As healthcare organizations continue to face rising costs, creating and maintaining an efficient revenue cycle is more vital than ever. In doing so, many of today’s providers have focused their efforts on a critical RCM subset: compliance. To avoid being penalized, providers, physicians, and other clinical staff must ensure their practices are compliant with the various regulations established by both state and federal governments, as well as the payers they fund.
During the billing and collections process specifically, violations and errors in Medicare/Medicaid payments can not only increase the risk of financial penalties but also damage the reputation of an organization as a competent healthcare provider. Ultimately, by understanding and following regulations, and considering the impact of patient-focused compliance on an organization’s revenue cycle, you can develop a system that ensures low-risk, preventative, billing and submission processes that boost your revenue.
Claims can be deemed non-compliant for a number of reasons. Those who do not follow Medicare regulations or comply with HIPAA may find themselves facing heavy fines, loss of privileges, and even prison time.
Complying with Medicare and Other Regulations
Medicare generally doesn’t require providers to go out of their way to meet regulations. Common reasons for non-compliant claims, however, can come from simply not providing patients with key paperwork. By creating a process that does not overlook this simple step, you can ensure that you are compliant and not at risk of being penalized.
Advance Beneficiary Notice (ABN)
- Medicare may penalize providers for not providing the Advance Beneficiary Notice of Noncoverage (ABN) to patients who are undergoing procedures that may be deemed medically unnecessary.
- Failing to comply with this requirement puts providers at risk of no longer being allowed to bill patients for these elective procedures.
- Mitigate the risks of non-compliance by creating a workflow system that alerts staff to those patients who may not be pre-authorized for procedures. Implement training for those staff members who handle pre-authorizations so that patients who require the ABN paperwork are identified ahead of time.
Medicare Secondary Payer (MSP)
- Medicare also requires providers to give patients the Medicare Secondary Payer (MSP) questionnaire or risk similar penalties.
- Consistent non-compliance can lead to Medicare revoking a provider’s Medicare reimbursement privileges, in addition to possible civil or criminal penalties.
- Adding hard stops to your patient arrival processes will ensure that the questionnaire is given to all Medicare patients before moving them on to the next step of the intake process.
HIPAA regulations are in place to protect patient privacy. These requirements outline the manner in which healthcare providers are to collect, store, and share patient information, including paper records and electronic health documents. Complying with HIPAA regulations is necessary. Those providers who disclose information, whether intentionally or accidentally, can face incredibly harsh fines and, in some cases, jail time. Fines can be as large as $250,000, along with up to ten years in prison.
To make certain your organization is complying with HIPAA, ensure all clinical personnel complete a mandatory HIPAA compliance training course and attend regular refresher classes. Vendors also need to comply with HIPAA. Review their contracts regularly to make sure that they contain HIPAA compliance provisions. Finally, do site checks; evaluating which employees and vendors are consistently following regulations.
Utilization reviews are often performed to monitor cases that could result in inefficient care, rejected claims, or improperly submitted claims. Any inappropriate admission can lead to severe penalties from Medicare, including losing the right to participate in Medicare programs. To combat this risk, you want to ensure that all staff members have access to the information they need and are communicating with the appropriate medical personnel.
Using Analytics to Encourage Compliance and Revenue Cycle Collaboration
Making use of analytics can help ensure that you are compliant with all necessary regulations as a way to protect your revenue cycle and your reputation. Being compliant goes hand in hand with having a strong revenue cycle. Should you be associated with non-compliant practices, in addition to facing hefty fines, your patient attraction/retention rate might decrease, as many will seek care elsewhere. This causes many providers to look at compliance risks alongside financial risk and to observe the overlap between them.
To minimize risks in these areas, it is necessary to review your transactions. Analytic tools can be used to identify the points within your transaction activity that you face potential risks and to determine the underlying causes of those risks. The data revealed by these tools often shows that the risks you face are common to both non-compliance and financial risks. This makes it possible to combat both risks in an economical and efficient way.
By implementing proactive measures that mitigate risks to your revenue cycle from non-compliance and from other financial risks, you can strengthen your profits while also maintaining a positive reputation. Doing this on your own does require immense dedication and the right resources, however. That’s why many healthcare providers have sought out specialty services, including those offered by eRecievables.
eRecievables focuses on addressing and collecting claims through a formal appeals process. With their compliant-focused, front-and-back-end strategies, and patented appeals process, eRecievables has cut down the risks and costs associated with the billing and collections processes.