January 2, 2023

Privacy gets (more) complicated

We’ve said it before – the US is overdue for a national conversation on privacy. 2023 only increased the stakes with the increased adoption of AI, stark state-level differences on social policies, and the prevalence of cybersecurity threats.  Navigating these conflicts – in the absence of a national privacy framework – will be increasingly time-consuming and high-stakes for privacy and compliance professionals.

Patients will be the primary focus

Healthcare consumerism and patient-centered care have been hot topics in 2023 and will remain so in 2024. One area that hasn’t received as much attention is the emphasis on individual patient factors – for example, what constitutes a burden for some patients when requesting records is not for others.  Information blocking exceptions specifically prioritize individual factors in the preventing harm and content/manner exceptions. It will no longer be enough to have a black-and-white procedure manual; instead, organizations may want to consider a “playbook” of factors to be considered.

Expect regulatory activity, especially in early 2024

The last Congress will be one of the least productive in memory – and there weren’t high hopes given the ideological polarization and thin margins in both chambers. Expect to see regulatory agencies attempt to step in through rulemaking.  Early 2024 will likely see the most activity – agencies will want to publish or enact any rules prior to 60 days before a potential change in administrations.

and as always …

Executing on fundamentals is key

This one goes across all areas – we can’t stop emphasizing fundamentals while we handle increasing complexities. It’s the little things that get you in the end. Keep on top of cybersecurity by emphasizing employee cyberhygiene, patient privacy and safety by verifying patients with two identifiers, and patient access by improving request processes and adding new delivery options.

By Barbara Carr, RHIA

In today’s ever-evolving healthcare landscape, navigating the challenges posed by increasing payer audits and denials demands a proactive and expertly crafted approach to claims accuracy and compliance. To effectively tackle these challenges, healthcare organizations must adopt an integrated solution that tracks the entire audit process from initial request receipt to denial and appeal resolution. This comprehensive and systematic approach is vital for mitigating the financial risks associated with payer audits and ensuring sustained success.

Herea are some top reasons you should focus on optimizing your payer audit management process:

Enhanced Efficiency and Organization: The integration of all audit-related information and documents into a centralized system streamlines the entire audit process. This eliminates manual tracking, reduces administrative burdens, and safeguards against missing critical deadlines.

Timely Response to Audits: By diligently tracking audits from the moment of request, Release of Information Specialists (ROIS) can promptly respond to audit inquiries, reducing the likelihood of delayed or incomplete responses that may lead to denials. An integrated system also provides valuable data on the status of audits, ensuring that deadlines are met.

Improved Visibility and Transparency: Payer audits involve multiple steps and stakeholders. A comprehensive system offers real-time visibility into the audit status, empowering coding teams, clinical documentation teams, compliance officers, and management to stay informed about audit progress, denials, and appeals.

Identification of Patterns and Trends: With an effective audit management process, organizations can identify patterns and trends in coding audits and denials. Analyzing this data enables a proactive approach to address root causes and prevent future denials, ultimately leading to improved financial outcomes.

Compliance and Regulatory Adherence: Adherence to coding and billing regulations is critical for healthcare organizations. Your audit tracking solution should be built to ensure systematic compliance with these requirements.

Effective Appeals Management: Tracking audits through the denial and appeal process is essential for efficient appeals management. With proper audit management technology, an audit team can identify common reasons for denials and develop targeted strategies to overturn them.

Data-Driven Decision Making: Comprehensive reporting capabilities (beyond spreadsheets) enables an audit team to gather data on audit outcomes, denials, and appeal success rates. Armed with this critical data, financial teams can make informed decisions regarding coding practices, training needs, and resource allocation.

Proactive Risk Mitigation: Vigilant monitoring of audits and denials allows organizations to proactively address potential compliance risks and coding errors. This approach reduces the financial impact of denials and minimizes the risk of audits leading to legal or regulatory issues.

A comprehensive approach to payer audit management supported by advanced technology is essential for healthcare organizations to achieve sustained success in an increasingly complex healthcare landscape. By focusing on optimizing this process, organizations can stay ahead of payer audits and denials, safeguard financial stability, and maintain a commitment to delivering high-quality patient care.