MINIMIZING REVENUE LEAKAGE IN PATIENT OPENED EPISODES: A DESCRIPTIVE STUDY IN A TERTIARY CARE MULTISPECIALTY HOSPITAL IN BANGALORE

Abstract

 Revenue integrity represents a critical component of financial sustainability within modern healthcare organizations. Hospitals function in a highly complex environment where the delivery of clinical care must be effectively aligned with financial and administrative processes. In outpatient departments (OPD), patient episodes are generated at the time of registration for consultations, procedures, diagnostic investigations, or treatment services. Ideally, all services provided during a patient episode should be accurately documented, appropriately coded, billed, and closed within a defined timeframe. However, operational inefficiencies, gaps in clinical documentation, fragmented workflows, and system-related limitations often result in episodes being generated but remaining either unbilled or partially billed. Such unclosed episodes contribute significantly to revenue leakage, reduced cash flow, and diminished financial transparency. This descriptive study was conducted in a tertiary care multispecialty hospital in Bangalore to assess the magnitude, trends, and underlying causes of unbilled and partially billed OPD episodes. A total of 4,087 OPD cases were reviewed over a three-month period from September to November, of which 560 cases were identified as either unbilled or partially billed. Trend analysis revealed a persistent occurrence of unbilled cases across all three months, with the associated revenue loss increasing from ₹77,660 in September to ₹92,600 in November. Unpaid bills constituted 84% of the total revenue leakage, while uncollected service charges and charges not applied in accordance with physician orders each accounted for 8%. The findings indicate that outstanding patient dues and physician-directed non-billable procedures are the primary contributors to revenue leakage. Additional contributing factors include uncertainty in procedure coding, delays in order entry, multiple process handoffs, reliance on manual communication, and high patient volumes within the OPD setting. To mitigate these challenges, structured interventions such as the implementation of standardized procedure packages, mandatory justification prompts within the billing system, automation-enabled alerts, and regular audit mechanisms are recommended. These measures have the potential to reduce revenue leakage by approximately 30–50% within a relatively short operational period. Strengthening charge capture processes will enhance billing accuracy, improve cash flow stability, and support the long-term financial sustainability of healthcare institutions.