Business office personnel release millions of medical records annually to commercial health plans and government payers to expedite payment of claims, appeal denials, or fulfill auditor requests. Time spent by billers and collectors aggregating and sending this protected health information (PHI) represents a significant distraction and efficiency challenge for business office directors and revenue cycle leadership. The interference in workflow also reduces revenue-producing claims-processing time for uniquely skilled business office staff. Furthermore, a nonstandardized process may increase the chance of a costly HIPAA violation. By considering alternative workflow options, business office leaders can improve their billing processes and decrease denials.
It’s All About Time: 4 Examples of Business Office Disclosures
There are four points in the claims process when billers and collectors disclose PHI: as part of initial claims submission, during claims processing, for retrospective audits and reviews, and in response to attorney requests. PHI disclosure is necessary to get claims paid, in general—but not in every case. Careful and strategic tracking of what information is released, to whom, and why, can make the PHI disclosure process more efficient.
Unsolicited, proactive disclosures. In some cases, billers proactively send portions of the record or the entire encounter along with the initial claim to help expedite payment. These unsolicited submissions of patient documentation are common when billing specific diagnoses and procedures in an attempt to prevent insurers from rejecting or denying the initial claim.. Over time, billers become keenly aware of what medical record documents are requested by each insurer and for each type of claim. However, keeping track of unsolicited disclosures can provide insight inot when these extra efforts may not be warranted.
Additional documentation requests. Other business office disclosures are made in response to the insurer’s request for additional medical record documentation during claims processing. Billers should document which specific records, and what sections of each, were sent. Recording and monitoring these data over time and comparing the data with denial data can help organizations identify which types of cases benefit from proactive record release. Also, knowledge of what specific information was sent is extremely valuable when insurers deny receipt of records or misplace the data.
Retrospective payer audits and reviews. Between 2013 and 2017, the number of requests for Healthcare Effectiveness Data and Information Set (HEDIS) and risk-adjustment reviews increased from 1 percent to 14 percent of the total release of information requests received by MRO. This statistic is in addition to the millions of records requested nationwide for Medicare’s recovery audit contractor (RAC) reviews. Sending records for retrospective audits and reviews represents a significant time commitment for business office and health information management (HIM) staff.
Attorney requests for itemized bills. Bills often are requested by attorneys in support of litigation for personal injury claims. These requests may be in conjunction with the medical record.
Two Workflow Options to Consider
Organizations that task business office staff with PHI disclosure should consider the following workflow options (or a hybrid) to improve efficiency, reduce costs, and maintain focus on collecting revenue for the facility.
Centralize all requests for records. Specific, assigned staff in a centralized location can process and fulfill all requests, minimizing administrative burden from billers and collectors at each location. Centralization also promotes consistent, standardized processes. These dedicated business office staff should be thoroughly trained in proper PHI disclosure management to maximize efficiency, eliminate redundancy, and mitigate risk of HIPAA breach.
Transfer the work to HIM. HIM staff are well versed in processing requests for information. They possess the knowledge and expertise to fulfill requests efficiently and in compliance with all HIPAA rules.
However, some business office personnel are reluctant to delegate this function to HIM citing concerns regarding timeliness and stringent payer deadlines. To mitigate turnaround time fears, the following four best practices should be implemented:
- Ensure open and ongoing communication between the business office and HIM
- Optimize the use of EHR and PHI disclosure management technologies to route requests and share information
- Assign a dedicated release of information expert to support the business office and process requests
- Conduct regular meetings to discuss new trends in payer requests and proactively improve PHI disclosure workflows
Small Steps to Save Time, Major Strides to Improve Efficiency
Release of medical records from an organization’s business office could cost unnecessary time, effort, and money. Instead of distracting billers and collectors from their core objective of collecting revenue, savvy business offices should consider alternatives to effectively improve business office efficiency including centralization, delegation to HIM, or outsourcing PHI disclosure management.
Don Hardwick is vice president, client relations and account management, MRO, Norristown, Pa. The views and opinions expressed in this article are those of the author and do not necessarily reflect or represent the views, opinions, or policies of MRO.