Dawn Crump (dcrump@mrocorp.com) is Senior Director, Revenue Cycle Solutions, at MRO Corporation in Norristown, PA. Emilie Sturm (emilie.sturm@trinity-health.org) is Senior Revenue Management Consultant, Trinity Health in Livonia, MI.
Throughout the history of healthcare in the United States, departments have worked within their own silos. Today, with increased managed care recipients, the shift to value-based reimbursement, and unprecedented demands due to COVID-19, a team-based approach is more important than ever. Collaboration between compliance officers and revenue cycle leaders is critical to reduce risk, bridge communication gaps, and promote teamwork while also supporting billing integrity and revenue recovery for the organization. With increased requests for audits and access to electronic health records (EHRs), departments must find a way to work together to create efficiencies, promote compliance, and retain revenue.
This article offers guidance to improve compliance in a centralized revenue cycle environment with focus on shoring up business office processes that may lead to inadvertent protected health information (PHI) disclosures during payer conversations, audits, and disputes. The challenges present an opportunity to make teamwork a meaningful, inclusive practice to promote collaboration across silos and address the top three compliance risks within the revenue cycle:
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How to manage disclosure of PHI within revenue cycle departments,
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How to evaluate levels of direct payer access to EHR systems, and
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How to effectively unite revenue cycle departments.
If departments are not communicating, breakdowns at various points can lead to detrimental financial and compliance risks. Patient access and registration must validate patient identity and insurance information. Utilization and case management must get proper authorizations for appropriate billing. Clinical documentation improvement must work with clinicians to capture appropriate clinical status.
Many healthcare organizations are now addressing compliance concerns through collaborative revenue cycle processes. The first step is to identify areas of risk and compliance concerns.
PHI disclosure management
As the ultimate custodian of patient health records, health information management (HIM) professionals are tasked with increasingly complex challenges when it comes to proper release of compliant information:
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Multiple points of disclosure within revenue cycle departments;
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Resource limitations to maintain monitoring and control all record releases;
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Accountability to provide complete, compliant medical records:
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Missing record elements—patient care, reimbursement, and regulatory implications
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Specific records needed depending on the request reason
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Legal Health Record versus Designated Record Set
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Components of a complete medical record derived from multiple sources—pathology reports, radiology, operating rooms, rehab facilities/units, pharmacy, emergency department and emergency medical technician notes, clinic electronic medical records, utilization management (UM) systems, and other outpatient departments. Failure to provide complete medical records can result in denials.
Though HIM is primarily responsible for managing compliant PHI disclosures, other departments receive release of information requests, such as radiology and the business office. Staff who are not trained to release medical records lack knowledge of the rules and regulations that govern proper disclosure of PHI, which can lead to privacy, security, and financial risks. Health Insurance Portability and Accountability Act (HIPAA) compliance is a critical concern when ancillary departments disclose patient information.
Collaboration between HIM and the business office is necessary to ensure a streamlined process for tracking all releases. The business office releases high volumes of medical records to government payers and health plans to meet requirements for claims, appeals, and audit requests. It is important to capture the number of records requested by a certain payer within a given time frame and to understand the potential risks. For each request, determine the reason for the review and make sure it is within contractual obligations. This promotes understanding of the financial impact and provides an opportunity to be proactive in supplying information appropriately to prevent delay in payment.
