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.

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