Updated on: June 8, 2021

Ensuring Data Integrity and Protecting Your Organization’s Bottom Line: Part III

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Original story posted on: June 7, 2021

Part III in this series discusses expanding HIM’s visibility with payer policy management.

As you may know, the purpose of this series of articles is to expand the visibility of health information management (HIM) professionals and utilize their skills to benefit organizations. I think it’s time for HIM to take on one much-needed task in particular for the revenue cycle: payer policy management.

What is this? Well, payers are changing their rules every day. For example, pre-authorization requirements are expanding, put into place by both governmental and commercial payers alike. Authorization denials represent 9.6-14.7 percent of all denials, according to an American Hospital Association (AHA) report. But who is monitoring the various requirements of the many payers with which a healthcare facility or physician practice deals? 

There are subscription services that will send emails to subscribers about payers policy changes for a fee, often gauged to a number of payers. But putting the emails in a payer-specific folder for each isn’t any better, and managing emails is just another hassle. 

However, if we don’t know the payers’ rules, we can’t play the game. Yet keeping up with every payer’s policies is a task that few organizations effectively manage. That’s why this is a big opportunity for HIM. HIM is familiar with reading regulations, interpreting techno-jargon, and certainly, understanding clinical terminology. Plus, HIMers have the skill sets to do what it takes to create an organized database that is up to date and easily accessible by all stakeholders. 

So, what needs to happen?

First: Identify your stakeholders. These should include, but not be limited to:

  • Contract management;
  • Patient financial services (PFS);
  • Access;
  • Case and utilization management (including their physician advisors);
  • Physician office billing;
  • Denials management;
  • Coding;
  • IT;
  • Compliance; and
  • Charge capture (if it’s its own department).

Second: Peel the onion – don’t take on every payers with which your organization has contracted on day one. Choose two to five payers to start. I suggest that these be ones that PFS or case management tells you are the most challenging or generate the most denials, especially “surprise” denials for issues that blindsided your organization.

Third: Ask PFS to capture the denials by type and associated dollar value for each of the payers selected. These numbers will serve as your baselines, against which you’ll be able to measure your performance and the value of your efforts.

Fourth: Get access to the policies. How? Notify each of the selected payers to start sending all communications to you (make sure you let your stakeholders know you’re planning to do this.) Recognize that you’re going to receive stuff that’s not payer policies, such as address changes, educational pieces, contact and contract changes, and denial notifications. Make a copy of contract changes to review for any policy changes. Otherwise, you need to make sure that these other documents are routed promptly to the person who needs to address them. 

Additionally, if the educational announcements appear worthwhile, you may wish to do a group share to all your stakeholders, and register yourself to attend in case there is a policy addressed that you need to incorporate in your database.

Finally, weed out the policies that require your review from all the other stuff you received. Then, dissect, summarize, and categorize them by issues your stakeholders desire, such as:

  • Authorization requirements;
  • Specific clinical condition requirements;
  • Coding requirements;
  • Claim format requirements;
  • Appeal requirements; and
  • Attachment requirements, etc.

Identify any new requirements that may require system intervention, such as your claims, edit, or registration systems, and promptly refer these to the appropriate IT, PFS, and/or access system managers.

Fifth (and Most Important): Once the above is done, it’s time for you to strut your stuff: 

  • Display the policies in an easily readable and searchable format. Ensure that all your stakeholders are personally trained on the database, how to access it, and how to search it, and ask for their input on any enhancements. Attach a PDF of each policy in your database so that users not only see your summary, but can read the entire policy if they desire.
  • Segregate policies that apply to your physicians from those that apply to your facility.
  • Ensure that all stakeholders have access to your database.
  • On a quarterly basis, educate the respective stakeholder staffs and providers on the new rules. Use lunch-and-learn options to make it easy for folks to attend. Remember, access is a 24/7 operation, so multiple educational sessions will be needed to cover the three shifts. Consider podcasts as an alternative for delivering the educations.
  • Attend and present at medical staff meetings: it doesn’t hurt to gain some visibility with the medical staff, but keep it brief. You’ll be lucky if you get five minutes on their agenda; however, if they like what you share, you’ll be invited back.
  • Routinely check on denial rates and their respective dollar amounts to determine how much your involvement has improved results, and share your positive impacts with the CFO. When that smile appears – you’ve succeeded. Then take on another one or two payers.

Good luck!

Program Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays at 10 a.m. Eastern.

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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