Hayes' Healthcare Blog

Quality Management Is Key to Optimizing the Business of Healthcare

Posted by Robert Freedman on January 31, 2019 at 9:30 AM

Quality Management is a familiar concept in healthcare, especially when it comes to organizational excellence and patient safety. Minimizing risks and ensuring safe outcomes for those under your care are critical goals in every healthcare setting.

But patient care isn’t the only area where quality management matters. An effective quality management system is an essential element of a revenue integrity program. In order to provide the best healthcare to your patients, you must build a strong revenue integrity foundation that ensures a financially viable organization. To reach that goal, you need a quality management approach that incorporates auditing and corrective action to optimize every aspect of your business and revenue cycle operations.

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Topics: Audits, compliance programs, revenue integrity, Revenue

Why External Audits are the Best Way to Ensure Revenue Integrity

Posted by Vasilios Nassiopoulos on December 20, 2018 at 11:30 AM


Healthcare organizations take pride in building and maintaining an effective internal auditing team. A robust internal audit program is crucial to avoid the perils of penalties and overpayments that can sabotage both top and bottom lines. Yet despite their best intentions, healthcare organizations that rely exclusively on internal monitoring and auditing functions – regardless of how effective they may be – can face significant pitfalls. 

To ensure that the organization's financial operations are performing to the required standards, it is essential that billing compliance programs go through periodic reviews from an independent, external entity.

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Topics: Audits, compliance programs, revenue integrity, Revenue

How Analytics Can Benefit 4 Key Members of the Compliance Team

Posted by Robert Freedman on February 1, 2017 at 9:00 AM

As healthcare organizations have reached near universal adoption of EHR and practice management systems, the amount of available billing and claims data has grown exponentially. This data has the potential to offer insight to issues that can adversely affect the organization both from a regulatory and financial standpoint. Compliance and revenue cycle leaders are both coming to realize the benefits of collecting and analyzing this valuable information.

However, as compliance teams move from static auditing schedules to proactive risk-based programs to help identify and manage risks, it has become clear that it’s not just managers and supervisors who can benefit from data analytics. A robust analytics program can provide valuable insight that can help every member of the compliance team perform his or her job better.

In particular, use of analytics can significantly improve communication between the compliance team and other departments in the organization. There can often be friction between an auditor and those being audited, but focusing on data and providing a bigger picture view for both parties helps foster better working relationships and more effective issue resolution.

Using actual data instead of hypothetical situations can diffuse disputes and make audit finding discussions positive and more productive. It can also provide a wider view of a potential issue that can aid in instituting effective corrective action, both huge benefits for the compliance team.

For example, an auditor may find an instance of an incorrect E&M billing. It can easily be written off by the physician as a one-time error. However, analytics can reveal a pattern and show it was not an isolated instance. The auditor and physician can then rationally discuss the issue backed by data. That can be a tremendous advantage for compliance teams and helps take the emotion out of findings discussions.

Here are four key members of the compliance team that can get significant value from an organization’s analytics program.

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Topics: Healthcare Analytics, compliance programs

False Claims Act Penalties Doubling: Time to Beef Up Your Compliance Program

Posted by Robert Freedman on September 28, 2016 at 9:00 AM

If you mistakenly submit a single claim that results in a $100 government over reimbursement, you could now be subject to a penalty of over $20,000, according to the lawyers at Mintz Levin, specialists in healthcare law.[1] And that’s for every single claim.

To quote Alec Baldwin’s character in the famous Glengarry Glenn Ross monologue, “Have I got your attention now?”

The Department of Justice recently passed an interim final rule that has nearly doubled the civil penalties under the False Claims Act (FCA) from an already oppressive $5500 minimum to $11,000 maximum per claim to a minimum of $10,781 and maximum of $21,562. The increases – which went into effect August 1 - are the result of a “catch-up” clause in the 2015 Adjustment Act that amended the Federal Civil Penalties Inflation Adjustment Act of 1990.

The act mandates agency heads to adjust civil monetary penalties based on the difference between the Consumer Price Index in October of the year they were established and October 2015. After this initial catch-up, agencies must make additional annual adjustments, so the costs are only going to increase from these new dizzying heights.

The impact for the healthcare industry is seismic. The cost of any slip up in Medicare and Medicaid claims can be financially disastrous and the doubling of penalties means a doubling of “whistleblower” rewards, so organizations can expect increased scrutiny from employees, former employees and competitors looking to cash in.

To make matters worse, because of the sharing of Medicaid costs, the act incentivizes individual states to pass FCA laws in addition to Federal statutes. The pressure on healthcare organizations to “get it right” when it comes to claims submittal has never been greater. With the financial stakes ratcheted even higher, it may be time to refocus your efforts on compliance.

Here are five ideas to help strengthen your compliance program.

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Topics: billing compliance software, mdaudit, compliance programs

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