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.

By Connie Renda, MA, RHIA, CHDA

Challenges in HI Staffing

Understaffing

Understaffing is a perennial issue that plagues healthcare information management. The demand for skilled professionals often surpasses the available talent pool. A report from the Society for Human Resource Management (SHRM) notes that finding suitable candidates and retaining employees will be paramount for organizations in 2023. However, this search for top talent often collides with budget constraints, creating significant challenges, especially in an era marked by concerns over inflation. Many organizations find themselves handcuffed by hiring freezes or grappling with staff shortages due to employees on FMLA leave, compounding the problem further. The critical HIM duties cannot be deferred and require a dependable workforce, which isn’t always readily accessible when needed.

Skill Gaps

In the ever-evolving healthcare landscape, skill gaps are another major headache for healthcare information leaders. As Forbes aptly points out, the industry is grappling with substantial talent shortages as skill sets struggle to keep pace with rapidly advancing technology. This disconnect between the demands of modern healthcare and the available skill sets places additional pressure on organizations striving to maintain efficiency and compliance in their operations.

Fluctuating Workloads

Fluctuating workloads compound the woes of healthcare information leaders. The volume of work can oscillate dramatically, leading to unexpected spikes in demand that strain an already stretched workforce. Coping with these variations efficiently while maintaining a high standard of service becomes an ongoing challenge.

What Can We Do?

Develop a Flexible Workforce Strategy

Maintaining staff agility is one way to ensure operational continuity and peace of mind. My colleagues had many great ideas to achieve this from cross training to assigning multiple job roles. More experienced staff (or outsourced partners) are motivated by new learning experiences and can help address staff shortages, workload surges, and unique projects. In fact, this is such an effective strategy that Verisma launched a team dedicated for this purpose called Verisma bench.  

Consider Efficiency Gains Through Outsourcing

In addition to ROI, many other administrative HIM tasks can frustrate staff who could be spending more time working at the top of their license. Outside partners can alleviate these burdens and improve efficiency, while eliminating the headaches of hiring and training. Verisma, for instance, can manage tasks like prior authorizations, purge projects, inbound document management, and referral management. so staff can focus on what matters most – patient care. 

Leverage Technology-Enabled Strategic Partnerships

Strategic partnerships are more than supplemental staff. They’re relationships built on experience, consistency, time, and effort. Better yet, technology-enabled service companies do more than complete tasks – they build for the future. Working with a trusted company like Verisma to help with staffing challenges makes sense and allows you to share the burden of finding a qualified, reliable team to address talent shortages.