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For other articles and previous issues click here. January 24, 2005 Policing
Transcription Costs The prospective buyer must take control of the line definition in the request for proposal. Choose a pricing mechanism that is unambiguous and easily auditable. The industry standard is moving toward the visible black character—what you see on the page is what you pay for. This strategy prevents gaming by vendors. Taking control of the bottom line with transcription costs starts with first understanding where that line begins—and, more importantly, what constitutes a line. When it comes to transcription vendors billing for their services, it is not as simple as visible black characters, 65-character lines, or even visible lines. Jeff S. Litvack, a principal with SSI Advisors, explains, “Historically, in the industry, people are used to quoting things in lines, but lines are not a measurable metric. The other problem is the ability of individuals to manipulate the metric.” One analogy Litvack uses is that when quoting prices, many people will think of prices in American dollars, but it could be Canadian dollars or British pounds. He cautions that definitions need to be clearly understood by both parties and must leave no room for interpretation. Whether the manipulation is intentional or simply a by-product of pricing in an industry that has no clearly defined standard, people managing or auditing transcription accounts are sometimes hard-pressed to convert the measuring and billing metric into a coherent, easily definable unit. Transcription billing discrepancies can just as likely be caused by vaguely defined billing methods or noncompliance with contractual billing terms; comparing metrics is not a simple task. And the problem is compounded by the absence of an industry standard. Getting What You Pay For “Price is important, but the other items need to be considered, and depending on the needs of the hospital, one might outweigh the other,” Litvack says. “But when you are looking at pricing, I would have visible black characters as my first choice and then a 65-character line, as those are the two most verifiable and will give the most competitive pricing.” Judging a document and comparing vendors by the visible black character will always be the most definitive measurement, says Dale Kivi, vice president of marketing at CyMed. “Even if you have to get out a sharp pencil and start counting, there are only so many characters on a document,” he says. “All other calculation methods allow the software to introduce different variables.” To make an informed purchasing decision about a vendor, Kivi says the first thing the prospective buyer must do is take control of the line definition in the RFP. “If the buyer expresses the line definition in a way that cannot be manipulated, it forces the vendors to comply with the definition. Vendors study the price-per-line definition more closely than any other part of the RFP,” he says. Measuring visible black characters eliminates variables, Kivi asserts. “The visible black character, in my opinion, as well as quite a few industry veterans, levels the playing field for all parties involved in the price issue,” he says. Kivi and his associates believe so strongly in this method that it is the one they recommend to their clients. “Quite often, though, our clients will insist on a 65-character line because that’s what they are comfortable with. And when that happens, we offer some languages and educate them to make that definition more definitive and as unambiguous as possible.” Looking for pricing on a per-character metric allows vendors to write a macro that may be 65 characters, but when a return is hit, it counts as a space. And when that is multiplied by numerous documents, prices could be almost invisibly inflated by the vendor. “You need to avoid the space, path, and return issue,” Litvack says. “Paying for headers and footers is another area where manipulations can occur.” Claudia Tessier, CAE, RHIA, former CEO of the American Association for Medical Transcription, says she isn’t certain whether there is one measurable unit customers should insist on. “If you have a preference, you simply have to be very clear to your vendors as to how you want to be billed. And if you don’t understand, they should be willing to go over that bill line by line until it can be understood.” If a hospital is working with a company whose bills are undecipherable, Tessier recommends switching vendors. “When choosing a vendor, you have to know not only how they charge but how you can confirm that documentation,” she notes. In addition to knowing what metric is being used
to calculate the charges, Tessier says those responsible for auditing
the bills need to know the following: “Also,” Tessier continues, “what are the ‘unexpecteds’ in the contract? Will you be charged for requesting quick turnaround times?” Kivi agrees that price is not the only variable. “Certainly price is an important consideration, but the efficiency of the implementation process, pricing of interfaces, as well as the ability of those interfaces to mesh with present operating systems, quality of work, and turnaround time, need to be considered.” Technology and Transcription Singh’s advice is threefold. He explains that hospitals should control their technology when it comes to auditing transcription services. “You want to audit each service using the appropriate algorithm to compare and make certain none are playing games,” he says. Not letting the vendor control the technologies used for transcription is another way to keep costs in line. “Tomorrow, speech recognition may make a difference if your vendor is using it to gain efficiencies, and they may not want to decrease their profit margins by passing those savings along to the hospitals,” Singh explains. Finally, Singh says that when a large healthcare system purchases MedRemote’s auditing, transcription, and dictation equipment, they can now use more than one vendor. “The vendors have to compete with each other on price and quality because the hospital controls the technology,” he says. “All of the components—from the voice, the text, and the reporting—should be separated from the services because if you don’t, then you can get into problems with billing,” Singh says. “Letting the transcription vendor be your dictation capture provider and your transcription auditor can lead to problems.” For example, Singh explains that MedRemote’s system allows a 650-bed hospital to utilize three separate transcription companies, but all use MedRemote’s systems. “We are the transcription hub for the technology,” he says. Auditing — A Means to an
End? “When sending samples for pricing, ask for the tools that were used to audit the counts on the samples,” Kivi says. “Make certain you can recreate those counts so you can audit the bills in an ongoing, everyday course of business.” Kivi cautions that bills are a “snapshot in time.” For example, he explains, a document that must be edited after a bill has been produced will change the final counts on that document in the database and will have an impact on the number of lines. “Slight variations should be expected when you are auditing after a bill has been generated,” he says. “A 2% or less variation is likely acceptable.” One critical point Kivi stresses is that “precise line counts will show up in the vendor’s billing cycle as it relates to transcription labor because they will have to know what they paid to their transcriptionists for payroll.” “You want to get to the point where you are confident that the audit is representative of what the hospital normally turns around in a month,” Tessier says. “You should be able to get to the point where you say, ‘If I’m getting the same amount of work every month, why do my bills fluctuate so wildly?’ You need to look at trends.” MedRemote’s Auditor audits every document for billing and turnaround time. For example, at a large system that owns nearly 70 hospitals, all transcription performed by any vendor passes through MedRemote’s technology. This ensures that not only every invoice from any transcription services is accurate but also that if there are any turnaround time violations, the hospital receives commensurate refunds. The Bottom Line Whether auditing is done on a daily, weekly, or monthly basis, it is something that must be done either internally or with an outside vendor to control costs and make certain the vendor is adhering to the contract. “Most buyers know their average transcription cost because it is part of a department budget,” Kivi says, adding that there will always be fluctuations based on census and the time of year. Kivi recommends auditing the first few billing cycles into a contract to validate that the contract bid pricing method is actually being complied with. “Once that’s done and you’re confident it’s being managed appropriately, spot checking should be all that is necessary,” he says. When it comes to keeping control of costs, Litvack says buyers should also attempt to control how much work is being sent offshore. “If the transcription is being moved offshore, you should be getting a price break,” he says. “The vendor is getting a price break, and that should be passed along to the hospital.” Because transcription pricing is not an exact science and because billing discrepancies in transcription can be caused by either vaguely defined billing methods or noncompliance with contractual billing terms, it is up to the buyers to beware and make certain the wording of contracts and the language for counting transcription services is in their favor. Litvack says the bottom line is that hospitals need to choose a pricing mechanism that is unambiguous and easily auditable. “The industry standard is a move toward visible black character—what you see on the page is what you pay for,” he says. “If you can’t see something, you shouldn’t pay for it, and this strategy prevents the gaming we have seen before.” — Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.
While the range has typically been from 55 to 80 keystrokes, more recently a 65-keystroke (gross character) line has emerged as something of an industry standard. Even with the 65-keystroke line count, variation still exists. In other words, a 65-character line can still mean different things to different people. Some companies actually have two ways of measuring a line: one for billing purposes and one for wage payment purposes. The idea is to create a small spread—bill for all keystrokes while paying only for hard characters. The following are definitions found within the transcription industry (culled from sources such as the Medical Transcription Training Web site and MAG Mutual Healthcare Solutions) for ways to measure lines either by count or measurement: • Gross character. Any letter, number, symbol, or function key necessary for the final appearance and content of a document, including the space bar, carriage return, underscore, bold, and any character contained within a macro, header, or footer. The American Association for Medical Transcription prefers the character as the basic unit of measure, where such measures are appropriate. • Net character. Printed characters only. Note: To convert to gross characters, multiply net characters by 1.2. • Net line. A defined line length that includes a predetermined number of gross characters (eg, 55, 60, 65, 70, 75). Note: Net lines are generally determined by dividing the total gross characters in a report by the defined line length. • Gross line. Any printed line that has one or more characters. Note: No distinction is made here between full and partial lines. (To convert gross lines to net lines, multiply gross lines by 0.7.) • Word. An example would be five characters. Total character count can be converted to words by dividing character count by the specified number of characters in a word—five. • Line. An example would be 65 characters. The total number of lines for reporting purposes is determined by dividing the total characters by the specified number of characters in a line. Margins may vary, resulting in gross lines of varying numbers of characters. (See gross line of transcription below.) Measurement — Comments below demonstrate the inadequacies of using units other than line counting to measure medical transcription services. • Keystroke. The strike of a single key. Measures “input” only, reducing a macro to entry strokes rather than meaningful output terms. Each stroke of a key is counted, including the space bar, carriage return, underscore, and bold. Note: Macros become an issue here. Technically, if a macro requires three keystrokes, then for billing purposes, three keystrokes would be billed. • Gross line of transcription. A line of print with one or more printed characters. Obsolete and inconsistent, a gross line may consist of a single character or as many characters as will fit between the margins (see “line” above). Gross lines may be manipulated by margins and font sizes. • Minute of dictation. A measure of access time to a dictation unit or system. The definition of access time may vary among units/systems, so a minute of dictation is not consistent among units/systems. One recorded minute of dictation is equal to an average of 777 gross characters for medical records dictation (including the emergency department) and an average of 782 gross characters for physician practices’ dictation. • Page of transcription. One side of any size sheet of paper with one or more printed characters on it. Inconsistent measurement device because the paper can be of any size, with any number of printed characters. — RH |
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