CHAPTER 5

Compliance And Risk Management

CHAPTER 5

Compliance And Risk Management

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Providers continue to experience significant financial challenges and must do all they can to protect revenue. Shoring up compliance and risk management efforts in the mid-cycle is essential to this effort. Implementing a comprehensive internal compliance audit program is a great place to begin. This should include regular evaluation and management (E&M) utilization reviews since payers give special attention to this area. Doing so can help mitigate payer audits and investigations and provide insight into problematic trends so they can be addressed before a payer audit has a chance to occur.

Payers are using increasingly sophisticated technology to detect claims with potential issues, especially around medical necessity, resulting in increasing payer audits, takebacks, and penalties. The American Medical Association says payer takebacks cost hospitals and physicians over $1.6 billion a month.1

Another area of increasing risk for providers is privacy and security. Between January and August of 2023, 463 healthcare data breaches were reported, a 21.4% month-over-month increase.2 Data breaches are particularly costly and can cause significant harm to provider organizations and their patients. To prevent data breaches or hacking events, organizations must ensure HIPAA compliance and have a comprehensive security program that evolves as new threats are identified. Since most ransomware hacks stem from phishing emails, employee education and awareness are critical3

A third critical area providers need to focus on is billing compliance, which should include a plan aligned with the organization’s corporate contingency policies and the development of incident protocols and response teams. Third-party billers and vendors should be part of this plan.

eBook: Navigating the Heart of Healthcare Revenue

A Comprehensive Guide to the Mid-Cycle and Revenue Maximization

This eBook offers an extensive overview of mid-cycle operations within healthcare provider organizations. It emphasizes the critical importance of coding, clinical documentation integrity, revenue integrity, and health information management. The guide underscores that these processes are not isolated but are integral to both the front-end and back-end of the revenue cycle, affecting overall financial health and compliance.

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