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Breaking down the walls: Strategies to reduce compliance risk in the revenue cycle

Dawn Crump (dcrump@mrocorp.com) is Senior Director, Revenue Cycle Solutions, at MRO Corporation in Norristown, PA. Emilie Sturm (emilie.sturm@trinity-health.org) is Senior Revenue Management Consultant, Trinity Health in Livonia, MI.

Throughout the history of healthcare in the United States, departments have worked within their own silos. Today, with increased managed care recipients, the shift to value-based reimbursement, and unprecedented demands due to COVID-19, a team-based approach is more important than ever. Collaboration between compliance officers and revenue cycle leaders is critical to reduce risk, bridge communication gaps, and promote teamwork while also supporting billing integrity and revenue recovery for the organization. With increased requests for audits and access to electronic health records (EHRs), departments must find a way to work together to create efficiencies, promote compliance, and retain revenue.

This article offers guidance to improve compliance in a centralized revenue cycle environment with focus on shoring up business office processes that may lead to inadvertent protected health information (PHI) disclosures during payer conversations, audits, and disputes. The challenges present an opportunity to make teamwork a meaningful, inclusive practice to promote collaboration across silos and address the top three compliance risks within the revenue cycle:

  • How to manage disclosure of PHI within revenue cycle departments,

  • How to evaluate levels of direct payer access to EHR systems, and

  • How to effectively unite revenue cycle departments.

If departments are not communicating, breakdowns at various points can lead to detrimental financial and compliance risks. Patient access and registration must validate patient identity and insurance information. Utilization and case management must get proper authorizations for appropriate billing. Clinical documentation improvement must work with clinicians to capture appropriate clinical status.

Many healthcare organizations are now addressing compliance concerns through collaborative revenue cycle processes. The first step is to identify areas of risk and compliance concerns.

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