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ROI and Revenue Cycle Crossover Calls for Collaboration

By Dawn Crump

The crossover between the release of information (ROI) process and revenue cycle involves multiple touch points and considerations, particularly for HIM professionals responsible for the secure disclosure of protected health information. With increased requests for audits and access to EHRs, collaboration between HIM and the business office is more important than ever before.

Audit Update for 2020
For hospitals, the increase in targeted commercial payer audits is especially troubling as those audits are not subject to the same guidelines as government payer audits requiring experienced staff and established processes. Making sure all commercial payer audit information is sent to a single department or individual is difficult. As a result, communications about the same audit request may go to HIM and the business office. The following are strategies to help HIM and the business office improve communication, collaboration, and efficiency.

• Create a team featuring representatives from both departments to establish standardized, centralized processes and procedures.
• Track audits by payer—eg, type, prepayment or postpayment, dollar value, service line, volume, timelines.
• Review payer guidelines to understand the requirements for medical necessity.
• Evaluate your managed care contract and update language to close loops.
• Set policies to make sure records are complete before sending to the payer—proper signatures, notes, and queries to substantiate treatment.

As the COVID-19 crisis continues to wreak havoc on the US health care system, providers are struggling to meet unprecedented patient care demands while also protecting revenue cycle operations. To ease the potential economic impact, Medicare and commercial payers are expediting payment to providers. Many payment integrity audits have been suspended as resources are funneled toward COVID-19 treatment.

We expect audits to resume later this year as payers review medical documentation for payment integrity, fraud, and quality. Compiling and analyzing the information will assist in future treatments and operational recommendations. Commercial payers will likely resume auditing sooner than others. Unfortunately, documentation and coding errors are inevitable with so little time to educate on new codes. Proactive reviews of documentation by HIM and CDI teams will help providers avoid substantial revenue loss.

Payer Access to EHRs
Though payers propose that access to EHRs can expedite claims processing, reviews, and audits, there are potential risks to providers’ privacy, security, and financial health. In fact, direct access to patient records will likely facilitate the growing trend of prepayment reviews, denials, and recoupments. Providers should maintain strict HIM governance of ROI for all payment audits and reviews.

For claims processing purposes, payers should never have unrestricted automated access to the entire patient record. It is critical to monitor access to a specific episode of care pertaining to the claim. Proper monitoring requires knowing exactly who is reviewing the record, what they are reviewing, and why. Otherwise, the revenue cycle is vulnerable to financial risk due to takebacks.

To mitigate risk, it is important to ensure the medical record is complete and that the language in the managed care agreement clearly specifies limitations on volumes, particularly with the shift toward prepayment reviews.

Managing Payer Requests
To expedite payer requests for information, a business office release process with a quick turnaround time is recommended. A clean, efficient process works well to get the medical record to the payer as quickly as possible to alleviate impact on claim adjudication. In addition, it is important for any department, especially within the revenue cycle, to track the number of records requested by certain payers and set limitations on what they are allowed to view according to the managed care agreement. Again, visibility into who is reviewing the medical record, the reason for the review, and the eventual outcome are critical.

Building Collaboration Between HIM and the Business Office
Collaboration between HIM and the business office requires a streamlined process to track releases and ensure all releases are properly captured. The business office should be able to easily show how many records were requested by a certain payer within a given timeframe. It also needs to understand the downstream financial impacts. For example, were codes removed? If so, determine why they were removed and make sure an appeal is filed.

From a business office user standpoint, a record may be sent multiple times because it did not make it to the payer the first time, or there was no tracking mechanism, or it went to the wrong division within a payer organization. The result is an aging denial, leaking revenue due to delays that could be avoided with proper tracking.

A collaborative approach is beneficial to both HIM and the business office. A streamlined process enables the business office users, follow-up teams, and collections teams to focus on optimal reimbursement, while HIM achieves complete accounting of disclosures and secure, compliant exchange of protected health information.

Benefits of Collaboration

Rationale for Revenue Cycle Releases

• Claim attachment. Medical records needed for payment, which are sent with the initial claim to the payer or immediately following claim submission to expedite claims payment.
• Prepayment. Medical records are requested by the payer after receipt of the initial claim for review of documentation (prepayment, predenial).
• Postpayment. Medical records are requested by a payer after a claim has been paid for a postpayment audit or retrospective review.
• Denial. Medical records are requested by the payer after billing but prior to payment. Payer has designated that the claim is denied due to missing information.
• Appeal. Medical records are required to substantiate an appeal for determination of medical necessity or some other verification of service.
• Authorizations. Records or record components are needed to obtain authorization for services.

Common Revenue Cycle Releases

• HIM – Routine ROI
  Medical records are needed for patient care/continuation of care, patient use, and third-party requests such as those involving attorneys, disability claims, and insurance.
• HIM – Clinical Documentation Improvement
  Medical records are provided during the query follow-up process postdischarge.
• HIM – Coding
  Medical records are provided during order follow-up to clarify diagnoses.
• Utilization/Case Management
  Medical records are requested and provided to the insurance company for verification of coverage and to qualify the services to be provided.
• Discharge Planning
  Medical records are provided to the next level of care for patient acceptance and transfer.

— Dawn Crump is an experienced health care leader with extensive knowledge of provider compliance and revenue cycle operations. She has held leadership roles in large health systems, small revenue cycle startups, and in a value-based care technology company where she managed quality and compliance. Prior to her current role as senior director of revenue cycle solutions at MRO, she held a senior leader position for CIOX Health where she managed the audit software and denial consulting division. Crump has a passion for improving health care and reducing administrative burdens, especially across revenue cycle functions and payer audits. She currently serves as secretary of the Greater Heartland HFMA chapter.

Legal Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect or represent the views, opinions, or policies of MRO Corporation.