Client News Coverage

Cleveland-based University Hospitals tapped Harris Data Integrity Solutions to clean up Concord Township, Ohio-based Lake Health's patient index before transitioning to Epic.

The health system is working to eliminate crossover patient records and eliminate errors before it transitions to Epic. Lake Health joined University Hospitals in April 2021, according to an Aug. 8 Harris Data Integrity Solutions news release.

The ongoing – and worsening – labor shortage plaguing all corners of the healthcare ecosystem is hitting revenue cycle management (RCM) particularly hard, with RCM and billing departments reporting vacancy rates as high as 75%. Exacerbating an already significant challenge is the threat it poses to revenues at a time when hospital operating margins continue hovering near zero.

To keep their limited RCM teams from drowning and avoid the inevitable impact on the revenue cycle, healthcare finance executives are increasingly turning to technology to automate manual billing compliance processes and deploy advanced analytics as they recruit skilled professionals to close staffing gaps.

Overcoding is in the crosshairs as the Centers for Medicare and Medicaid Services (CMS) continues its quest to ferret out fraud and abuse and recoup improper reimbursements-a focus that returns $8 for every $1 spent on audits. There are no signs that they are letting up any time in the future, as the federal government has increased funding for audits and fraud investigations.

Overcoding-intentional or accidental-can bring significant fines in addition to repayment of the original claim. And the reputational damage of a fraud finding is hard to overcome. As such, provider organizations need to be vigilant with their compliance and education programs to avoid finding themselves on the losing end of a CMS or other third-party audit. Overpayments also have a negative impact on patient acquisition and experience, thereby deflating growth. The whole idea of declaring financial results to the public domain and restating the results repeatedly due to uncertain compliance risks is a nightmare for most of the financial leaders within health systems.

BC Advantage»

Revenue cycle management (RCM) has never been more important to the success of healthcare providers across the care spectrum, but the industry faces myriad challenges. A continuing labor shortage and lack of skilled workers threaten revenues at a time when hospital operating margins hover near zero.

While highly skilled professionals are still needed, RCM teams can work smarter and not harder by using technology to automate manual processes and deploy advanced analytics to identify the cause of denials. Further, as private insurers follow Medicare’s lead by increasing third-party audits, providers need to understand their claims and auditing process at a foundational level to support their billing practices and maximize legitimate revenue.

The payer/provider relationship is often seen as adversarial, with delays and denials by insurerstaking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

The payer/provider relationship is often seen as adversarial, with delays and denials by insurerstaking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

Revenue cycle management (RCM) has never been more important to the success of healthcare providers across the care spectrum, but the industry faces myriad challenges. A continuing labor shortage and lack of skilled workers threaten revenues at a time when hospital operating margins hover near zero.

While highly skilled professionals are still needed, RCM teams can work smarter and not harder by using technology to automate manual processes and deploy advanced analytics to identify the cause of denials. Further, as private insurers follow Medicare’s lead by increasing third-party audits, providers need to understand their claims and auditing process at a foundational level to support their billing practices and maximize legitimate revenue.

During a virtual media briefing this week, the HIMSS Electronic Health Record Association outlined some of the comments it plans to send the Office of the National Coordinator for Health IT about its draft Health Data, Technology and Interoperability: Certification Program Updates, Algorithm Transparency and Information Sharing proposed rule, or HTI-1.

While some of the rule's details are still being parsed, EHRA said it has reservations about the ability of its member IT companies to balance new regulatory compliance with other HHS requirements – and has questions about a lack of provider incentives, information blocking rule challenges and more.

When the federal Public Health Emergency (PHE) ended on May 11, many of the waivers that kept external audits in check also vanished. As a result, healthcare organizations are bracing for an influx of demand letters, claim changes, and heightened regulatory and billing practice scrutiny by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Supplemental Medical Review Contractors (SMRCs), Unified Program Integrity Contractors (UPICs), Targeted Probe-and-Educate (TPEs), Comprehensive Error Rate Testing (CERT), and commercial payors.

The uptick in audit activity doesn’t have to leave provider organizations exposed, however. Proper planning and a well-designed external audit strategy can ensure a rapid, effective, and compliant response while mitigating future risk.

With revenue cycle (76%), clinical administration (55%), and finance (36%) among the top five areas benefiting most from automation and artificial intelligence (AI), it’s easy to see why 98% of health care leaders say their organizations have implemented or are planning to implement AI. That includes nearly 48% that have already taken the leap, according to Optum’s annual survey on AI in health care.

However, it makes no difference how large the investment or advanced the technology solution is if the patient data flowing through it lacks integrity. In other words, when it comes to AI and patient data, the adage “garbage in, garbage out” still applies. It’s also a very real problem, as evidenced by an average duplicate patient record rate that runs as high as 18% in the typical facility and patient misidentification issues that cost the health care industry more than $6 billion in denied claims.

Patrice Wolfe, MBA is CEO of AGS Health of Washington, DC.

When health systems are immersed in data related to billing, denials, internal audits, and external payer audits, it can be overwhelming to track, manage, and process what is an overwhelming amount of raw data. Creating a value-generating revenue integrity team and pairing it with technology is the answer to harnessing that data and using it to positively affect the tight margins experienced by many healthcare organizations.

While this might seem like a bold statement, the only way to productively use your data is to employ sophisticated analytics that will provide actionable insights on how to improve billing compliance and maximize revenues.

Nashville - AGS Health works with scores of hospitals providers on revenue cycle management and helping sure organizations get money more quickly, but the company is also working with organizations on health equity.

Cheryl Cruver, chief revenue officer of AGS Health, spoke about the growing interest in health equity in a conversation with Chief Healthcare Executive® at the ViVE Conference.

Revenue cycle management solutions leader AGS Health is pleased to launch operations in Manilla, Philippines. Serving as a strategic growth partner to more than 100 major healthcare providers across the U.S., the expansion will offer AGS Health and its customers increased access to global talent.

MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to retain revenue and reduce risk, sees the retirement of its long-time president and CEO, Peter J. Butler, effective March 31, 2023. Stepping into the CEO role will be the company’s current COO, Ritesh Ramesh.

Butler will continue serving on MDaudit’s Board of Directors and as an investor, advising on future investments and growth opportunities for the company. He has been with MDaudit for 30 years, including the past 16 as president and CEO.