OK . . . this might seem a little self-serving, but I truly believe this is a good idea. I remember having this thought more than 10 years ago at an HCCA conference. I was thinking about performing an effectiveness review and how when I see a hospital has the support of experts, especially those I know and trust, it provides a lot of comfort that things are on the right track.
Having the support of experienced consultants and experts in the field to maintain compliance in all areas of the revenue cycle can make a huge difference as organizations go through change. Hospitals should not be going it alone and reinventing the wheel. You also don’t have to have a large consulting budget to tap into experts that can help train new employees, leave knowledge in-house, and help ensure consistency with turnover. Oftentimes you can have “maintenance” agreements so that the organization can tap into experts and resources quickly as things come up to help maintain compliance.
So what areas am I talking about? I look at it this way: Let’s break down the organization’s risks and processes to mitigate that risk. One big part of this is awareness of regulatory requirements and keeping up. There are also firms that will provide access to experts in several areas within one firm. You can gather information about who is supporting your organization to keep up with regulatory change and assisting in monitoring that policies and processes are staying on track in these areas:
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Patient registration
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Noncovered
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Advanced beneficiary notices (ABN)
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Coordination of benefits
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Authorizations
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Utilization management
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Medical necessity
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Inpatient vs. observation
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Discharge disposition coding
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Case management
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Program for Evaluating Payment Patterns Electronic Report
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Health information management
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Release of information
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Timely response
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Outpatient coding
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Inpatient coding
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Evaluation and management coding
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Denials management
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Appeals processes
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Charge description master
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Revenue cycle
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Recovery audit contractor and other payer responses
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Compliance program effectiveness
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HIPAA privacy
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HIPAA security
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Physician contracts
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Fair market valuation
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Emergency Medical Treatment and Labor Act
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Cost report
It might be a good discussion as part of your compliance risk assessment to inquire how each area keeps up with regulatory changes, who are the recognized experts in each area, what topics are covered at industry conferences, how is compliance monitored, etc. This could be an opportunity for compliance professionals to learn more about operations and assist department leaders with baking in controls to mitigate risk and increase compliance.