The following is a HIM Scene guest blog post by Lula Jensen, MBA, RHIA, CCS, Director of Product Management at MRO. This is the second 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.
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. It is not their core competency.
Whether the request is unsolicited or solicited by the payer, time required to compile information and respond wreaks havoc on business office productivity. Also in efforts to meet payer deadlines and expedite claims, human mistakes can be made. Incorrect patient information might slip through the cracks.
Despite concerns, many business office directors prefer that payer disclosures be sent out by their own business staff—versus by the HIM department. If your organization follows that practice, this HIM Scene blog post is for you.
Two Types of Business Office Requests
There are two instances of business office Release of Information (ROI) to know: unsolicited and solicited requests. The unsolicited process takes place when medical documentation containing all the additional information pertinent to the service being billed is submitted proactively by the provider with the initial claim. The solicited process occurs when the original claim is sent without additional supporting medical record documentation and the payer subsequently (during the adjudication process) determines that additional information is needed. The payer then places a request for the additional documentation from the provider.
Unsolicited Releases During Claims Processing
The purpose of releasing information during claims processing is to expedite payment. In an effort to get the claim paid faster, medical records are sent proactively with the claim. This is especially true for high-dollar claims, payer policies, readmissions within 30 days and the published Office of Inspector General (OIG) Work Plan.
Sounds like a good intention with the organization’s best financial interests in mind. However, three concerns arise when business offices send medical record documentation to payers—versus having HIM professionals take charge.
- 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 breach.
- 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. This creates a huge administrative burden on payers.
Similar challenges ensue with solicited payer medical record requests that occur during the adjudication process or retrospective reviews.
Business Office Disclosures for Payer Audits and Reviews
There has been significant uptick in payer audits and reviews, a topic that was covered by HIM Scene last month. This includes governmental and third-party commercial. According to one central business office director at an MRO client site, “The pull lists for payer audits and reviews keep getting longer and the piles of medical records to send keep getting higher.”
To reduce administrative burdens with payers, some organizations are allowing payers direct access to their EMRs and EHRs to obtain the required information during audits and reviews. While this process may lighten the load for billing personnel, it is laden with additional privacy risks.
Business office personnel complain about the travails of responding to all the various requests for records. However, a significant number of business office directors still insist on owning the ROI process for payer audits and reviews. When this is the case, there are several important steps for HIM directors to consider.
Three Steps for HIM: Educate, Track and Talk
For both types of business office disclosures, it is important to educate billing staff about the implications of a HIPAA breach and privacy risks listed above. Establish an organization-wide standard for ROI to keep PHI safe during all types of business office disclosures. Educating all personnel involved in business office ROI (whether for claims processing, audits or reviews) helps relieve frustration with the record release process.
Billers should also track which specific records, and what sections of each, were sent. By documenting and then reviewing this information, organizations gain valuable knowledge about payer trends—insights that can be used to prevent denials and negotiate more favorable terms for payer contracts.
Collaborate with privacy and the business office to determine which release information to track. Then establish a common database or software application to document each release to payers. Here are four ways to make the most of business office ROI tracking data:
- Look for patterns in what payers are requesting. Any trends in payer request activity could offer opportunities for provider improvement.
- Identify risk. Analytics can help business offices detect weaknesses in the revenue cycle, involving coding, documentation or other internal processes.
- Educate coders, biller, collectors, physicians, etc. on payer trends and how collaboration can promote accurate, complete billing for services rendered and support a claim via medical record documentation.
- Use data analysis. When payer contract negotiations arise, use payer trend statistics to your advantage in the next round of negotiations.
Talk with local payers and stay updated on policy changes related to claims processing, audits and retrospective reviews. Open communication with each payer is recommended to ensure records are sent in the most secure way possible. Communication with payers also reduces phone tag and minimizes payer-provider abrasion.
Finally, due to the importance of collecting medical record documentation, health plans are willing to pay for records. Business offices and HIM departments fulfilling these requests are encouraged to discuss and pursue reimbursement from payers.
About Lula Jensen
In her role as Director of Product Management for MRO, Jensen drives product enhancements and new product initiatives to ensure MRO’s suite of solutions enable the highest levels of client success and end-user satisfaction. She has more than 15 years of experience in healthcare, focusing on Health Information Management (HIM), Revenue Cycle Management, analytics, software development and consulting. In addition to holding product management roles at McKesson Health Solutions and CIOX Health, she also served as Revenue Cycle Manager at Fox Chase Cancer Center and taught a course on ICD-9 CM Coding and Reimbursement at Bucks County Community College. Jensen is an active member of the Healthcare Financial Management Association (HFMA), American Health Information Management Association (AHIMA) and Pennsylvania Health Information Management Association (PHIMA); she is a 2005 PHIMA Scholar Award recipient. Jensen holds a B.S. in HIM from Temple University and an M.B.A. in Health Care Administration from Holy Family University.
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