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Improve the Healthcare Revenue Cycle-Compliance Relationship to Lessen Enforcement Action Risk

April 1, 2021
April 1, 2021

When different departments in healthcare organizations operate in silos, it is no wonder that problems arise. One example is when healthcare providers focus primarily on clinical outcomes, with a secondary level of attention on the administrative and clinical processes related to collecting and generating revenue.

However, the healthcare revenue cycle function is a complex one, with lots of room for errors.

The Heavy Burden of a Corporate Integrity Agreement (CIA)

Unfortunately, Corporate Integrity Agreements (CIAs) related to false claims and improper procedures in the revenue cycle are common. A CIA often results from the settlement of a regulatory violation claim between a healthcare entity and the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services. Typically, the organization found to be in violation must pay a monetary penalty and fulfill other onerous obligations in order to not be excluded from federal healthcare programs such as Medicare and Medicaid, which can be a majority of a provider’s revenue. Typically five years in duration, a CIA often has a training component. Whereas the training duration used to set in the settlement, it is now up to the organization to ensure it is sufficient and effective to meet the situation, covering such subjects as Anti-kickback/Stark Law violations, documentation regulations, HIPAA privacy requirements, etc. With 90-120 days to create a plan that must be approved by the OIG, the healthcare organization will have a certain amount of time to complete and report on the initial round of training, with annual reporting on successive training conducted thereafter for the remainder of the CIA.

The monetary penalties involved in a CIA can be significant. Below are examples of a few recent judgements:

  • A hospice provider paid $6 Million and submitted to a CIA for admitting non-eligible patients.
  • A physician practice paid $1.85 million and submitted to a CIA for improperly billing for A/M services and procedures on the same day.
  • A surgery group paid $12.5 million and submitted to a CIA for unbundling procedural claims in order to increase reimbursement.

Compliance and Revenue Cycle Should Be Interdependent

In order to combat painful judgments like these, revenue cycle departments should begin operating interdependently with the compliance function, starting with patient access operations. Staff need training to understand why their procedures matter and why processes occur in a certain way. The compliance function needs to do a regular targeted audit of this function, as well as a risk assessment. Education is an effective means for patient access staff to understand the importance of meticulous data entry and patient data capture. Staff needs to be aware that they play an important role in avoiding potential patient disasters as they verify medical records, look for allergy information, etc.

Training about Documentation

Another vital training area to help revenue cycle staff prevent compliance risk is medical record documentation, which must be accurate, specific, and complete. These employees need to understand how to protect their organizations, and that failure to prove medical necessity for any procedure or care will potentially lead to a false claim charge. In addition, problems with documentation can lead to revenue loss, which few healthcare providers can handle.

For the compliance department, it is very important for auditors to practice ongoing communication of their audit findings, with the goal of improving performance and mitigating risk. Frequent and open communication plays an essential role in making the process work better.

Budget for Revenue Cycle Training

An unfortunate trend for healthcare education is that few institutions budget adequately for ongoing training of patient access and revenue cycle staff. Focused education for these employees helps to create an atmosphere of compliance mindfulness, and it costs far less than a monetary judgement and the extensive training-focused CIA that may follow. When revenue cycle staff are trained on the “whys” involved in their processes, they are more likely to identify and stop compliance problems before they get out of hand.

This blog post is based on the HealthStream webinar, Avoiding a CIA: Optimizing the Relationship between Revenue Cycle and Compliance, during which presenters Debbie Newsholme, Christine Thomas, Kathleen Greene-Batt, and Susan Gurzynski-Wells discussed the importance of communication and education to avoid a CIA.

In addition to a wide range of education for patient access and other revenue cycle staff, HealthStream and our partner nThrive offer updated training materials around the imminent E/M coding changes. Learn how HealthStream and nThrive can help with solutions to your coding needs and other revenue cycle challenges.

To meet healthcare organizations’ compliance requirements, HealthStream provides online healthcare compliance training solutions to help health systems, facilities, and providers across the care continuum comply with government regulations and accrediting body requirements. These online training courses span the areas of Billing & Corporate Compliance, HIPAA, Privacy & Security, Research Compliance, and Workforce compliance. These courses are recognized for using video and other interactive elements to engage learners, increase retention, and change staff behavior.