How HI Professionals Can Translate Their Skill Sets to Managed Care Organizations

This article is part of a series detailing the opportunities and entry into a nontraditional health information management sector: managed care organizations (MCOs). The series began with a big-picture approach, understanding the impact of MCOs on the modern healthcare environment. The series now goes into the direct connections between MCO operations and the health information professional’s skill set. Lastly, it will end with how to transition and the professional benefits.

In the first part of this series, trends in healthcare were examined and why managed care organizations (MCOs) are a viable placement for health information (HI) professionals. We will now cover entry points and make direct connections between HI roles and skills in traditional settings and how they equate to MCOs.

On the provider side, HI professionals have indirect, daily interaction with payers. This includes responding to medical record requests or audits, coding charts for billing and reviewing determinations, ensuring documentation supports billing, and more. But what is unknown is what happens with that health information on the payer side.

What happens is in line with and requires the HI professional skill set as MCO service offerings call on the following health information management (HIM) domains: governance of data and information, information protection and sharing, informatics, revenue cycle, clinical foundation, and health law and compliance. All the standards, all the data, all the operations, and—most importantly—all the challenges are largely the same.

This article will help draw similarities between providers and MCOs to identify where HI professionals and their interests and background can add value and opportunity. In these examples, there are parallels between traditional HI professional areas and roles within an MCO.

Data and Information Governance, Informatics

MCOs generate health data but rely heavily on ingesting data from external entities, such as the government and provider networks. The information is needed to make decisions on operations, population and member initiatives, and manage quality and scoring like the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare star ratings.

MCOs are data-rich entities that are in the unique position of being an interpoint of data generation and sharing across the entire health care ecosystem.

HI professionals know data sharing and utilization are far from perfect or optimized. On the provider side, large-scale, electronic health record (EHR) and subsidiary systems produce a relevant amount of structured data. Due to the reliance on external information, most of the ingested data is unstructured on the MCO side. There is a keen need to have the ability to couple both unstructured and structured data. The effect is invaluable, as the full extent of both quantitative and qualitative portions of a person’s health record are needed to provide accurate and effective intervention

HI professionals already harness this ideology. Coding, diagnostic-related group (DRG) assignment, and case mix index are all a result of the marriage of these two data structures. Patient age, lab values, and body mass index (BMI) are all structured data elements; progress notes and operative reports are unstructured data elements. Together, they are quantifiable information that allows for measurement of severity and care; and aggregated, they allow for knowledge and problem solving at the population level. This creates insight for the literal transformation of the healthcare system to reach the Triple Aim. Data and analytic technology are rapidly evolving, but what is needed is the intermediary of a HI professional who understands not just how to link privacy and information sharing, but what the information is and how to use it, as well as how to control it.

Unhinged, data use can be detrimental. But the ability of a HI professional to facilitate the linkage of a single diagnosis code or DRG to implementing targeted interventions within the community and population is an unmeasurable value to any MCO. Highly specialized and technical skills are often top of mind with issues such as data governance.

Technical skills are needed for infrastructure, but other skills are needed to ensure quality data tells the story. It’s more than managing the raw data.  A skilled HI professional can turn data into knowledge.

Traditional HI Professional Areas:

Cancer/Tumor Registry, Information Governance, Health IT, Regulation, Medical Record/EHR Quality/Data Analyst, Case Mix Index

MCO Areas Where Skills Apply:

HEDIS, Data/Information Governance, Records Management, Business Analyst, Quality

Sharing and Protecting Health Information

Requests for information, bulk audit requests, direct access, direct connection, and health information exchanges (HIEs) are all operations and programs that occur on the payer side as well. The familiar patient/member request or lawyer requests, government and oversight agency requests, portals, master patient index (MPI), and technical maintenance attributed to multiple HIEs are all almost identical to payers. The difference is that there isn’t a central EHR acting as the nucleus for source information and as a channel to share.

On the payer side, there is added complexity. Information sources vary—created, ingested from external entities, and aggregated—and all reside in niche systems. This requires the same knowledge and skill set held by HI professionals, who serve as the privacy expert equipped with the technical know-how. And the same regulations apply: Health Insurance Portability and Accountability Act (HIPAA), stipulations of the Cures Act, the Health Information Technology for Economical and Clinical Health (HITECH) Act, as well as state contracts. But now, there are emerging regulations that will push and regulate interoperability between payer-to-provider and payer-to-payer.

The emerging regulations in the payer space follow suit from the provider space, such as new information sharing regulations with opt-in and opt-out standards for patients. Sound familiar? HI professionals have learned this lesson.

This skill set is even more valuable with the growing trend of payers acquiring providers and pharmacy benefit managers. As the distinction among payer, provider, and pharmacy blurs, the need for professionals who have been engaged with patient/consumer privacy and information sharing increases.

HI professionals can navigate the various regulations and consideration points for minors and specially protected information, serving as the advocate for the patient/consumer. The Interoperability and Patient Access Rule (CMS-9115-5) has two provisions that HI professionals have already faced in traditional settings. The first is the Patient Access Rule, which calls for increasing the ability for health plans to proactively provide information on claims and clinical data. Does Open Notes come to mind? There is a clear indication of the patient and data advocacy regulations being applied to the payer space. The second provision is the Payer-to-Payer Rule, which enables patients/consumers to request data transfer among health plans. This is only the tipping point of other payer-to-payer exchange regulations.

This is especially important in the MCO space as members move in and out of Medicaid based on qualifying factors, move to locations where their current MCO is not contracted to serve, or switch plans during reenrollment period. These regulations help ensure the continuity of care. Examples include prior authorizations carried forward to eliminate reevaluations and loss of coverage, case management and waiver program inclusion, and aggregated clinical history. Much of the enforcement of this final rule will take effect in 2023.

Traditional HI Professional Areas:

Release of Information, Privacy, Health Information Exchange

MCO Areas Where Skills Apply:

Information Governance, Records Management, Data Governance, Compliance, Privacy, Health Information Exchange, Release of Information

Revenue Cycle Management

On the provider side, documentation and coding not only enable billing representative of services provided, but also quantify the severity of illness of populations. The hospital setting focuses on Case Mix Index (CMI), while long-term care uses the Minimum Data Set. Each discipline has its index for illness and a level of resource needed to address those illness groupings.

For MCOs, that index is based on risk adjustment or a risk adjustment factor score that quantifies the level of resources an MCO needs to manage the care of its members. That resource is provided to MCOs by the government in monetary values on a per member, per month basis. The same work up and data aggregation that happens on the provider side goes into risk adjustment operations including medical record documentation review and improvement, diagnosis coding, procedural coding, and demographic data. This enables risk adjustment teams to accurately quantify member population care needs through a health scoring classification and taxonomy.

MCOs work directly with their providers to improve their documentation and coding. The myth is that payers want to “down code” to reduce payment. This is simply not true. MCOs rely on the highest level of justified coding to ensure they secure resources and scorings. The clinical documentation needs to be aligned and made available to support claims.  That documentation often is not provided at the start of the billing process cycle.

Records have to be requested from providers across the network at monumental volumes. In the best-case scenario, which is the minority of cases, a direct data feed or third party passes data supporting claims. In a less than ideal scenario, the MCO has access to the provider EHR.

This requires managing access to accounts for thousands of providers and extracting static information. The most common scenario is a traditional request for information process. All of this still requires intervention to extract information from static records to feed other systems and enable the operations of risk adjustment, claims, HEDIS, scoring, and more. It’s reminiscent of HI professionals’ ownership of enterprise/document content management systems.

On the provider side, HI professionals ensure clinical documentation represents episodes of care to enable accurate coding to the highest degree and that coding accurately captures and optimizes billing. To keep providing care, providers need reimbursement that matches the level of service. Similarly, MCOs perform the same functions for the same purpose, but with special consideration tied to the Triple Aim, controlling costs, and preventing overbilling.

In fact, overbilling and fraud are so prevalent that all payers have divisions devoted to payment integrity – another area where HI professionals can provide value. The National Health Care Anti-Fraud Association (NHCAA) estimates financial losses due to healthcare fraud account for billions of dollars each year. The NHCAA says a conservative estimate is 3 percent of total health care expenditures, yet some government and law enforcement agencies place the loss as high as 10 percent of the nation’s annual health outlay, totaling closer to more than $300 billion. Even in good faith, government payment structures have been identified by the Office of Management and Budget as at-risk for significant improper payments. In 2020, an estimated $130 billion was issued in improper payments across Medicare, Medicaid, and CHIP, money that will be sought through rectification.  

Traditional HI Professional Areas:

Coding, Clinical Documentation Improvement, Auditing, Release of Information

MCO Areas Where Skills Apply:

Risk Adjustment, Coder, Appeals and Grievance, Medical Record Retrieval, Program Integrity

Clinical Foundation

Like traditional healthcare settings, MCOs consist of clinical departments across all disciplines. Licensed practitioners are a part of every MCO to guide the mission and strategy. The clinical foundations and pathways come from the same medical and provider authority entities as used in the provider settings. Claims decisions, case management, and covered services are all based on universal standards of care and documented health information.

In the HI profession, it’s common knowledge that revenue models used to be based on the “heads in beds” model. Long lengths of stay and exhaustive workups backed fee-for-service and revenue. Hence, DRGs and clinical documentation improvement arrived, reducing costs as well as combating waste and ineffective care. On the provider side, HI professionals help ensure episodes of care are accurately reflected and warranted. But there are still gaps due to pure feasibility. Are CDI efforts touching every visit; do UB and billing forms capture all codes relevant information?

The Centers for Medicare and Medicaid Services’(CMS) hospital price transparency rule showed the price of healthcare is not consistent. MCOs are working on their members’ behalf to ensure accurate and equitable reimbursement. On the provider side, HI departments are the oversight for provider documentation compliance. Outside of clinical disciplines, HI teams have the closest relationships with providers in a healthcare organization — a unique skill that separates HI professionals from other roles in the healthcare setting.

While standards of care are universal and ample information is generated for each episode of care, the initial decision point between provider and payer only encompasses a fraction of the available information tied to an episode of care. Therefore, there is great need and value for HI professionals at the intersection of medical-technology-business.

The HI profession is needed in the MCO, just like in provider organizations, to balance and bridge the medical and the business sides of healthcare as the MCO clinical model is both at the individual and holistic level. MCOs employ nurses, physicians, social workers, psychologists —all clinical disciplines to not only provide direct care, but manage the care of members across  their network of providers.

Additionally, the MCO forms clinical models and service offerings to ensure members and populations have accessibility to what is needed for their well-being and health. An AHIMA survey found that nearly 80 percent of healthcare organizations are collecting data on social determinants of health (SDOH), but they can’t effectively use it for reasons that HI professionals are equipped to solve. A staff member with knowledge of medical records, diagnosis and procedure classifications, and the ability to quantify health information is needed to make SDOH data actionable. This is key to moving value-based care models forward. Quality health information and data translate to improved care if the appropriate HI professionals are in place.

Traditional HI Professional Areas:

Coding, Clinical Documentation, Deficiency Analysis, HIM Analyst

MCO Areas Where Skills Apply:

Risk Adjustment, HEDIS, Program Coordinator, Quality Performance, Population Health, Provider Network

Health Law and Compliance

At any given time, HI professionals must be experts in the realm of privacy standards, patient rights, accreditation regulations, and government conditions of participation. And this is in addition to always preparing and anticipating visits or audits.

All of these regulations can include gray areas that are constantly changing, or new regulations are popping up. MCOs must abide by those same standards in HIM curricula, such as HIPAA, the Health Information Trust Alliance (HITRUST) framework, and other CMS requirements.

There are even more layers with payer and MCO specific regulations. Medicare, the Office of the Inspector General (OIG), and the Office of the National Coordinator for Health Information Technology have federal regulations. Medicaid brings a trifecta of regulations — federal, state, and state contract. Additionally, as an MCO, there are other service offerings to ensure the well-being of members. Referred to as products, these include services such as long-term services (a good opportunity for skilled nursing facility and home health HI professionals), pharmacy benefits, behavioral health, dental, and social determinants.

The regulations for each vary by state and how the federal government interprets them. Since MCOs are a steward of government dollars, there are regulations around revenue cycle, including risk adjustment, value-based care models, carve outs, capitation, etc. MCOs are even responsible for provider scores and compliance. Using the HI skill set can aid smaller providers in compliance efforts, ensuring providers meet requirements to provide optimal service to members and managing the provider network.

Therefore, not having direct experience with payer regulations is not a barrier to exploring jobs with MCOs. Many of the same regulations HI professionals address are also pertinent in the payer space. But perhaps more important than familiarity with a scope of regulations is the ability to learn, master, and lead—skills HI professionals have demonstrated time and time again.  

Traditional HI Professional Areas:

Privacy, Compliance, Practice Management, Coding Auditing

MCO Areas Where Skills Apply:

Compliance, Provider Network, Regulatory, Audit, Internal Controls, Special Investigation, Coding Auditor, Risk

Stephen A. Young, RHIA, MBA, MSS, is director of records management organization for the enterprise risk management division of the AmeriHealth Caritas Family of Companies.

Statements of law, fact and views expressed are those of the author individually and are not the opinion or position of AmeriHealth Caritas Family of Companies, its parent organizations or its affiliates. The AmeriHealth Caritas Family of Companies does not endorse or approve, and assumes no responsibility for, the content, accuracy or completeness of the information presented.