3 steps to ensure proper payment and compliance

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Ritesh Ramesh, Chief Operating Officer, Hayes

A recent one report of the HHS Office of the Inspector General (OIG) turned its head to the healthcare industry after pointing out a marked increase in hospital stays where coding was believed to be the culprit. Compliance professionals who have been in the health care industry for a long time know what follows: Medicare and Medicaid Service Centers (CMS) -based billing reviews around hospital stays that are vulnerable to the coding.

More specifically, the OIG’s analysis for fiscal years 14 and 2019 found that hospitals are “increasingly billing inpatient stays at the highest severity level, which is the most expensive,” and that hospital stays hospitalized patients are accompanied by a significant medical condition, which represent the most expensive stays. It grew by 20%. In contrast to high-severity growth, medium- and low-severity hospital stays decreased by 22% and 12%, respectively. From the findings, one analysis suggests that kidney and urinary tract infections, pneumonia, and renal failure were conditions likely to have a high severity rating.

This was before the COVID-19 pandemic. In 2020, data from the Hayes Hospital Claims Cohort (representing approximately 42 million claims) reveal that denials related to DRG 871 (Septicemia or Severe Sepsis), also the most frequently billed MS-DRG during the fiscal year 2019, were valued at about $ 1 billion. they account for about 10% of denials. In particular, the lion’s share of denials was associated with grouping, coding, and eligibility, accounting for approximately $ 23 billion in charges.

Bottom line: a lot of money is at stake. Given the steady increase and the long adjudication period, providers can expect more audits around the cases of hospitalized patients with comorbidity (MCC) and comorbidity (CC) of high severity. In today’s climate, hospitals and health care systems need to minimize the risk that could result from non-compliance and future loss of revenue.

Holistic revenue integrity strategies that bring together the strengths of prospective and retrospective auditing can go a long way in containing coding risk. In this context, hospitals and healthcare systems can leverage technology to bring together compliance and billing teams collaboratively, while taking three key steps to improve prospects.

1. Prospective audit supported by AI: Increased intelligence and natural language search can help healthcare organizations anticipate potential problems by detecting anomalies in risk claims almost in real time. When systems are customized to automatically mark high money CC / MCC claims, potential problem cases can be identified and audited from the outset.

2. Retrospective audit with technology: Manual efforts to extract thousands and thousands of lines of complaints through denials and identify problematic trends for process improvement are often a start not for most low-resource compliance departments. There are advanced analytics discovery tools that can’t beat denials in minutes and provide useful information.

3. Consider the impact of pooling and eligibility for insurance: The conventional view of current coding is that it is a “coding” problem. However, Hayes’ internal data suggests that grouping and eligibility for insurance are also to blame. Grouping, which is the process of linking medical services under a single code, is a common practice in today’s billing departments.

While it can create efficiencies and improve patient care, it is also fraught with possibilities for error.

4. Monitoring and learning from your external audits: As several requests for external audits from federal and state payers arrive throughout the year, have a technology platform to handle all of these requests and leverage analytics and post-audit expertise with multifunctional equipment to learn. and improving can greatly help to avoid large penalties and fines associated with bottom-up coding.

Current vendor organizations face significant financial challenges as a result of COVID-19 and need to mitigate the risks associated with the upcoming CMS audit storm. Risk coding is an area in which hospitals and healthcare systems need to focus especially on the implementation of progressive income integrity strategies that address the problems. The best models rely on the power of advanced technology to address them comprehensively revenue cycle and optimize financial performance.


About Ritesh Ramesh

Ritesh Ramesh is the Chief Operating Officer of Hayes and leads customer technology and experience teams, overseeing product management, engineering, customer success, implementation / training, technical support, and audit platform security and revenue integrity MDaudit Enterprise. Ritesh has over 17 years of technology experience with extensive experience in emerging technologies, cloud, digital and AI.

Prior to joining Hayes, Ritesh had a successful career in the professional consulting industry working with a variety of business and technology leaders from multiple industries to drive next-generation digital, analytics, and technology initiatives that enhance the business experience. customer, revenue growth and operational excellence in their respective businesses. . Ritesh holds an MBA from the MIT Sloan School of Management and a master’s degree in computer science from the Illinois Institute of Technology.



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