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  The relationship between healthcare payers and providers is often complicated, tumultuous, and adversarial. The drastic increase in Recovery Auditor (RAC) and other third-party payer audits over the past several years has exacerbated this issue.

During a recent provider-payer panel session at the HealthPort’s annual Health Information (HIM) Education Summit, the presence of a deep language barrier dividing these entities became clear. Plan representatives mentioned that some providers understand their requests, but many do not. Likewise, providers expressed frustration with identifying exactly which documents and encounters auditors are requesting, and for what reasons.

Speakers suggested a bi-partisan educational effort to bridge the communication gap. What if the very thing (audits) that has deteriorated the payer-provider relationship can be used to ameliorate it?

It’s time we used the audit process to change the payer-provider relationship from adversarial to advantageous through automation, eliminating redundancies, improving communication, and maximizing audit data. To begin untangling the relationship, let’s uncover top audit concerns from both perspectives.

Provider Concerns: What Documents? How Many? How Fast?

Hospitals often have difficulty fully grasping the volume of requests received and records going out the door. Furthermore, multiple auditors may be on-site simultaneously conducting chart reviews. HIM departments and business offices are aware because they are the ones who receive requests and pull together the records, but executives and other departments generally do not. Regardless, the numbers often are astronomical.

Some auditors request hundreds of records. Some require only specific pieces of hundreds of records. Piecemeal data is harder to extract from an electronic health record (EHR). And it’s a tedious, manual process, with different EHRs having varying levels of complexity regarding finding and sending records.

In addition, the types of claims being reviewed often are not being monitored for internal use. Are there specific trends or knowledge gained from processing the initial requests? There is valuable data not just for the plans, but for the providers as well.

Finally, staffs also have to take into consideration the time it takes to process records in order to meet auditor deadlines. Understandably, common HIM questions arise, including:

  • What exactly does the payer want?
  • What am I required to gather and send?
  • If payers come on site, HIM will inevitably ask “Who are they?”
  • Are they authorized to review our records?

Bridging communication gaps and language barriers through clearer record requests would take the burden off the providers and alleviate plan problems by helping to answer these questions, and this would be an effective first step in solving the payer-provider conundrum.

Plan Concerns: What Service Location? What Information?

Health plans also experience issues surrounding the audit and record request process. Traditionally, they contact a multitude of healthcare providers to visit and retrieve requested medical records charts.

They struggle with determining exactly where to send a chart request when the only information available is the location of service listed with the claim. Time is often spent on the phone trying to determine the location of the chart and whether the right provider is being contacted.

Once records are received, health plans’ biggest complaint is that there’s not enough information, too much information, or not the right information.

During the same aforementioned panel session, education within the HIM department was recommended to help provider staffs identify exactly what documentation is required for each type of request and guide HIM professionals on a case-by-case basis.

The average chart retrieval rate is only 80 percent for most payer organizations. But an achievable goal, accomplished through strengthening communication, would be boosting this percentile to the high 80s to mid90s while also reducing administrative burdens for hospital staffs.

Automation of the electronic request and delivery process, whereby a health plan can contract for all medical record retrieval needs while keeping their protected health information (PHI) secure, is another solution to ease the paperwork burden for both parties.

Duplication and Redundancy: Concern for Both

The incidence of duplicate chart review processes for similar initiatives was also mentioned as a key concern. One example of redundancy is HEDIS and quality measures reporting.

HEDIS (Healthcare Effectiveness Data and Information Set) is part of a Medicare quality-improvement initiative with a clinical focus. The Centers for Medicare & Medicaid Services (CMS) has made it mandatory for Medicare Advantage plans to participate in, while providers can choose whether to participate. Commercial HMOs also can choose to participate; about 90 percent do. HEDIS data catalogs the services of various plans and providers and compares the qualities of plans based on type. However, there is overlap between the duties of HEDIS and the hospitals’ internal quality/risk teams.

While plans pay someone to retrieve charts and have their RNs review them, hospitals are doing the same reviews internally for quality abstracting and reporting measures. Every CMO and quality assurance department has teams to review Medicare quality risk measures. Redundancy in quality reviews runs rampant, and as mentioned above, varying EHRs present challenges in reviewing, abstracting, and submitting data.

At the end of the day, both providers and payers have the same goal: To improve Medicare quality and strengthen their bottom lines. They just approach how to achieve these goals differently.

Can we align these processes to work together better? The answer is yes. Collaboration and a better, more effective use of HEDIS data would assist in eliminating redundancies. Furthermore, a centralized request, fulfillment, and delivery program can help achieve this goal.

Risk Adjustment Models Drive Greater Volumes Ahead

In the past, there was just one type of risk adjustment model and only one payer impacted — Medicare Advantage plans. Then risk adjustments filtered into state Medicaid plans. Now, they also include commercial plans (individual insurance exchanges). The latter will hit hospitals, clinics, and physician groups by the end of this year or early in 2015.

Medicare pays a base rate, per member, per month. But each chronic condition identified and coded boosts the monthly rate. More comorbidities and conditions equal more a potential for greater reimbursement to treat the higher acuity. Also, more detailed data helps health plans get patients into care plans specific to their chronic diseases. The implementation of ICD-10 in October 2015 will provide even more detail into patient conditions via the submitted codes.

Like Medicare Advantage, the commercial plans will need medical records to validate any chronic conditions the insured patients may have. The major difference with commercial risk adjustment is rather than receiving additional funding from CMS for higher-acuity patients, plans with healthier populations will be required to “transfer payment” to plans with more at-risk populations. The first CMS filing date for the commercial plans is April 30, 2015.

Providers need to be prepared for more record requests due to so many new plan enrollees entering the system and a flood of new plan members from open enrollment periods.

Time for Change

The ultimate winner in improved communication between payers and providers is the patient. Both parties are focused on providing the patient with the best healthcare experience possible.

To achieve this goal, we all need to evaluate, learn, and educate based on our experiences. A first step is to ensure that payer-provider communications surrounding the request process are clear and then innovate to find new ways to relieve the administrative burden of audits for all.

Six Strategies to Consider Now

  • Begin speaking the same language in record requests and through face-to-face discussions and meetings.
  • Educate HIM departments on exactly what pieces of information are required for each type of request, and guide HIM professionals on a case-by-case basis.
  • Evaluate the requests and look for trends in the data to utilize during internal provider education.
  • Automate the request and delivery process whenever possible while keeping PHI private and secure.
  • Minimize impacts on staffing by contracting with a mutual third party for record retrieval, processing and distribution, thus easing the paperwork burden for both parties.
  • Align processes to work together better and discuss areas for collaboration (such as HEDIS and quality measures).
  • Prepare for greater numbers of record requests as new plan members from open enrollment periods enter the system, receive care, and need to have cases reviewed by plan staff.

About the Authors

Dawn Crump, MA, SSBB, CHC, has been in the healthcare compliance industry for more than 18 years and joined HealthPort in 2013 as vice president of audit management solutions. Prior to joining HealthPort, Ms. Crump was the network director of compliance for SSM. She has healthcare experience in education, organization development, quality improvement, and corporate compliance.

Trained as a six-sigma black belt, Ms. Crump used this holistic, fact-based approach to establish audit-tracking (RAC) programs. Her expertise includes coding and billing compliance as well as HIPAA compliance and government audit programs for acute-care facilities. She is a former board director of the Greater St. Louis Healthcare Finance Management Association chapter and currently serves as the networking chair. Ms. Crump is also a member of the Health Care Compliance Association (HCCA).

Jeannie Hennum serves as the vice president of sales in the ChartSecure Division, with responsibility for developing relationships between health plans and healthcare providers. She also is responsible for internal education regarding the importance of why medical records are utilized by health plans for initiatives such as NCQA/HEDIS and CMS Medicare Advantage, Medicaid, and commercial risk adjustment programs. 

Prior to joining HealthPort, Ms. Hennum worked at several healthcare information solutions companies, providing consultative services to the quality, revenue integrity, and claims adjudication departments at many national, regional, and local health plans.

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