Revenue Integrity: How to Reduce Costs and Retain Revenue

As the world prepares to navigate year three of COVID-19, the impact of the pandemic continues to touch every facet of healthcare. For health information (HI) professionals, demands to share patient information and support interoperability present multiple challenges related to the complexities of release of information (ROI). There has been a significant increase in medical record requests required to validate more complex care, including telehealth, telemedicine, and psychiatric care.

At the same time, revenue cycle teams, including business office and health information management, are focused on ways to reduce costs and retain revenue. A successful approach calls for communication and collaboration among various departments to achieve shared objectives:

• Evaluate ways to provide more efficient, scalable, and trackable information sharing to support claim payments and payer audits.
• Quantify specific expenses associated with the release of information to payers for claim adjudication.
• Enhance interdepartmental collaboration and dedicate respective teams to maximize compliance, production, and revenue associated with requests for information.

A crucial factor to consider is the recent increase in audits. Payers are creating and implementing payment integrity programs that place more conditions on payments, including upfront requests for records. This process can delay payments and add to lower reimbursements due to code changes, particularly for commercial plans and managed care plans. Payment integrity reviews have increased because commercial payers have followed in the footsteps of government recovery audit contractors and found there is considerable financial impact to ensuring accurate payments, often prior to initial payment—preferring to compare the documentation prior to paying.

Assess Costs and Resources

To support revenue retention, it is important to assess communication methods, actual costs, staff time, and resources.

Electronic Communication versus Paper Delivery – From a business perspective, electronic communication is preferable to ensure secure file transfer between the organization and the payer. Though paper is still the predominant method of delivery, especially on the audit side, electronic is the path toward the future.

Cost to Process – Begin with actual costs to print and mail documents—paper, toner, mailing supplies. What are staffing costs associated with this workflow? How long is the cycle time to get the records to the payers? What is the financial impact to the organization, in resources, aging accounts, and lack of transparency?

Paper Shipping Methods – Claims and medical records must be received by the payer in a timely manner and should be held accountable. Over the past year, mail has been less reliable, even certified mail with tracking. Payers have rejected shipments due to large page counts and reductions in on-site staff. Consider the options such as certified, priority, and FedEx. Determine how much is spent for each type of shipping service and payer accountability if not received or rejected.

Staff Time and Resources – Determine staff time to process a medical release from start to finish, including wait time (non-value added). If the business office identifies a medical record need, be sure to include time to print, package, ship, update the patient financial service system, and wait for payment. Wait time has been affected by remote work practices during COVID-19. If printed only once a week to send out medical records, then build in wait time. For example, consider that records are printed each Friday and sent out the following Wednesday. That means five days of wait time while accounts age. What is the cost/impact on accounts receivable?

FTE Costs to Process – Calculate FTE costs including salary and wages, time spent processing, time not available to process claims or manage other value-added tasks, and again wait time.

Prepare for Audits—Avoid Denials

Preparation for audits requires awareness of current trends and areas of focus. Auditors are consistently reviewing a larger volume of records for clinical reasons. Best practice is to know the auditors and what they are auditing. Look for key requirements based on contractual obligations and specific conditions of payment. What do they expect to see when they make a request? Was the record sent and didn’t have components they expected to see? Was documentation missing? The complete medical record is required to substantiate documentation and coding. To avoid denials, ensure the record template is complete and accurate for resubmission of claims or records while accounts age.

According to a 2020 Medicare CERT Report, missing or inadequate documentation accounted for 49 percent of improper payments, which equates to revenue loss for the organization. Improper payments can be managed, and HI leaders are working diligently to get this number down.

Documentation – Documentation is critical. The physician outlines patient care and services required to treat the patient—coding and billing specifications. Documentation by other clinicians can drive charges and impact audit outcomes whether it supports or conflicts with the physician documentation. Look for conflicting information or missing information and eliminate doubt that could prompt auditor requests for additional information.

Payer Guidelines – Variations in payer guidelines contribute to the complexity of the billing and validation process. If the organization is predominantly Medicare, then a focus on those guidelines is critical. However, with shifts to managed care expected to increase to more than 40 percent in 2022, there must be enhancement of the knowledge base to include commercial and managed care requirements and contractual guidelines. Working with the managed care department is critical to determine and understand payer variations, especially with top-audited types of requests. In addition, payers are increasing demands for documentation submission for condition of payment. HI professionals should participate in discussions to establish controls such as limitations on volume and requests. Now is the time to get involved and prepare for change.

PHI Disclosure Management

Health information management has become more complex with the change to electronic records, especially as more people have access to the patient record and the ability to release it. With multiple points of disclosure, it is difficult to ensure secure access. When handling reviews and ROI, centralized management by HIM is essential to compliant, efficient disclosure of protected health information. As the ultimate record custodian, HIM is expected to monitor and control releases according to an effective compliance program. They are responsible for providing complete, compliant medical records to support proper patient care and reimbursement.

When revenue cycle teams release medical records, it is important to understand the reasons for release to support reimbursement for care. Here are five common revenue cycle releases:

• HIM – Routine ROI – Medical records are needed for patient care/continuation of care, patient use, third-party requests such as attorney, disability claims and insurance.
• HIM – CDI – Medical records are provided during the query follow-up process.
• HIM – Coding – Medical records are provided to clarify diagnoses and correct coding.
• 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.

Complexities of a Multi-Facility Health System—Best Practices

CHRISTUS Health is a multi-facility organization that manages multiple applications across 11 regions. With this level of complexity, knowing where to access and release information is a challenge that requires a tracking mechanism. Payer access to medical records is a critical concern, particularly requests for access to legal health records. Collaboration with information technology and health plans can help with guidelines to place limits on payer access. Consider the following tips to ensure proper medical record access and release:

• Maintain a catalog or transaction of all record releases.
• Submit records via monitored mediums to minimize risk of unauthorized disclosure or technical denial—electronic portals, carrier shipping with tracking and delivery receipt.
• Define request/release scenarios and assign department responsibility.
• Work with the compliance and privacy team to provide annual training on record components and elements to release.
• Limit or prohibit direct payer access to the medical record system.

Collaborative revenue cycle processes support a large number of hospitals and multiple business offices that drive the financial impact of claim monitoring and adjudication. HIM and revenue cycle teams work together to achieve revenue integrity, guided by the following practices:

• Map the life of a medical record and claim, including denial and appeal. Identify opportunity for record disclosure during this life cycle. Refer to best practices and training to avoid unauthorized disclosure.
• Use tracking software for any denial and appeal activity. Ensure transparency between departments. Monitor and trend volume.
• Regularly monitor activity processed in revenue cycle departments. Promote a team environment and open communication. Assess risk.
• Audit ROI activity to ensure compliance. Satisfy each request with complete record components, review denial reasons compared with the records provided, and continue the audit process cycle with the revenue cycle team.  

Looking to the future, HI professionals can anticipate increased requests for access to medical records in response to the demand for complete, compliant information to support clinical decision-making, reduce costs, and retain revenue.

Dawn Crump is a senior director of revenue cycle solutions at MRO.

Prudence Budemer is a revenue cycle services director at CHRISTUS Health.

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.