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ROI in the Business Office: Why HIM Should Keep a Watchful Eye – HIM Scene

Posted on August 16, 2017 I Written By

The following is a HIM Scene guest blog post by Lula Jensen, MBA, RHIA, CCS, Director of Product Management at MRO.  This is the second 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.

According to most business office staff, pulling information and releasing medical record documentation to payers is a necessary evil to get claims paid and reduce accounts receivables. It is not their core competency.

Whether the request is unsolicited or solicited by the payer, time required to compile information and respond wreaks havoc on business office productivity. Also in efforts to meet payer deadlines and expedite claims, human mistakes can be made. Incorrect patient information might slip through the cracks.

Despite concerns, many business office directors prefer that payer disclosures be sent out by their own business staff—versus by the HIM department. If your organization follows that practice, this HIM Scene blog post is for you.

Two Types of Business Office Requests

There are two instances of business office Release of Information (ROI) to know: unsolicited and solicited requests. The unsolicited process takes place when medical documentation containing all the additional information pertinent to the service being billed is submitted proactively by the provider with the initial claim. The solicited process occurs when the original claim is sent without additional supporting medical record documentation and the payer subsequently (during the adjudication process) determines that additional information is needed. The payer then places a request for the additional documentation from the provider.

Unsolicited Releases During Claims Processing

The purpose of releasing information during claims processing is to expedite payment. In an effort to get the claim paid faster, medical records are sent proactively with the claim. This is especially true for high-dollar claims, payer policies, readmissions within 30 days and the published Office of Inspector General (OIG) Work Plan.

Sounds like a good intention with the organization’s best financial interests in mind. However, three concerns arise when business offices send medical record documentation to payers—versus having HIM professionals take charge.

  1. Business office staff may not know which parts of the medical record will be required to support the claim. Often, the entire chart is sent—a process that is not practical for high-dollar or long-length-of-stay cases.
  2. Sending the entire record is also not compliant with HIPAA’s Minimum Necessary Standard. By sending too much information, hospitals are at risk for HIPAA breach.
  3. Upon receipt of prepay documentation, the payer’s staff logs each record received, scans or otherwise digitizes the documents, and incorporates them into their own electronic systems. This creates a huge administrative burden on payers.

Similar challenges ensue with solicited payer medical record requests that occur during the adjudication process or retrospective reviews.

Business Office Disclosures for Payer Audits and Reviews

There has been significant uptick in payer audits and reviews, a topic that was covered by HIM Scene last month. This includes governmental and third-party commercial. According to one central business office director at an MRO client site, “The pull lists for payer audits and reviews keep getting longer and the piles of medical records to send keep getting higher.”

To reduce administrative burdens with payers, some organizations are allowing payers direct access to their EMRs and EHRs to obtain the required information during audits and reviews. While this process may lighten the load for billing personnel, it is laden with additional privacy risks.

Business office personnel complain about the travails of responding to all the various requests for records. However, a significant number of business office directors still insist on owning the ROI process for payer audits and reviews. When this is the case, there are several important steps for HIM directors to consider.

Three Steps for HIM: Educate, Track and Talk

For both types of business office disclosures, it is important to educate billing staff about the implications of a HIPAA breach and privacy risks listed above. Establish an organization-wide standard for ROI to keep PHI safe during all types of business office disclosures. Educating all personnel involved in business office ROI (whether for claims processing, audits or reviews) helps relieve frustration with the record release process.

Billers should also track which specific records, and what sections of each, were sent. By documenting and then reviewing this information, organizations gain valuable knowledge about payer trends—insights that can be used to prevent denials and negotiate more favorable terms for payer contracts.

Collaborate with privacy and the business office to determine which release information to track. Then establish a common database or software application to document each release to payers. Here are four ways to make the most of business office ROI tracking data:

  • Look for patterns in what payers are requesting. Any trends in payer request activity could offer opportunities for provider improvement.
  • Identify risk. Analytics can help business offices detect weaknesses in the revenue cycle, involving coding, documentation or other internal processes.
  • Educate coders, biller, collectors, physicians, etc. on payer trends and how collaboration can promote accurate, complete billing for services rendered and support a claim via medical record documentation.
  • Use data analysis. When payer contract negotiations arise, use payer trend statistics to your advantage in the next round of negotiations.

Talk with local payers and stay updated on policy changes related to claims processing, audits and retrospective reviews. Open communication with each payer is recommended to ensure records are sent in the most secure way possible. Communication with payers also reduces phone tag and minimizes payer-provider abrasion.

Finally, due to the importance of collecting medical record documentation, health plans are willing to pay for records. Business offices and HIM departments fulfilling these requests are encouraged to discuss and pursue reimbursement from payers.

About Lula Jensen

In her role as Director of Product Management for MRO, Jensen drives product enhancements and new product initiatives to ensure MRO’s suite of solutions enable the highest levels of client success and end-user satisfaction. She has more than 15 years of experience in healthcare, focusing on Health Information Management (HIM), Revenue Cycle Management, analytics, software development and consulting. In addition to holding product management roles at McKesson Health Solutions and CIOX Health, she also served as Revenue Cycle Manager at Fox Chase Cancer Center and taught a course on ICD-9 CM Coding and Reimbursement at Bucks County Community College. Jensen is an active member of the Healthcare Financial Management Association (HFMA), American Health Information Management Association (AHIMA) and Pennsylvania Health Information Management Association (PHIMA); she is a 2005 PHIMA Scholar Award recipient. Jensen holds a B.S. in HIM from Temple University and an M.B.A. in Health Care Administration from Holy Family University.

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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.