., is president, CBIZ KA Consulting Services, LLC, East Windsor, N.J., and a member of HFMA s New Jersey Chapter (sdonio@cbiz.com). Adam Abramowitz is business development coordinator, CBIZ KA Consulting Services, LLC, East Windsor, N.J. (AAbramowitz@CBIZ.com). Revenue Cycle Strategist Is Online Subscribers can access Revenue Cycle Strategist online. Go to and log on as a subscriber. You will need an HFMA log-in and password. If you can t remember your log-in/password, you may request it online or call HFMA Member Services at , ext April

6 Improvement Strategies By Rick Derer Using Software to Spot Underpayments Automating payment analysis can help hospital business offices improve collections by uncovering underpayments. Hospitals grappling with the effects of the economic recession are closely examining their revenue cycles to identify where they may be hemorrhaging revenue. But what does the term revenue cycle really mean? The term covers a lot of ground. Efforts to improve financial operations often tend to target the front end such as implementing patient access information systems to determine eligibility and collecting up-front patient payments more than the back end. Those front-end efforts are necessary, especially given the financial pressures facing hospitals, but back-end revenue cycle functions, such as insurer payment analysis, should not be neglected. The goal of analyzing payments is to ensure that the hospital is being paid appropriately by payers according to their respective contracts. The analysis process can also serve as a quality check for other areas of the revenue cycle. Issues Affecting Contract Analysis The primary basic issue that can lead to insurer underpayments is the complexity and ambiguity of payer contracts. Most contracts are too complex for older software to reconcile, resulting in costly errors. Some antiquated payer software that was written on a mainframe system may be unable to price claims correctly and handle housekeeping chores such as tracking expiring contracts, implementing new amendments, and updating fee schedules and code sets. This software cannot be easily modified to accept changes in negotiated contracts. As a result, hospitals that have older software rely on laborious in-house manual processes, hire consultants, or avoid payment analysis altogether. A secondary issue that can lead to underpayments is ambiguity and complexity in contract terms. Contract language should be free of any subjective criteria so the contract is accurately interpreted by computer systems. Some contracts include services that could be reimbursed under multiple contract terms; confusion then occurs over which term trumps the other. Some terms are based on complicated if/then/else scenarios that could be construed differently by different analysts and could be incorrectly entered into the carrier s software. What appears to be incorrect may just be a difference of opinion as to the intent of the reimbursement term. Some confusing contract language is inevitable due to the need to be reimbursed appropriately, but some of this confusion could be removed by What to Look for in Software Hospitals should make sure they purchase software that has the ability to perform underpayment analysis cost-effectively and efficiently. Systems are now available that will effectively manage underpayments for a large (400 beds or more) hospital for approximately $30,000 in up-front implementation costs with annual support fees of approximately $3,500, requiring one FTE. Some software providers will manage the software themselves at a cost of about $24,000 annually, eliminating the need for the hospital FTE. The software should be able to: > Group underpaid claims and present them to the payer in batches as opposed to submitting them individually > Produce documentation required by the payer while providing hospital staff with tools they need to organize and track their submissions soliciting regular opinions from colleagues on how they interpret the language. Hospitals that do examine contracts and seek out underpayments may find other deficiencies in systems and processes that can and should be corrected. Among the usual suspects is incorrect billing. Underpayment analysis can uncover payment inaccuracies due to billing departments not sufficiently disciplined in using the standard billing formats (XX1,XX5, XX7) or because interim claims are billed incorrectly (not using the series). Another example is a billing department not using correct or optimal revenue codes, correct procedural terminology, or diagnosis-related group (DRG) codes. Correct coding is especially important for institutions, because using Medicare severity DRG codes incorrectly can result in substantial underpayment. Upstream there are registration issues, which, although usually associated with > Confirm that payment has eventually been made and identify the slow-paying or most troublesome payers > Have a pricing engine that, while searching for underpayments, can net payments and reduce total hospital accounts receivable > Handle simulation, the technique of pricing claims with multiple versions of the same contract (Simulation allows the hospital to model and predict payment based on its actual claims mix.) > Allow business office employees to copy terms from an existing contract, tweak the terms, and fine-tune projected payments before or during negotiations with payers > Store these simulations and export them to financial systems so the hospital finance team can run hypothetical scenarios and experiment with various stop loss amounts, carveouts, and add-ons 6 April 2010 Revenue Cycle Strategist

7 Leadership Style By David Cavell front-end quality assurance, sometimes are not caught until they surface later in the revenue cycle. For example, claims that list the wrong insurance plan for patients may show up as false variances during payment analysis, and the associated value for the hospital could be highlighting and correcting chronic registration problems. Software may flag a mispayment on an insurance reimbursement for a particular claim based on Plan A when the patient was registered under Plan B, which pays differently. Further review will see that the insurance reimbursement based on Plan A is correct. How Automated Payment Analysis Can Help In the past, hospitals often relied on consultants to find these and other reasons for underpayments. Unfortunately, those hospitals were at risk for take backs if a future audit negated the findings of the consultants. Today, hospitals can buy or license software programs that can continually monitor their information systems for underpayments. These software programs may be more cost-effective and more accurate than consultants, and they provide a means of ongoing audit. The fruits of payment analysis can be great, but the process is complex. The sheer volume of data alone can discourage and overwhelm already busy hospital business office staff. However, software can alleviate much of that burden. A recommended practice is to have at least one back-end employee dedicated to using underpayment software properly and to its full potential. Recoveries of several hundred thousand dollars to $1 million are not unheard of for large hospitals that have not previously audited their payments. Hospitals need to think of payment analysis as a datamining process and should focus on the low-hanging fruit the large dollars or the high-volume shortfalls. How Much of Your Receivables Do You Control? A simple exercise can help revenue cycle directors monitor how well they are managing their receivables. We like to believe that we are in control. The revenue cycle is similar to a long row of dominos. The dominos must all be placed properly if the end results are to be positive. Therefore, we feel the need to control all the dominos. Similarly, once a patient account is billed, we definitely know it is ours to manage to massage the account along and ensure that we receive the right number of dollars and are paid quickly. We control this stage. But when the account is inhouse or uncoded, we have little impact on it. During the first 30 days after a claim has been filed, many insurance carriers still have the claim in their system. We are not able to follow up on the claim during that time. Because we don t control this early stage, we should focus our receivables management on what we can control. The following example from Chelsea Community Hospital illustrates this point: > In-house accounts: $816,794 (still here) > Suspense accounts: $1,857,394 (hold days) > Held for coding: $2,137,503 (not included in hold days) > 0 to 30 days in accounts receivable (A/R): $7,258,845 (You have to take a little responsibility here, but the majority of the accounts are untouchable.) Few hospitals have the time or the need to examine every claim. Software can help focus attention on the claims that will provide the most return. Perform Payment Analysis A hospital revenue cycle should not necessarily close when the insurer has made payment. A thorough analysis of The total A/R for the period is $18,982,458. Of this amount, you control 36 percent, but you have minimal impact on 64 percent. ([$816,794 $1,857,394 $2,137,503 $7,258,845] $18,982,458 64%) Following the format used in the example above, you can plug in your numbers to determine what percentage you, as revenue cycle director, control. Do this calculation at month end and compare the result with previous months data. You can use the Chelsea Community Hospital numbers shown here as a benchmark example to compare against. After you have performed this calculation for a while, your competitive measurements will be against yourself. The revenue cycle process is so multiphased that identifying clearly the percentage under your control helps you in planning and managing your A/R. An increase in the percentages in out-of-control areas (coding or in-house) explains why your A/R is up this month but should be down next. I recommend logging the day of the week at closing; this day affects voucher posting and, therefore, your numbers. Wednesdays and Thursdays are great days to close on; Sundays are not. You are accumulating charges over the weekend but not posting cash. David Cavell, CHFP, is business office director, Chelsea Community Hospital, Chelsea, Mich., and a member of HFMA s Eastern Michigan Chapter (dcavell@cch.org). insurer payments will determine whether contracts are performing as expected and find other potential deficiencies affecting the bottom line. Rick Derer is senior project manager, Nebo Systems, a division of Passport Health Communications Inc., Oakbrook Terrace, Ill. (rick.derer@passporthealth.com, twitter.com/revcyclerick). April

8 PRESORTED STANDARD U.S. POSTAGE PAID PERMIT NO CHICAGO, IL Two Westbrook Corporate Center Suite 700 Westchester, IL To subscribe, call HFMA, ext. 2. Or visit Sponsored by Figures at a Glance 2009 Medicare Cost Report Results Median Values Days cash on hand: A measure of total liquidity for the organization; indicates the number of days the organization could meet its average cash payment without collecting any revenue. Total margin: The percentage of total revenue that has been realized in the form of net income, or excess revenues over expenses. Days in accounts receivable: A measure of average time that receivables are outstanding, or average collection period. Profit per discharge: A measure of the total production cost per inpatient discharge. Inpatient data Urban Rural Critical Access Number of hospitals 1, ,051 Days cash on hand, all sources Total margin Days in accounts receivable Profit per discharge Medicare length of stay Medicare length of stay: A measure of the average number of days a Medicare patient spends in the hospital. Source: 2010 Almanac of Hospital Financial and Operating Indicators, Ingenix, 2009.