The Role of HIM Professionals in Collections

Four areas where HIM professionals impact collections.

I met with a coding manager recently who shared that her annual pay increase would be partially based on collections. Of course, we both looked at each other and said “why?!” But then I reflected on it and said, “why not?” 

We know that our coding staff does not directly do any “dialing for dollars,” or even check the payer websites to see if claims have been adjudicated or queued up for payment. But health information management (HIM) and coding can directly impact whether our organizations are getting paid for a claim in a timely manner.

In prior sessions, we talked about coding denials, and we know that the best denial management program is denial prevention. If we receive a rejection or denial from a payer, collections halt until we finish our rebuttals and a final determination is achieved. This means that we need to address rejections and denials, and on a timely basis. Each day we wait means that we cannot collect, and the impact on accounts receivable grows.

In this article I will review four areas where we impact collections:

1. Release of Information: When we receive an additional development request (ADR), we know right off the bat that the claim is pended at the payer until we produce the records they are requesting. The ADRs hold up collections. So let’s put a process in place that prioritizes these requests – not before continuity of care requests, but shortly after them. The Healthcare Financial Management Association (HFMA) published guidance in 2010 noting that insurer requests should be responded to within two business days. I don’t think that’s unreasonable, given that most of us have electronic health records (EHRs) now. However, an alternative that somewhat removes HIM and the release of information staff from the equation, and is present in many organizations, is allowing the patient financial services (PFS) staff to prepare the packet of information to respond to those ADR requests and release to the payers directly. Now, note that I said “somewhat” purposely. HIM, in collaboration with the privacy office, should provide education for the PFS staff about the components of the record and minimum necessary expectations, as well as ensure that there is a method to log what was released for accounting of disclosure purposes.
2. Coding Delays: This is vacation season, and it’s our responsibility as managers to ensure that we have the resources in place to cover our staff’s time off. As part of our planning efforts, we already avoid allowing all the coders to go on vacation at the same time. However, what may happen is that no backup resources are arranged for, the other staff being expected to work some overtime to keep their queues cleared (while at the same time coding some of the vacationing person’s cases), or the vacationing person’s work just sitting there until the individual returns to work. The vacationer in that last case would return to a backlog, and then the next employee takes off. The result: spiraling discharged not final coded (DNFC) – which by default delays collections.

   Recovering from this situation is not an overnight event. To avoid it, identify an internal or external resource at least two months in advance that can provide some coding support during the vacation season to keep DNFC down and collections coming through the door.

3. Record Completion: HFMA once published metrics, again circa 2010, noting that our medical record delinquency rate should be less than 10 percent. I think that’s too loose. I’d actually say that our total delinquencies should be less than 5 percent. For many organizations, we’re on an EHR. Let me state up front, I realize that some EHRs are more sophisticated than others, so some of these suggestions may be able to be leveraged with your EHR and others may not.

   Physicians should be signing documentation as they go. There should be alerts built into our EHR systems prompting physicians for certain documentation, such as an H&P, operative report, or discharge summary, triggered by their respective events – that is, an admission, the presence of an operative session flagged by an anesthesia document or anesthetic drug charge, and a discharge order. The operative report is the most challenging to program since more than one surgeon may perform procedures, and the anesthetic record may not have a required field to identify the surgeon.

   Orders throughout the stay should be signed in real-time, but yes, those verbal and telephone orders continue. However, when a discharge order is written, it should trigger a “go to jail” workflow that prevents the physician from closing out until he or she signs any remaining documentation, including orders. Pleasant for the physician? No. Life-sustaining to the organization? Yes. Will these system supports eliminate incomplete records? No. But the fewer we have, the more cases we can code, allowing more claims to go out the door and collections to come in.

4. Payer Audits: When payers conduct audits, it may be pre- or post-payment. The guidance I am sharing applies to both, but the impact on collections is when audits are conducted pre-bill. Unlike the ADR requests discussed earlier, the audits typically require intervention from HIM or IT to queue the records electronically for access by the payer’s auditor or to prepare the copies and transmit or send them to the payer for the audit.

   PFS should ask the payer to make payment for the audit activities (copies) in accordance with the payer-provider contract. We should always verify the start date, but more importantly, when the payer will report the findings to us and what our appeal rights are.

   When we pull the list of records, one or more coding professionals should review the sample to see if there is a common thread. Regardless, the coding should be validated to ensure that all codes claimed are correct and that all codes that should have been claimed were coded.

   Number the pages if copies of the records are being sent to facilitate appeals later. Double-check to make sure all pertinent documents are sent.

   Finally, follow up at least twice to a) make sure the records were received, and b) to obtain the findings.

   Preparing the requested records in a timely and complete manner will eliminate “re-dos” and allow us to be confident that our record documentation supports the claims we submitted. With this in mind, we should be able to collect our entitled reimbursement.

In summary, yes, collections should be in our evaluations, because we are a contributor to the success or failure of the collections team achieving the organization’s goals. We’re all in this together.