Revenue cycle and documentation optimization for a multi-facility emergency medicine program
Case study: A four-facility regional health system moved emergency medicine to an employed clinician model with management support—onboarding 10 FTE clinicians, lowering LWOT from 5% to under 2%, and improving documentation capture and accuracy. Coding audit compliance reached 98%, physician retention reached 95%, and query volume fell year over year.
At a glance
Metric
Result
Left without treatment (LWOT)
Reduced from 5% to under 2%
Coding audit compliance
98%
Physician retention
95%
Average RVU growth (2023-2025)
Reduced from 5% to under 2%
Year-over-year query volume
Reduced (<5% year-over-year)
Setting
Four-facility regional health system, ~130,000 ED visits annually
The challenge: Transparency and culture for in-house employment
A four-facility regional health system in a metropolitan market had outsourced emergency medicine staffing to a series of vendors for years. The clinical service ran, but administrative leadership had grown dissatisfied with the limited transparency, inconsistent quality reporting, and uneven cultural fit those relationships produced. The system made the strategic decision to bring emergency medicine clinicians in-house under an employed model—but recognized that the transition itself, and the operating discipline required to sustain it, would need experienced strategic partners.
Three goals were defined at the outset:
- Stand up a fully staffed ED across the four facilities with sustainable clinician contracts.
- Reduce LWOT rates across the network.
- Improve documentation capture and accuracy—to support accurate records, coding compliance, and long-term operational stability.
The system selected SCP Health Performance Edge—a wrap-around operating model that supports an employed clinician strategy with the operational expertise, leadership, and revenue cycle infrastructure most health systems would otherwise have to build from scratch.
The approach: Management services for an employed clinician model
Work began with an operational assessment at each of the four facilities. The assessment surfaced facility-specific dynamics, set priorities, and shaped the sequencing of changes. From there, five interlocking workstreams ran in parallel.
Competitive compensation and culture-driven recruiting
Using market intelligence, SCP was able to advise the system on competitive clinician rates, recruitment positioning, onboarding flow, and credentialing and enrollment process design.
Medical director selection and leadership development
An effective selection process for Medical Directors was implemented across the four sites, paired with ongoing medical director and clinical leadership development. Local leadership credibility is the difference between an employed model that thrives and one that quietly erodes; the program invested accordingly.
Revenue cycle transformation and goal-oriented projections
Billing and collections operations were rebuilt around transparent performance expectations, consistent reporting, and compliance-focused workflows. Standing revenue cycle management teams were aligned to the program with clear performance commitments and a single reporting framework, replacing the patchwork the system had inherited from prior vendors.
Documentation quality and service-line certified coders
Service-line certified coders were embedded into the revenue cycle workflow, focused on the documentation and coding patterns specific to emergency medicine. The result was more accurate first-pass coding, fewer retrospective clinician queries, and stronger compliance performance—the operational backbone of clinical documentation improvement (CDI) done well.
Structured governance with system leadership
Monthly, structured committee meetings brought system and clinical leadership together to review wins, surface issues, and work through a consistent set of ED performance and quality metrics. The cadence and consistency turned individual workstreams into a coherent program.
The impact: Rapid, measurable value across the network
Across the four facilities, the combination of appropriate staffing, leadership development, and rebuilt revenue cycle operations produced compounding gains.
Staffing and culture. Ten full-time-equivalent clinicians were hired, credentialed, and onboarded, building toward a fully staffed network. Physician retention reached 95%—strong evidence that the employed model, supported by structured management services, delivered the cultural alignment system leadership originally set out to achieve.
Patient access. LWOT rates fell from 5% to under 2% across the network, an indicator of improved front-end flow and patient experience.
Documentation and coding. With service-line certified coders embedded in the workflow, the program reached 98% coding audit compliance. Year-over-year query volume to clinicians declined—a meaningful reduction in administrative burden—while average RVU per encounter grew at roughly 0.64% per year from 2023 through 2025.
Why it worked
Three factors distinguish revenue cycle programs that provide sustainable results.
1. Documentation and coding sit inside one workflow
Service-line certified coders who understand emergency medicine—not generalist coders working from a checklist—produce cleaner first-pass coding and fewer downstream queries. Embedding them adjacent to the clinical workflow, rather than at the end of it, is what reduces administrative burden on clinicians while improving accuracy.
2. Leadership development is part of the program, not an afterthought
An employed ED model is largely dependent on local clinical leadership. Selecting medical directors well and investing in their development is the single largest determinant of whether the program’s quality and culture gains compound year over year.
3. A consistent dashboard and a consistent cadence
Monthly reviews with system leadership against a stable set of metrics turn individual improvements into a program. Variability in what gets reviewed produces variability in what gets sustained.
Implications for hospital and health system leaders
Health systems considering a move to an employed model—or considering deeper investment in the revenue cycle infrastructure underneath an existing one—can stress-test their approach against four questions:
- Do clinicians and coders work in the same workflow, or are coders downstream cleanup? Programs that integrate coders into the workflow are better positioned to support high compliance and reduce avoidable clinician queries.
- Is medical director selection structured, or is it informal? Structured selection plus ongoing leadership development is the strongest predictor of retention.
- Is the revenue cycle managed against goal-oriented projections, or against last year’s numbers? Goal-oriented projections create the accountability that surfaces problems early.
- Does system and clinical leadership review the same data at the same cadence? If not, performance will revert to whatever the loudest stakeholder cares about that month.
Frequently asked questions
Can a health system self-employ its ED clinicians without sacrificing performance?
Yes—provided the system pairs the employed model with the operating infrastructure that makes it sustainable: competitive compensation, structured medical director development, a revenue cycle function with service-line certified coders, and a consistent performance review cadence with system leadership. The case study described here demonstrates that pattern, achieving 95% physician retention and 98% coding audit compliance.
What is clinical documentation improvement (CDI) in emergency medicine?
Clinical documentation improvement in emergency medicine is the practice of ensuring that ED clinical documentation accurately reflects the complexity, acuity, and resources involved in a patient’s care. Strong CDI programs combine clinician education, real-time feedback, and service-line certified coders who understand emergency medicine documentation conventions. The result is higher first-pass coding accuracy, fewer queries back to clinicians, and reduced compliance risk.
How can an emergency department strengthen revenue cycle performance while maintaining compliance?
Collections per encounter improve when several levers move together: documentation captures the care actually delivered, coding accurately reflects the documentation, charges drop cleanly into the revenue cycle, and denials are worked promptly. Embedding service-line certified coders in the workflow, running revenue cycle operations against goal-oriented projections, and reviewing performance on a consistent cadence with system leadership are the operational practices most associated with sustained gains, as evidenced by the results above, and SCP’s overall 98% clean claims rate.
What is the role of service-line certified coders?
Service-line certified coders are coders trained and credentialed specifically for the documentation patterns of a clinical service line—in this case, emergency medicine. Compared to generalist coders, they recognize the documentation cues that distinguish levels of evaluation and management and code more accurately. This results in documentation and coding that more consistently reflect the care delivered, with fewer retrospective queries for clinicians and stronger audit performance. They are a core ingredient in any high-performing ED revenue cycle program.
How is coding audit compliance measured?
Coding audit compliance is typically measured by reviewing a sample of coded charts against the underlying documentation and applicable coding guidelines, then calculating the percentage of charts that meet the standard. Industry benchmarks vary by setting, but 95% or higher is considered a strong target for emergency medicine programs. The case study described here sustained 98%.
How long does it take to see results from a revenue cycle transformation?
Initial gains in coding accuracy and query volume typically appear within the first 90 to 180 days, once service-line certified coders and revenue cycle teams are aligned to the program. Full revenue cycle optimization lags slightly because of payor cycle times but become visible by month six and compound over the first 18 to 24 months. Sustaining the gains requires ongoing measurement and structured review with system leadership.
How does this approach affect LWOT?
LWOT improvements come primarily from the operational and staffing workstreams—full staffing, strong medical director leadership, and consistent front-end flow—rather than from the revenue cycle work directly. In this engagement, LWOT fell from 5% to under 2% across the four-facility network as the program stabilized.
Related insights and case studies
- Service: Emergency medicine services
- Insight: Clinical documentation improvement
- Insight: Medical director development
About SCP Health: SCP Health partners with hospitals and health systems to deliver clinical and operational solutions across emergency medicine, hospital medicine, critical care, and integrated acute care. We support more than 6,500 clinicians serving 10 million patient encounters annually across hundreds of programs nationwide.
