The primary function of the hospital business office is to submit, process, and collect payment for healthcare claims. To complete these tasks effectively, millions of medical records are sent to third-party payers by business office personnel every year. These business office disclosures occur during the claims submission process or as part of retrospective payer reviews and audits.
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. However, proactive revenue cycle professionals are beginning to discover a new silver lining in the onerous task of business office release of information (ROI): payer insights.
By analyzing the who, what, and when of business office disclosures, providers open the door to a gold mine of payer trend information that can allow them to prevent future denials and expedite claims. Whether the medical record release is unsolicited by the payer or a solicited request during retrospective reviews, keeping track of disclosures helps organizations remain proactive and reduces payer-provider abrasion.
This article explores the inherent risks, challenges, and best practices in two specific areas of business office ROI: during claims submission and as part of retrospective payer audits and reviews.
During Claims Processing
For high-dollar claims, readmissions within 30 days, and published U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG)-targeted diagnoses or procedures, many business offices proactively send medical record documentation with their claims or shortly thereafter. In these cases, billers know the payer will require records – knowledge gleaned from their prior data analysis of denied claims.
By sending documentation along with the claim, providers hope to expedite payment and mitigate the risk of a denied claim. These unsolicited requests can be received by some payers electronically, but in many cases paper documentation is produced and sent manually. Records may also be requested during a conversation between the biller and payer, or shortly after claims submission if the payer needs the record to pay the claim.
The goal of business office ROI during claims processing is to reduce paperwork and get the claim paid faster. This sounds like a win-win, but there are three specific challenges:
- 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.
- 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 violations.
- 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. The is a huge administrative burden on payers also.
Billers should document which specific records, and what sections of each, were sent. Recording and monitoring this data over time and comparing it to denial data can help organizations identify which types of cases benefit from proactive record release. Conversely, keeping track of unsolicited disclosures also illustrates when these extra efforts may not be warranted.
Finally, open communication with each payer is recommended to ensure that records are sent in the most secure way possible. Communication unites these disparate groups, reduces back-and-forth communications, and minimizes payer-provider conflict throughout the claims process.
During Retrospective Payer Audits and Reviews
The volume of payer reviews and audits is up nationally. With the uptick come thousands of requests for medical record information. For example, between 2013 and 2016, the number of requests for Healthcare Effectiveness Data and Information Set (HEDIS) and risk adjustment reviews increased from 1 percent to 11 percent of the total ROI requests received by MRO. This is in addition to the millions of records requested nationwide for Medicare’s Recovery Audit Contractor (RAC) reviews.
According to one central business office director at an MRO client site, “the pull lists keep getting longer and the piles of medical records to send keep getting higher.” While payer audits carry a potential negative impact on hospital revenue, payer reviews do not. Post-payment DRG validation, cost outlier reviews, and ongoing quality reviews are the most common types of third-party commercial payer requests.
To alleviate the administrative burden on health information management (HIM) and business office personnel in the ROI process for retrospective payer audits and reviews, some organizations are allowing payers direct access to electronic medical records (EMRs) and electronic health records (EHRs) to obtain the required information. While this process may lighten the load for hospital personnel, it is riddled with privacy and security risks.
The best antidote for conflict during retrospective reviews and audits is knowledge. Educating all personnel involved in audits and reviews helps relieve frustration with the record release process. Staff can better understand how their efforts lead to improvements in patient care, population outcomes, and payer relationships.
Both post-payment audit and review requests are usually chargeable to the requesting party. Due to the importance of collecting medical record documentation, health plans often are willing to pay for records. Business offices and HIM departments fulfilling these requests are encouraged to pursue reimbursement from the payer.
Finally, the reports created following payer reviews and audits typically contain a wealth of information about provider performance and shifts in your patient population. Here are three ways to get more value for your record release efforts:
- Look for opportunities to improve and share the information with all involved parties: business office, HIM, and clinical documentation improvement (CDI).
- Identify opportunities for additional patient service lines or new provider relationships based on specific patient population patterns and trends.
- Define how patients will use quality reports to shop for healthcare, choose providers, and identify health systems with the best outcomes.
To shift medical record disclosures conducted by business office staff from a paperwork burden to a departmental asset, thorough tracking of every release is essential. Here are three final best practices to consider:
- Collaborate with HIM and privacy to implement standardized record release processes and guidelines, including how to document each medical record release to payers.
- Establish an organization-wide standard for ROI to keep personal health information (PHI) safe and provide consistent data recording.
- Hold frequent communication meetings with local payers and stay updated on policy changes related to claims processing, audits, and retrospective reviews
Knowledge gained from business office disclosures helps providers prevent denials, reduce accounts receivables, and ultimately negotiate more favorable terms for tomorrow’s value-based reimbursement rules.