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Finding Civility in Payer Relationships: Audits, Reviews and HIM – HIM Scene

Posted on July 19, 2017 I Written By

The following is a HIM Scene guest blog post by Greg Ford, Director, Requester Relations and Receivables Administration at MRO.  This is the first blog in a three-part sponsored blog post series focused on the relationship between HIM departments and third-party payers. Each month, a different MRO expert will share insights on how to reduce payer-provider abrasion, protect information privacy and streamline the medical record release process during health plan or third-party commercial payer audits and reviews.

Civility is defined by Webster’s as courtesy and politeness. It is a mannerly act or expression between two parties. While civility in politics has waned, it appears to be on the rise in healthcare.

New opportunities for civility between payers and providers have emerged with the shift from fee-for-service to value-based reimbursement. Population health, quality payment programs and other alternative payment models (APMs) are opening the door to better collaboration and communications with payers. Optimal patient care is a mutual goal between payers and providers.

HIM professionals can also contribute to stronger payer-provider relationships. Our best opportunity to build civility with health plans and payers is during audits and reviews. HIM professionals who take the time to understand the differences will make notable strides toward a more polite and respectful healthcare experience.

Payer Audits vs. Payer Reviews: What’s the Difference?

It’s no secret to most HIM professionals that the volume of health plan medical record requests continues to increase significantly. In fact, between 2013 and 2016 the number of requests for HEDIS and Risk Adjustment reviews increased from one percent to 11 percent of the total Release of Information requests received by MRO.

The main difference between audits and reviews is the potential negative financial impact to providers. Payer audits include risk for revenue recoupment while payer reviews do not.

For example, audits conducted by third-party payers are intended to recoup funds on overpaid claims. The most common reason for a post-payment payer audit is to confirm correct coding and sequencing as billed on the claim to determine if payment was made to the provider correctly. In audits, the health plan’s intention is to recoup funds on overpaid claims.

Payer reviews do not carry financial risk to the provider. Instead, payer reviews deliver valuable insights providers can use to improve their relationships with health plans and patient populations.

The Upside of Payer Reviews

HEDIS and Risk Adjustment reviews are the most common types of payer reviews. Payer data submissions for HEDIS are due to the National Committee for Quality Assurance (NCQA) by June of every year. Medicare Risk Adjustment results are due in January and Commercial in May.

Since these payer reviews both overlap and occur simultaneously, HIM departments are deluged with medical record requests. Understanding the importance of these reviews improves communication between HIM, Release of Information staff and health plan requesters.

HEDIS Reviews

HEDIS reviews can benefit providers during contract negotiations because the HEDIS performance rankings can be used to gauge the quality and effectiveness of different health plans for potential participation with the facility.

Risk Adjustment Reviews

With these reviews, health plans are required to prove the needs of the population to CMS so they can continue to provide services for higher risk patients and pay providers for the care of this population.

In both cases, medical records are needed to provide the analysis, so HIM is involved.

HIM’s Role: Reimbursable Release of Information

In 2015, 85 percent of MRO’s audit and review requests came from third-party vendors representing health plans. Both post-payment audit and review requests are typically chargeable to the requesting party. Due to the importance of collecting medical record documentation, health plans and payers are willing to pay for records.

HIM professionals are encouraged to pursue reimbursement for payer requests. This is especially true if your HIM department is working diligently to accommodate the payer deadline for record receipt.

A provider’s Release of Information staff should be able to work directly with these requesters to ensure payment for the timely delivery of records. HIM professionals can reduce payer-provider abrasion and ultimately strengthen relationships to improve compliance. It’s the first step to increasing civility in healthcare.

Watch for our August HIM Scene post to learn more about how to secure patient privacy when sending records to payers and health plans.

About Greg Ford
In his role as Director of Requester Relations and Receivables Administration for MRO, Ford serves as a liaison between MRO’s healthcare provider clients and payers requesting large volumes of medical records for purposes of post-payment audits, as well as HEDIS and risk adjustment reviews. He oversees payer audit and review projects end-to-end, from educating and supporting clients on proper billing practices and procedural obligations, to streamlining processes that ensure timely delivery of medical documentation to the requesting payers. Prior to joining MRO, Ford worked as Director of Operations and Sales at ARC Document Solutions for 15 years. He received his B.A. from Delaware Valley University.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

HIM Leadership

Posted on February 25, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Healthcare leadership is not for the faint of heart; this is especially true in these rapidly changing times we are experiencing in healthcare. There are many different moving parts involved in not only providing medical care but in the important behind the scenes tasks that keep healthcare operations running smoothly. Health Information Management responsibilities are part of these important tasks as they cover many different, multi-layered tasks that are governed by strict laws and guidelines within hospitals, physician practices, and other healthcare roles.

Throughout the day, an HIM leader’s conversation can quickly shift between coding and revenue cycle to physician documentation and workflow to scanning records and analyzing reports to releasing information and HIPAA compliance and everything in between. We have to have a thorough understanding of all of these areas and how they overlap with other departments and providers. Of course, none of these responsibilities occur in a consistent or predictable manner on any given day.

By nature, I am a sorter and an organizer and I feel content when everything has a place. But when my daily responsibilities jump around chaotically, I start to squirm a little. Some days I can’t even begin to jot down a to-do list with prioritization because everything is urgent and important and everything is needed now. My point is not to complain about having too much to do but rather to successfully accept all of the responsibility and strategize around it. One of my favorite quotes reminds us:

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The key is to never try to do it all alone. It is not a good idea to try to do everything yourself just because it seems there is no time to train others. Having a great team to support your goals is absolutely critical. Hiring skilled HIM professionals and delegating important tasks to them will create an outlet for these professionals to use their skills and creativity to explore new ways to get the job done. The end result is typically a win-win for HIM professionals, HIM leaders, and organizational performance. Another great quote says:

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This is definitely the key to successfully accomplishing goals and objectives when they seem overwhelming and numerous. We must work smarter not harder; especially when teams are shorthanded.

I know this is probably nothing new to those in similar HIM leadership roles but it always helps to hear that you are not alone. There are probably never going to be perfect days where everything works smoothly and everything fits into its proper place. Tackle all of those tasks as best you can, delegate the responsibility, encourage teamwork, and share in the success.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

The Power of Networking in HIM

Posted on November 4, 2015 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

I have always been a huge proponent of networking with other HIM professionals. Even when I was a student, I found great value in meeting other students who were going through all of the same milestones of HIM education. Talking with seasoned HIM professionals was a great way to discover what the HIM field had to offer, who I needed to be introduced to, and what I needed to do to land a job in HIM.

As a more seasoned HIM professional, there is even more value in networking with peers. It’s great to know you are not alone because there many others out there going through the exact same issues (such as ICD-10, reimbursement changes, regulatory requirements, etc.). We always say that HIM is a small world and it really is true. It seems you can travel to any part of the country for a conference and run into someone you know or someone who knows someone you know through networking.

It appears that HIM product vendors know how important networking is to HIM professionals therefore they seek opportunities to bring current, preferably happy customers together with prospective customers through seminars and social gatherings. This sets the stage for socializing and sharing experiences with certain products and gives potential customers a contact to reach out to in the future. Many lasting friendships are also made in the process.

Another great way to meet like-minded HIM professionals is through volunteering. Organizations and conference event planners are always looking for engaged volunteers to help and there are many benefits to both the organization and the volunteer. There is a lot to be learned through volunteering and it can open up many new opportunities through the experience.

Networking doesn’t have to be confined to in-person meetings and conferences. There are many opportunities to network through social media and various online forums. In a previous post, I made a plea for more HIM professionals to take advantage of the vast networking opportunities on Twitter. There are subject matter experts for almost anything you can imagine and they are usually accessible and responsive through virtual networking. I have had many conversations with HIM professionals I have found through LinkedIn and Twitter long before I met them in person. The benefit of using social media for virtual networking is that it can be done at any time and fit into anyone’s schedule. In-person meetings are great but may only be once per year, too far geographically, expensive, or may have scheduling conflicts.

Networking is not only successful for talking business but it’s also fun to get to know others with similar interests and backgrounds. With the many different opportunities and venues to enhance networking, it is convenient for almost any schedule or situation. Do take the time to partake in in-person networking, virtual networking, volunteering, or all of the above (and bring your business cards). The professional and personal benefits are endless.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Why and Who Should Ensure Quality Health Data?

Posted on August 12, 2015 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Contrary to common belief, technology does not own health data. Data exists as a result of the input of multiple sources of information throughout each patient’s healthcare continuum. The data does not exist only because of the technology but rather because of the careful selection of meaningful data items that need to be captured and at what frequency (ie. instantly, daily, weekly, etc.).

We in healthcare collect granular data on anything ranging from demographics, past medical, surgical, and social history, medication dosage and usage, health issues and problem lists, disease and comorbidity prevalence, vital statistics, and everything in between. We collect data on financial performance with benchmarks and reimbursement trends using individual data elements from accounting transactions. Healthcare organizations have been collecting the same or similar data for decades but never before have we been able to operate with such efficiency as we do now thanks to advances in technology.

We have become so data rich in the healthcare environment in a short amount of time and this data continues to multiply daily. But are we still information poor? When we continue to generate data but fail to aggregate the data into quality information, we are essentially wasting bandwidth and storage space with meaningless and disconnected data.

Every time patients have interactions with healthcare providers and facilities, data is generated. Over time, the data that is generated could (and should) be used to paint a picture of trends in patient demographics, population health, best practices in care, comorbidities and disease management, payment models, and clinical outcomes. This information becomes useful in meeting regulatory requirements, overcoming reimbursement hurdles, clinical quality initiatives, and even promotional and marketing material for healthcare organizations. This data could have opposite effects if not properly governed and utilized.

It goes back to the saying “garbage in, garbage out.” If the data cannot be standardized or trusted, it is useless. Input of data must be controlled with data models, hard-stops, templates, and collaborative development of clinical content. Capturing wrong or inconsistent data in healthcare can be dangerous to the patients and healthcare quality measurements as well as leading to unwanted legal actions for clinicians.

So who is the right person for the job of ensuring quality data and information? I have seen bidding wars take place over the ownership of the data and tasks surrounding data analysis, database administration, and data governance. Information Technology/Systems wants to provide data ownership due to the skills in the development and implementation of the technology needed to generate and access data. Clinical Informatics professionals feel they are appropriate for the task due to the understanding of clinical workflow and EHR system optimization. Financial, Accounting, Revenue Integrity, and Decision Support departments feel comfortable handling data but may have motives focused too heavily on the financial impact. Other areas may provide input on clinical quality initiatives and govern clinician education and compliance but may be primarily focused on the input of data instead of the entire data lifecycle.

When searching for an appropriate home for health data and information governance, organizations should look no further than Health Information Management (HIM) professionals. Information management is what HIM does and has always done. We have adapted and developed the data analytics skills needed to support the drive for quality data abstraction and data usage (just look at the education and credentialing criteria). HIM departments are a hub of information, both financial and clinical therefore governing data and information is an appropriate responsibility for this area. HIM also ensures an emphasis on HIPAA guidelines to keep data secure and in the right hands. Ensuring quality data is one of the most important tasks in healthcare today and trusting this task to HIM In collaboration with IT, Informatics, and other departments is the logical and appropriate choice.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

The Importance of Defining a Legal Health Record with Mary Beth Haugen, RHIA, MS

Posted on September 8, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In this interview, we sat down with Mary Beth Haugen, founder and CEO of Haugen Consulting Group, about the intricacies and challenges of the legal health record and how it’s been impacted by EHR and other healthcare technology. Plus, we give HIM leaders some firepower on how to convince hospital leadership that defining the legal health record is important for every healthcare organization. Enjoy the video below.