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The Rising Tide of Payer Requests for Medical Records: How to Shore Up Your Defense

 

 

 

 

 

 

 

 

Last month I had the privilege of presenting the first installment of MRO’s 2019 PHI Disclosure Management Webinar Series to healthcare professionals across the country about the rising tide of payer requests for medical records. Judging by the attendance and feedback, it is a topic that garnered a lot of attention. Based on the high level of interest, MRO plans to continue to provide content on this topic. Here is an overview of “The Rising Tide of Payer Requests for Medical Records: How to Shore Up Your Defense” presentation.

Payer Audits vs. Reviews

First, we covered the difference between audits and reviews as it is important to make the distinction and not group them together in the same category. DRG audits (post-payment audits) are not the provider’s friend. As payers attempt to review records for paid claims to recoup payment from the provider, audits occur throughout the year. Payers review the record to make sure the claim and record information match, so they can determine if the claim has been overpaid and recoup funds if necessary. These audits are typically time sensitive and due within 30 to 45 days of the date on the request letter.

The other category, reviews, includes HEDIS (Health Effectiveness Data and Information Set) and Risk Adjustment (Medicare Advantage, Medicaid, and commercial) requests. Review requests are seasonal projects that do benefit payers, but providers are not subject to negative financial impact and requests should be prioritized accordingly. The payer may impose an unrealistic time frame of 10 to 15 days when in reality there’s a broader time frame. Because HEDIS and Risk Adjustment reviews are seasonal, providers have more than 30 to 45 days to produce records.

Payer Requests for Medical Records: Deep Dive into Trends, Issues and Statistics

Next, we examined the current environment, trends, issues and statistics related to rising payer requests for medical records. It is common that audits (year round) and reviews (seasonal) overlap, causing a burden on HIM departments. HEDIS and commercial Risk Adjustment projects overlap with HEDIS, running from January through early May, and commercial Risk Adjustment running from September through mid-April. In addition, Medicare Risk Adjustment projects are beginning earlier every year. MRO has already seen requests come in during April 2019.

In recent years, healthcare organizations have experienced a steady increase in DRG/post-payment audits and HEDIS/Risk Adjustment reviews. According to MRO statistics from 2017 to 2018, overall payer requests increased 70 percent due to a significant upsurge in core categories—DRG audits up 52 percent, HEDIS reviews up 62 percent, and Risk Adjustment reviews up 80 percent.

Handling Large Audit and Review Projects: Recommended ROI Workflows

The growing trend of payer requests for medical records may seem overwhelming at times, but there are solutions to lessen the burden on HIM departments. The presentation also provided the following recommended Release of Information (ROI) workflows for handling large review projects:

  • Build stronger relationships with payers and health plans to better manage the surge in medical ROI. Establish project due dates instead of 30-day completion.
  • To offset the cost burden associated with producing these high-volume review requests for records, ensure the health plans will compensate for the records provided in a timely manner.
  • Ask your ROI vendor to work directly with the health plan to coordinate disclosure management instead of using internal staff or engaging a third-party vendor. Establish project due dates, rates and electronic delivery.
  • Use your ROI vendor’s remote services capabilities to process these large review projects so that HIM labor resources can focus on the daily workload.

Managed Care Contracts: Medical Record Language

Understanding the medical records section of the managed care agreements also plays an important role in how payers request medical records. An organization’s managed care agreement governs the payer/provider relationship and includes a medical records section that specifies the payer cost to audit a healthcare provider. Unfortunately, the medical records section is often a low priority because the managed care team may not understand the burden on HIM or the financial risk for the entire organization. The presentation provided details of recommended language for managed care contracts to ensure optimal outcomes for provider organizations. You can learn more by downloading the slides.

Payer Access to EMRs

The last topic covered the emerging concerns around payer requests for direct access to EMRs. Payers want access to medical records for the aforementioned reasons (post-payment audits, HEDIS, Risk Adjustment) and for initial claims processing. Payers are making a variety of proposals as to the types of access they would like to be granted. These levels of access and aggregation of records have different levels of associated risk. Here are four areas of concern for providers and patients:

  • Financial—Direct, automated access to a wide band of patient records will facilitate the growing trend of post-payment audits, denials and recoupments.
  • Privacy and Consent—Unlike the healthcare community, payers have not earned patients’ trust to serve as custodians of their most personal and private information. Learning of payer aggregation and storage of these records by payers is not a practice patients would approve, and learning of it after the fact could lead to strong patient dissatisfaction.
  • Information Governance (IG)—Automated sharing of full patient records with payers, and aggregating those records for permanent use, raises multiple legal and IG concerns. These include managing distributed health records, meeting HIPAA requirements for minimum use and correction of errors, and inadvertently sharing encounters for which the payer was not the guarantor.
  • Security—Automated access to health data by payers increases a provider’s exposure to cyberattack, and the aggregation and storage of that data in the payer’s IT system widens the potential exposure to large-scale breach.

The presentation included recommendations for payer access to EMRs. For those details, please complete the form below.

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What to Do and Not Do When Changing Health Information Management Vendors

 

 

 

 

 

 

 

 

The April 2019 Journal of AHIMA article “What to Do (and Not Do) When Changing HIM Vendors” served as a virtual roundtable featuring the experiences of three HIM leaders who successfully navigated HIM service vendor transitions. The MRO client panelists were Cindy M. Phelps, RHIA, Sr. Director, TSG Business Relationship Management, Carilion Clinic; Sherine Koshy, MHA, RHIA, CCS, Corporate Director HIM, Penn Medicine; and Kathleen J. Edlund, M.M., RHIA, Director of HIM, Trinity Health.

Topics discussed in the roundtable included challenges, lessons learned and practical strategies that help ensure quality service and a lasting collaborative partnership. As moderator of the discussion, I had an opportunity to focus on each expert’s type of vendor transition: transcription, EHR and Release of Information (ROI).

Challenges

Choosing the right vendor can be a challenging and daunting task, especially if your current service has been in place for a long time. Whether the service being considered for outsourcing options is in-house or with another vendor, the key to a successful transition is in the planning.

Some of the common challenges that prompted the panelists’ organizations to seek a better solution were: the need to have all users on one platform, service and quality issues, communication problems and lack of client support.

Lessons Learned

From their experiences addressing the challenges listed above, each HIM expert offered lessons learned and suggestions for other organizations to consider when transitioning service vendors. Here is a summary of their recommendations:

  • Conduct benchmark, research, and reference checks.
  • Establish key performance indicators (KPIs).
  • Engage multidisciplinary teams.
  • Conduct a pilot test.
  • Communicate and collaborate to build a trusted partnership.
  • Create a project charter.
  • Provide training and education.
  • Complete pre-implementation assessment documentation.
  • Create a visual diagram model of the process flow.
  • Ensure understanding of ancillary departmental (EHR) software systems.
  • Preserve a working relationship with the outgoing vendor.

Strategies to help ensure a lasting collaborative partnership

Each panelist offered components of a strong, collaborative partnership that promotes ongoing optimal outcomes. Here are five essential factors:

  • Monthly review meetings and open communication to discuss successes, concerns and issues with the vendor.
  • Engagement and availability of the vendor in the daily operational business.
  • Vendor sharing latest trends with development and with their other clients.
  • Annual onsite business review to highlight current state and share future state with key stakeholders.
  • Investment in the training and resources necessary to meet the needs of your organization.

The Journal of AHIMA article provides additional details regarding lessons learned, strategies and expert recommendations. To download a copy of the article, fill out the form below.

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2019 HCCA Compliance Institute Recap

 

 

 

 

 

 

 

 

The 23rd Annual HCCA Compliance Institute provided a wonderful learning experience focused on compliance in various areas of healthcare delivery. MRO was fortunate to have several representatives attending informative sessions and engaging in meaningful conversations with other attendees.

I was pleased to have the opportunity to co-present with our client, Melissa Landry, RHIA, Assistant Vice President of Health Information Management (HIM), Ochsner Health System on “Incident Response: Best Practices in Breach Management.” We covered the following topics during our presentation:

  • Current Environment and Statistics Related to Healthcare Breaches
  • Breaches under HIPAA and State Law
  • HIPAA Security Rule Safeguards that Address Incident Response Plans
  • Best Practices for Incident Response Plans
  • The First 24 Hours Following a Breach

Fill out the form below to request a copy of our presentation.

Session Takeaways

Of the numerous breakout sessions and learning tracks I attended, there were two in particular that I found to be very informative and insightful—updates from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and the Center for Medicare and Medicaid Services (CMS).

OIG Update

Joanne Chiedi, Principal Deputy Inspector General, HHS OIG, provided an enlightening keynote address. Her presentation encouraged compliance professionals to be bold and take action. Chiedi shared that at this time of disruptive innovation in healthcare, compliance must engage in these innovative conversations. Here are a few of her other key points:

  • We cannot oversee what we do not understand. Effective oversight requires understanding how healthcare is delivered today and how it will be delivered in the future.
  • Give Compliance the data. If anyone in your organization has data, Compliance should have access to it.
  • Compliance and innovation must advance together. Compliance can and should play a big part in getting innovation right in healthcare.

This presentation offered a comprehensive overview of the current healthcare ecosystem along with a description of the role compliance professionals play in upholding quality standards and processes.

CMS Update

Kimberly Brandt, Principal Deputy Administrator for Operations, CMS, joined the conference to deliver this update. Here is a preview of announcements that we can expect from CMS:

  • Patients over Paperwork
  • Interoperability and MyHealthEData
  • Opioid Epidemic
  • Program Integrity

This presentation provided attendees with the inside scoop and a great overview of what is on the horizon with CMS.

Continue Your Compliance Education by Attending MRO’s Upcoming Webinar

Privacy and security within a healthcare enterprise are top of mind in an era of regulatory reform and breach. With risks including financial penalties, lawsuits and reputational damage, healthcare organizations are seeking ways to mitigate risk and ensure proper disclosure of PHI through new technology and HIPAA-compliant policies and procedures.

In MRO’s upcoming webinar “Enterprise-Wide Disclosure Management: Closing the Compliance Gaps,” I will cover the benefits of implementing an enterprise-wide PHI disclosure management strategy to close compliance gaps. This session is pre-approved by AHIMA for one (1) CEU in the privacy and security domain. Secure your spot today by registering here.

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