Amid changes in healthcare delivery since the pandemic, the role of billing compliance teams has become more important in delivering value for healthcare organizations.
According to MDaudit research, the number of compliance teams with 10 or more auditors increased from 26% to 33% between 2021 and 2022. The reasons for expanded staffing vary and include higher denial rates from federal and private payers, an increase in external payer audits, and the desire to manage compliance and revenue risk in collaboration with other stakeholders in coding, revenue integrity, and clinical documentation integrity (CDI).
“Compliance teams have expanded in size since 2021, demonstrating their increasing scope and importance as enterprise value drivers within healthcare organizations,” says Dana Finnegan, Director of Market Strategy for MDaudit.
During 2023, billing compliance staff are focusing their efforts on these five areas.
1. Preserving revenue.
While growing top-line revenue is important for growth, preserving revenue is becoming just as critical. Payers are taking longer to respond to claims initially, and the dollar amounts represented by each denial are rising, which leaves significant funds in play for longer periods. The pace of federal audits has also picked up, fueled by a healthy return on past auditing efforts and an influx of funding to scale up those efforts.
2. Monitoring compliance risks.
Preserving revenue starts with accurate coding. Overcoding remains an issue in professional office visits. Billing compliance staff should pay particular attention to evaluation and management (E&M) coding, which drives reimbursement. Among hospital billing, bundling is a major driver of compliance issues, followed by billing and coding errors. Top focus areas for both professional and hospital visits include diagnosis codes, CPT/HCPCS codes, and modifiers. Staff must strike a balance between accurately capturing the scope of the visit, procedure, test, or hospital stay and overcoding, which brings potential risk for regulatory fines and reputational damage.
3. Starting with good data.
Due to the dynamic nature of emerging risks, billing compliance leaders must leverage data and analytics as a catalyst to proactively detect risks and perform audits for corrective action. Data-driven, risk-based audits can complement the annual compliance plan to ensure effective audit scope coverage. Across MDaudit clients, risk-based audits increased by 28% in 2022 compared to the previous year. Auditing staff needs claims data in a single location to allow real-time analysis and collaboration with other stakeholders, along with the ability to launch an audit in a few keystrokes.
4. Deploying a hybrid auditing strategy.
The correct auditing strategy should be a mix of prospective and risk-based auditing. In theory, prospective auditing increases overall revenues by ensuring claims are correct the first time. In practice, however, the sheer number of edits and fixes required would slow claims to the point that revenue stops. Retrospective audits help organizations learn from past experience, allowing adjustments that increase claims accuracy going forward. MDaudit benchmarking data shows that organizations deploying both auditing methods achieve better outcomes. According to our research, prospective audits increased by 31% in 2022 compared to 2021.
5. Collaborating to accelerate outcomes.
To solve systemic challenges and drive outcomes, billing compliance teams must partner with departments such as coding, revenue integrity, revenue cycle, CDI, IT, and others. Organizations need a unified platform that combines data from multiple internal and external sources, including billing, payment, auditing, market-level costs, and payer data. Adopting cloud-based technologies with integrated workflows and powerful analytics can enable collaboration and accelerate outcomes.
Billing Compliance Excellence Starts with the Right Technology
To keep pace with evolving governmental and private payer oversight responsibilities, healthcare organizations must be flexible, agile, and adaptable. An integrated cloud-based platform to support the evolving role of billing compliance enables organizations to reduce compliance risk, improve efficiency, and retain more revenue stream by providing workflow automation, risk monitoring, and built-in analytics and benchmarking capabilities.
Armed with the right technology, billing compliance can proactively reduce denials and improve speed to reimbursement using insights from historical data to identify and resolve systemic risks.
For a more in-depth view into how this large healthcare system was able to grow its compliance program, check out this insightful case study on Nemours Children’s Health.
