Hayes' Healthcare Blog

Rules, Regulations, and Reimbursement: Straining Relationships Among Clinicians, Compliance and Revenue Cycle Teams

Posted by Vasilios Nassiopoulos on August 15, 2018 at 2:00 PM

This is the third in a series of four posts discussing how a revenue integrity program can help clinical, compliance and revenue cycle teams join forces to address the increasing challenges of compliance. In our first post, we discussed how a revenue integrity program can be a unifying force in the organization and in the second we explored the growing complexity of physician practices as regulatory demands grow.

In our previous post we discussed the increasing regulatory burden on the healthcare industry, and how it spurred the creation of large physician groups who could afford to staff their organizations with compliance teams and revenue cycle departments. Today we’ll look at how these regulatory demands sometimes put these groups at odds, and how a strong revenue integrity program can help bring them together in a new spirit of cooperation. 

Gentlemen, take your corners

The growing oversight by government payers and insurance companies caused a splintering inside healthcare organizations into three groups, each with seemingly different goals and responsibilities:

  • Physicians. Practicing clinicians were forced to balance the desire to spend quality time with their patients with the need to fulfill documentation demands.
  • Compliance teams. In an effort to avoid the penalties and reimbursement costs associated with compliance violations, compliance professionals became the "watch dogs" – responsible for monitoring clinicians to make sure they were adhering to the new requirements.
  • Revenue cycle departments. As clinicians began to “play it safe” and under-code the services they were providing in order to avoid compliance penalties, the revenue streams of their organizations began to suffer. This required establishing another team the revenue cycle department to monitor payments to ensure the organization was being properly reimbursed.
Increasing pressures cause tension

As each group diligently attempted to carry out its mandate, it was inevitable that relationships between them would become strained. For example, when Medicare changed the DRG reporting requirements in 2008, another new group was created Clinical Documentation Improvement (CDI) to “support” physicians to tell them how to document their services according to the new requirements. However, many clinicians interpreted this as payers dictating to them how to practice medicine in order to be compliant, causing further frustration. At the same time, revenue cycle teams, who were trying to collect for the services provided, would often become irritated when claims were rejected because of improper coding or insufficient documentation.

The shift from fee-for-service to value-based care increased the pressure on all three groups. Because of the additional risks posed by the new requirements, which could result in inadequate reimbursement for services delivered if they didn’t meet certain quality standards, compliance teams now also had to audit clinicians to make sure they were complying with new requirements. They also had to protect the organization from additional penalties for not complying with new mandates.

Increasing cost burden

The costs associated with the additional resources needed to monitor compliance and protect revenue streams - plus the reduction in the time that physicians could spend with patients - all contributed to a hit on both the top and bottom lines, creating a fiscal nightmare for many healthcare organizations. Over the years the mountain of regulations has taken its toll: suppressing revenue; imposing new controls on clinicians and how they practice medicine; inducing fear of financial penalties for non-compliance; and causing conflict across all three groups instead of bringing them together as collaborators.

It doesn’t have to be that way. Focusing the resources and experience of all three groups to provide quality care, to help make the organization profitable, and to remain in compliance can be much more effective approach. In the fourth and final post of the series, we will outline how you can set up a revenue integrity program that will break down silos and get clinicians, compliance groups and revenue cycle teams to work together to reach those common goals.

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Topics: Revenue Cycle Health, Healthcare Regulatory Compliance, Telehealth

Leading the Path with Information Governance

Posted by Johanna Legaspi on September 7, 2016 at 9:00 AM

Security Issues

When hearing the words "information governance", at first glance, you think 'does this deal with the government'? In fact, it is a part of something larger than we expected: healthcare information and data security. Lately in the healthcare news, we have been hearing a significant increase surrounding cyber security threats to healthcare industry most especially in patient data breach or ransomware. Why is this happening? Security breaches are what we have been dealing with since healthcare has become digitalized. There has been a significant surge in patient data collected, shared, and analyzed on a daily basis.

Ransomware is a type of malware that prevents or limits users from accessing the system with encrypted files.  Then forces the victims to pay ransom via online to grant them access. Hospitals are the perfect mark for this kind of extortion because they provide critical care and rely on up-to-date information from patient records. 

These types of attacks create fear and anxiety. And if we’re educating our healthcare leaders to today's best standards then we can take appropriate actions as opposed to reaction. It is the responsibility of the executive in charge of information security at a healthcare organization to help C-suite executives understand and digest technical and threat assessments, which can be quite complex. The appropriate answer is to build an information governance program.

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Topics: Information Governance, Healthcare Regulatory Compliance, Cybersecurity

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