What is operational compliance in Revenue Cycle Management? Every step of the administrative and operative processes must be intimately intertwined with the overarching theme of integrity and adherence to the law. Compliance needs to become granular for it to truly succeed.
For this to happen, several principles need to be appreciated. Firstly, a structure that enhances workflow and makes it transparent is critical. The creation of transparency is a byproduct of efforts that focus on creating cultural awareness, ensuring that the design of technology makes data accessible and available, and leadership buy-in. Transparency occurs when the hierarchy of the organization prevents the creation of departmental silos and when communication between them all is encouraged and unhampered. The ability for every employee to be authentic and to voice his or her opinions is critical to openness. Above all, transparency becomes second nature only if it is actively encouraged by leadership.
Secondly, every step needs to be delineated and parsed out. Compliance cannot happen without pursuing excellence in every process, and excellence cannot happen without compliance. One very good way to break down every step of a process is to create a technologically engineered and documented workflow design. As each step of a process is broken down into its constituents, many things become clear to the reviewers including redundancies and waste of resources. Redesigned steps can make them more efficient and effective.
Thirdly, compliance is not only about processes but also about people. 95% of compliance is about people, how they are hired, oriented, on-boarded, trained, tested, reviewed, rewarded, and reprimanded or fired. The vision and missions of the organization constantly need emphasis and ingraining among the employees until compliance becomes second- or rather first-nature to them.
Finally, in this advanced age of technology, data and things are an integral part of the inventory or property of any organization. The data and things have to be tested, validated, verified, and certified as true and authentic.
To create a strong medical office operational system in Revenue Cycle Management (RCM), compliance needs to be emphasized right from the beginning, i.e., at the time of recruiting or hiring of employees. This may perhaps be the most important step in creating the right milieu and expectation from the prospective employees. The advertisements for recruitment need to be fully thought out and the process of interviewing for hire, background check, and screening should be deliberate and carefully vetted.
In a medical office, a strong credentialing program that tracks each individual’s qualifications, contracts, certifications, licenses and other pertinent data is essential to the creation of a Provider and Employee data warehouse or Employee Information Exchange. This would assist in talent development, staff engagement, career reviews, and timely tracking of any variable that is pertinent to an employee’s work-related requirements.
A strong Information Exchange reduces the time for regular updates, ensures that remuneration to employees is as per contracts and agreements, licenses are active, improves communication, and helps in the analytics and design of staff education and training. In the past, we have experienced some providers hired without proper credentialing with certain insurance carriers. Unfortunately, upon this discovery, due to this oversight, we had to refund the charges made for testing ordered by them in our organization’s radiology center. We have also seen providers letting their medical licenses lapse, thus becoming ineligible to see patients until licensure restoration. In some cases, the providers had no idea that they were practicing without a license. Talk about risk!
Compliant documentation of patient visits with providers is the next most crucial step in RCM. Supporting medical necessity, proper and appropriate records created and closed on time and the referencing of diagnostics within the encounter documentation are key elements. Each note needs to be complete in itself and have all the necessary information within it to stand on its own during an adjudication or an audit. The only way a strong care management program, a quality improvement program, and correct levels of E and M codes along with the right Medicare Risk Adjustment can be ensured is with compliant documentation. To ascertain billing is proper, special attention must focus on the red flag issues, like incident-to billing, note cloning, shared visits, bundling and unbundling, upcoding or down coding and contradictory information within an encounter note. We know what issues to analyze and install corrective processes to avoid as the Office of Inspector General (OIG) delineates the red flag issues that they will audit each year in their annual OIG Work Plan.
Accomplishing the verification of each diagnosis or level of service requires a validation process that also logs this information so that it is available at the time of future audits. Regularly scheduled pre-billing audits and sampling identifies any areas of deficiency requiring intervention. Third-party consultants can be of great help in the process of review to remove bias or bring expertise in certain areas as needed.
You should utilize certified auditors who carry the proper credentials with agencies that follow or create the standards, such as the American Association of Professional Coders. We recommend you set up a system whereby you audit the auditors to validate their unquestionable skill-set and knowledge.
The billing system, including management of accounts receivable, the refunding of money received incorrectly or tracking of denials is an elaborate but critical aspect of RCM. Appropriate coding by well-trained and specialized coders is a sine qua non to ensure the plugging of all the possible lacunae into the complex interweaving of data, people, processes, and equipment.
The standard requirements of universal compliance, such as the monitoring of Fraud, Waste, and Abuse, OSHA and HIPAA, continue to apply. You must not sweep any concerns brought to light by billers, coders, or auditors under the rug. You must respond to each one in a timely, complete, and transparent manner. The result of failing to do so often results in Qui tam complaints, a reality in RCM, when problems are not addressed right away and risk assessments are not held in earnest.
The alignment of incentives needs its foundation built upon quality, compliance, evidence-based medicine, and patient safety and not financial returns alone. Inducement of services, Stark and anti-kickback along with Corporate Practice of Medicine are areas that may need input from legal counsel.
When in doubt, return to the source. Feel free to reach out to CMS or other regulatory agencies. They are resourceful and keen to help. Training of employees has to be incessant and ongoing and organizational memory with the help of greater retention can be of great value in becoming compliant and staying compliant.
Compliance succeeds if it becomes an organizational project and obsession. No one person can ensure adherence to regulations all the time but if everyone is awake to this need to have integrity at each step, then a very high standard or even benchmark of compliance in RCM may become possible.