Managing DNFB in Healthcare to Increase Revenue Outcomes

What is DNFB in healthcare?

In healthcare billing, accounts are designated Discharged not Final Billed (DNFB) when patients have been discharged from the healthcare facility, but the final bill for the visit has not been generated. Facilities typically have a hold period on an account after discharge, usually between 3 to 5 days. That hold time is used to ensure all proper documentation is on file or in the patient chart and to enter any outstanding documentation such as charges, coding, signature on notes, surgery logs and more. After that 3 to 5 day hold period, the claim should be sent to the clearinghouse. Usually, EHRs have some generic rules that stop the claim from processing due to missing diagnosis codes, billing rules and other omitted documentation.

Depending on the sophistication of the EHR, those rules could be categorized into worklists. Once the EHR detects no issues with an account, the claim will be sent to a clearinghouse. The clearinghouse automatically attempts to drop the bill again, but may kick out due to their more advanced rules.  If an error is caught, the claim will go on a worklist inside the clearinghouse.

How is the DNFB calculated?

To determine which claims will be categorized as DNFB, the gross dollars in DNFB are divided by the average daily gross patient service revenue.  The days in total discharged not final billed is one the of the Healthcare Financial Management Association’s (HFMA) MAP Keys.  This key indicates the revenue cycle’s performance and pinpoints issues impacting cash flow for the organization.

The DNFB rate is just one MAP key standard created by the HFMA.

What causes DNFB to increase?

DNFB in medical billing can increase due to a multitude of issues.  Before EHRs were common in hospitals, the Business Office and Medical Records departments had to work collaboratively to review the DNFB list of every account that did not bill and determine the cause.  Today, technological advancements enable reports to be pulled from with the EHR.  Final diagnosis, principal diagnosis, secondary diagnosis, procedures, documentation on date of discharge and timeliness are areas which could cause a claim to be tagged as DNFB.

Other causes of DNFB include:

• Medical Necessity​
• Charge reconciliation / separation of services​
• No insurance authorization​
• Incorrect insurance / payor billed​
• Invalid insurance / insurance verification ​

A hospital’s EHR must be updated on a regular basis to ensure correct links to charges and procedures.  If the field is incorrect, the claim will go to DNFB. For example, CPT codes are updated annually in October.  Ensuring these are updated in the EHR will help reduce DNFB.

Why does the DNFB matter so much?

DNFB in medical billing negatively affects the hospital’s bottom line.  If claims are held up in DNFB, then no cash is flowing to the hospital.  Each day in the DNFB is associated with a dollar mark.  Health Information Management (HIM) personnel need to know that amount to determine the total impact the DNFB represents to the facility.

During one JTS client engagement, the DNFB was reduced by 56% representing over $25 million in cash flow.  Clearly, DNFB has a substantial impact on revenue outcomes.

How do you manage DNFB in the revenue cycle?

To manage DNFB, it is important to have a defined plan in place.  Daily monitoring of the DNFB list and determining the cause of each issue is vital.  If the issue is related to physicians having incomplete documentation, the strategy should include working with the physician to improve clinical documentation follow up.  In addition, understanding and following insurance contract rules within your organization is key to reducing denials.  Overall, ensuring clean claims are going out the door is the best way to decease DNFB.

Who monitors DNFB?

The DNFB strategy should include a standard work process that designates the responsible party for monitoring and managing DNFB.  In most cases, the HIM manager and/or department designee and Information Technology (IT) hold this role collaboratively.  In addition, the Chief Financial Officer (CFO) is also part of the overall monitoring of DNFB.

What is a DNFB report?

Before EHRs were utilized in hospitals, the DNFB report was compiled manually.  Thanks to advances in the industry and dependent upon the type of EHR, the DNFB report may be extracted from the EHR.  JTS developed a vendor agnostic analytics as a service model, nCREAS™, that pulls data to create highly detailed DNFB reports that includes the length of time on the DNFB list, the dollar amount associated with the claim, total of DNFB, amount by payor and the reason for denial.  nCREAS™ allows near real time access to the reporting.

5 steps to reduce DNFB

DNFB may be caused by many variables including human error and technology issues, but can be improved by following the steps below:

1. Ensure your revenue cycle strategy

Revenue Cycle Management (RCM) is the complete process of a patient’s first contact with the hospital until the final bill is resolved.  Having a revenue cycle strategy in place that monitors the DNFB is essential to the financial health of the hospital.

2. Streamline process automation with revenue cycle technology

Work smarter, not harder.  Utilize reporting within the EHR as well as consult with revenue cycle experts like JTS to improve your processes.

3.  Invest in targeted training and adequate office staffing levels

Training staff in departmental processes and technology is key.  Change is constant in healthcare, therefore keeping on top of changes in pricing, coding updates and technology improvements will help decrease DNFB.  JTS offers automated coding and education audits (nCREAS™) to consistently improve your coding teams accuracy and compliance.

4. Maintain a quality Charge Description Master (CDM)

According to AHIMA, the Charge Description Master (CDM) is the list of all billable items that go on a patient’s account that could produce a charge.  Sometimes called the chargemaster, the CDM contains the descriptions, revenue codes, department associations and alternate CPT/HCPCS codes payors.  If the CDM is not updated and accurate, claims will be marked as DNFB when trying to process.

5. Embrace Analytics

The introduction of analytics to the healthcare industry has streamlined many processes.  All data inside nCREAS™ denials management reports prescriptively identify the action by drilling down through our hierarchy levels to a single account number.  This report reviews DNFB trends and levels.

Another nCREAS™ report looks at the total value of the DNFB and what categories make up the total. In addition, it reveals the age of the accounts (how long they have been on the DNFB).

How does JTS Health Partners help with managing DNFB in healthcare?

JTS utilizes nCREAS™ to break down the DNFB by category and creates a strategy that works for the client.

JTS collaborates with the client to identify aged accounts within the DNFB to clear them quickly so timely filing is not an issue.  JTS then breaks the DNFB down by location and pinpoints which physicians are holding up accounts because of the delay in documentation.  Updated policies and procedures are then created for the physicians to improve their processes.