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PHI Disclosure Management in the Business Office

Business office personnel, often in collaboration with their Health Information Management (HIM) counterparts, release millions of medical records annually to commercial and government payers to expedite payment of claims, appeal denials or fulfill auditor requests.

Time spent by billers and collectors aggregating and delivering this Protected Health Information (PHI) represents a significant distraction and efficiency challenge for business office directors and other revenue cycle leaders. The interference in workflow also reduces revenue-producing claims-processing time for uniquely skilled business office staff.

By considering streamlined workflow options for sharing patient records, healthcare leaders can improve business office/HIM interdepartmental collaboration, efficiency, cost savings and compliance.

MRO, rated #1 by KLAS for Release of Information since 2013, empowers revenue cycle leadership with our expertise and solutions for secure, compliant and efficient PHI exchange:

Government and Commercial Payer Audit Management
Offload the burden of payer audits and reviews to MRO and feel confident that your organization will respond to requests compliantly and ahead of deadline. Learn more…

Business Office Medical Record Attachment Services
Improve efficiency, cost savings and compliance with streamlined processes for aggregating and delivering patient records to support claim payments. Learn more…

It’s All About Time: 4 Example of Business Office Disclosures

Excerpt from HFMA article PHI Disclosure Management in the Business Office: Two Options for Greater Efficiency”

There are four points in the claims process when billers and collectors disclose PHI: as part of initial claims submission, during claims processing, for retrospective audits and reviews, and in response to attorney requests. PHI disclosure is necessary to get claims paid, in general—but not in every case. Careful and strategic tracking of what information is released, to whom, and why, can make the PHI disclosure process more efficient.

Unsolicited, proactive disclosures. In some cases, billers proactively send portions of the record or the entire encounter along with the initial claim to help expedite payment. These unsolicited submissions of patient documentation are common when billing specific diagnoses and procedures in an attempt to prevent insurers from rejecting or denying the initial claim. Over time, billers become keenly aware of what medical record documents are requested by each insurer and for each type of claim. However, keeping track of unsolicited disclosures can provide insight into when these extra efforts may not be warranted.

Additional documentation requests. Other business office disclosures are made in response to the insurer’s request for additional medical record documentation during claims processing. Billers should document which specific records, and what sections of each, were sent. Recording and monitoring this data over time and comparing the data with denial data can help organizations identify which types of cases benefit from proactive record release. Also, knowledge of what specific information was sent is extremely valuable when insurers deny receipt of records or misplace the data.

Retrospective payer audits and reviews. Between 2013 and 2017, the number of requests for Healthcare Effectiveness Data and Information Set (HEDIS) and risk-adjustment reviews increased from 1 percent to 14 percent of the total Release of Information requests received by MRO. This statistic is in addition to the millions of records requested nationwide for Medicare’s RAC reviews. Sending records for retrospective audits and reviews represents a significant time commitment for business office and HIM staff.

Attorney requests for itemized bills. Bills often are requested by attorneys in support of litigation for personal injury claims. These requests may be in conjunction with the medical record.