Operational compliance in Revenue Cycle Management (RCM) hinges on integrity and legal adherence, intricately woven into every administrative and operative process. Success lies in appreciating key principles, starting with a structured workflow that fosters transparency. This transparency emerges through cultural awareness, accessible technology design, and leadership support, ensuring smooth communication and eliminating departmental silos. Authenticity and open communication among employees nurture transparency, actively encouraged by leadership.
Delineating and parsing each step of the process is vital, as compliance relies on pursuing excellence in every aspect. Technologically engineered and documented workflow designs help identify redundancies and resource wastage, allowing for efficient and effective redesigning of steps.
Crucially, compliance revolves around people, constituting 95% of the process. Properly hiring, orienting, onboarding, training, testing, reviewing, rewarding, and addressing non-compliance is essential. Constantly emphasizing and ingraining the organization’s vision and mission among employees fosters a culture where compliance becomes second nature.
In the digital era, data and assets hold immense value. Ensuring data and asset integrity demands rigorous testing, validation, verification, and certification. Embracing operational compliance at every level fortifies the foundation of a successful RCM process.
Prioritizing compliance for a robust medical office operational system in RCM
Building a strong medical office operational system in Revenue Cycle Management (RCM) begins with a steadfast focus on compliance right from the recruitment stage. This foundational step shapes the environment and sets clear expectations for potential employees. Thoughtful recruitment advertisements and a meticulous interviewing process, including background checks and screenings, are imperative components.
Within a medical office, a robust credentialing program plays a vital role by tracking the qualifications, contracts, certifications, licenses, and other pertinent data of each individual. This leads to the creation of a comprehensive Provider and Employee data warehouse or Employee Information Exchange. Such a system proves instrumental in talent development, promoting staff engagement, conducting thorough career reviews, and timely tracking of work-related requirements for employees.
A strong Information Exchange streamlines regular updates, ensuring adherence to contracts and agreements for employee remuneration, and monitoring the active status of licenses. This fosters improved communication and aids in analytics and designing effective staff education and training programs. Past experiences have highlighted the significance of proper credentialing, as oversight in this area can lead to costly repercussions, including refunds and license-related issues. Emphasizing compliance and implementing a robust operational system are essential steps in mitigating risks and paving the way for success in RCM within the healthcare setting.
Ensuring compliant documentation: A critical RCM step
In Revenue Cycle Management (RCM), compliant documentation of patient visits with providers emerges as the next vital step. Key elements encompass supporting medical necessity, creating and closing proper records promptly, and accurately referencing diagnostics within encounter documentation. Each note must be comprehensive, containing all essential information to stand independently during adjudication or audits. Compliant documentation forms the bedrock for a robust care management program, quality improvement program, precise E and M codes, and accurate Medicare Risk Adjustment.
To ensure proper billing, special attention must be directed toward addressing red flag issues such as incident-to billing, note cloning, shared visits, bundling, and unbundling, upcoding or downcoding, and contradictory information within an encounter note. Awareness of issues delineated by the Office of Inspector General (OIG) in their annual OIG Work Plan aids in implementing corrective processes and avoiding potential pitfalls. Compliant documentation is indispensable in upholding billing integrity and safeguarding healthcare organizations against audit risks, reinforcing a resilient RCM framework.
Validating documentation and billing: Ensuring integrity in RCM
In Revenue Cycle Management (RCM), achieving verification for each diagnosis or level of service demands a robust validation process. Logging this information for future audits ensures transparency and accountability. Regularly scheduled pre-billing audits and sampling effectively pinpoint areas requiring intervention and improvement. Third-party consultants can be invaluable in providing unbiased reviews and specialized expertise as needed.
To maintain the highest standards, certified auditors with proper credentials, such as those affiliated with the American Association of Professional Coders, should be utilized. Implementing a system to audit the auditors validates their unquestionable skill set and knowledge, reinforcing the credibility of the auditing process.
The billing system, including efficient management of accounts receivable, refunding incorrect payments, and tracking denials, is a complex yet indispensable aspect of RCM. Precise and appropriate coding by well-trained and specialized coders is essential to address any gaps in the intricate interweaving of data, processes, people, and equipment. Emphasizing validation and integrity in documentation and billing strengthens the foundation of a successful RCM strategy, ensuring financial stability and accuracy in healthcare organizations.
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.
Fostering compliance-centric incentives for robust RCM
To build a strong foundation for aligning incentives, emphasis must be placed on quality, compliance, evidence-based medicine, and patient safety, rather than solely focusing on financial returns. Key areas like inducement of services, Stark, anti-kickback, and Corporate Practice of Medicine may necessitate legal counsel input.
In uncertain situations, seeking guidance from authoritative sources such as CMS or other regulatory agencies proves invaluable. Their expertise and willingness to assist can help navigate complex compliance matters. Continuous and relentless employee training, along with enhanced organizational memory through greater retention, holds immense value in achieving and sustaining compliance.
Compliance flourishes when it transforms into an organizational project and obsession. While no single individual can guarantee constant adherence to regulations, a collective awareness of the significance of integrity at each step can set a high standard or even a benchmark of compliance in RCM. Prioritizing compliance-centric incentives ensures ethical practices and financial stability within healthcare organizations.
