Release of Information’s Relationship with Audits: An Executive Overview

Healthcare providers have been releasing information contained in patient medical records for a very long time (known as the release of information process or ROI). They are legally required to release it and often receive up to thousands of requests a day. Many of these requests are time sensitive, due to patient continuation of care needs, payment for services, litigation, or insurance deadlines, so they must be expedited.

Requestors reimburse the healthcare provider for the records they receive. As such, they expect confidentiality and privacy of the information requested, promptness, accuracy, and high-levels of customer service for their money. Providers must comply with HIPAA guidelines while also meeting requestors’ turn-around time demands. Proper management and tracking of each request along with the knowledge and expertise of a highly skilled ROI specialist is essential to ensure a smooth, compliant and expeditious process.

• Education– Provide key facility stakeholders with access to historical information about the various types of audits so they can better understand how each can potentially affect revenue.
• Communication – Identify a core team to include different areas of the facility and diverse expertise and schedule regularly occurring meetings to discuss audit related issues.
• Tracking – Create a specific workflow or use database and tracking technology that follows a specific process, to manage audit requests.
• Request letter management process – Proper management of medical record requests is vital to optimal audit management.
• Decision letter management process– The decision letter must be reviewed and processed quickly.
• Appeals management process– Appeals must be meticulously tracked to ensure that deadlines are not missed.
• Establish real-time financial management and a dashboard review process– Tracking the dollars at risk is key to understanding the potential impact audits can have on revenue.
• Establish a process and procedures to prevent denial issues from reoccuring– Conduct internal audits and track and review the results regularly.

This white paper focuses specifically on the management of medical record requests and describes the dependency and therelationship of the recovery audit process and ROI. Fine-tuning tips of the ROI process and the oversight are presented along with practical advice on how to mitigate audit risk and revenue loss. Finally, new developments in record request, release and exchange will be presented.

If providers intend to appeal a RAC denial they must do so promptly. Deadlines to submit an appeal range from 10-45 days depending on the type of audit, with most averaging about 30 days. However, offsets to reimbursements occur on day 41. To prevent this offset, the re-determination request must be submitted prior to day 30. With so many deadlines and appeal levels, staying on top of the timing process is a best practice in order to minimize cash flow disruption.

Tip #2: Implement a View and Approve Workflow Process

Once records are gathered to fulfill a request they should be double checked to verify compliance. This step is called “view and approve”. Most providers are doing this to some extent. Due to volume issues and budget constraints, a sampling technique is most prevalent and technology to facilitate the process is ideal.

The view and approve step has some major workflow ramifications as it involves additional human resources and technology support. However, the upside of implementing a view and approve workflow are many. First, it is an important compliance step to assure the request is handled in a HIPAA- compliant manner and that only the appropriate information is forwarded on to the auditor. Secondly, reviewing records before they are sent to the auditor gives providers the opportunity to perform a self-assessment (how are they doing with the issue being reviewed). They can also check to make sure there are not other items in the packet that may carry additional risk. Finally, the view and approve step helps hospitals determine if they have a selfdisclosure issue and automatically provides a double check for the chart completion and other quality issues.

Secondly, there are reports of auditors under-reimbursing providers for records received. There have been instances of the auditor arguing that a lesser number of pages were received than were submitted by the provider. Retain proof of each page sent to help ensure correct reimbursement. And be aware that going back after these dollars may not be successful.

To mitigate these concerns, providers should be aware of any reported problems within their regions and incorporate the following steps into the ROI process:

• Keep a confirmation data base with such information as the FedEx tracking number and a scanned signature page.
• Retain a copy of the exact pages that were sent with the who, what and when information maintained in a central database.
• Have the exact record available after the fact for the appeals process and repeat submissions. It is difficult to go back and try to recreate what was sent.
• Maintain the integrity of the package during processing and the integrity of the record throughout the entire appeal process.

Delivering Records to Auditors: An Opportunity for Innovation

Currently, medical records are provided electronically as well as in paper format. For most requestors, electronic delivery is preferred. In fact, HealthPort currently delivers over 50% of requested records via electronic methods thereby reducing the need

As a participant, HealthPort will utilize its technology for the secure electronic transmittal of medical records in response to requests by RACs and other Medicare and Medicaid related audit requestors via the esMD gateway. CMS projects the “live” date for the first real transactions are estimated to be late 2011.

Electronic submission will help as there will be electronic tracking of request submissions as well as electronic tracking of page counts. Many of the issues and concerns addressed earlier in this paper will be alleviated. The project is starting with the submission of record delivery, but it is anticipated that it will move further to include requests and letters of denial, etc.

Audits and ROI: Dependency and Relationship

ROI is the first step in the audit management process and as such, its’ impact on reimbursement and the revenue cycle must be considered. Recovery audits have driven up the cost of retaining even less of providers’ revenue. Furthermore, the volume of audits is increasing as a plethora of federal agencies and commercial payers follow in CMS’s footsteps. Never before have so many dollars been at risk for such easy loss.

A solid release of information process is needed to expedite delivery of requests, eliminate technical denials and reduce the risk of financial penalties. Now is the time for healthcare executives to take a closer look at this hidden, but critical, process within HIM. By implementing the tips mentioned in this white paper alongside robust, audit management and tracking technology, providers can solve many of the problems mentioned while also minimizing costs and mitigating revenue risk.

Audit Definitions MIC – Medicaid Integrity Contractors Reviews provider claims, audits provider claims, identifies overpayments and educates or trains Medicaid employees Not involved in collections for over payments PERM – Payment Error Rate Measurement Measures payment accuracy rate Each state is reviewed once every three years CERT – Comprehensive Error Rate Testing Calculates a national paid claims error rate for Medicare Fee-for-Service program Reports on Carriers, and Fiscal Intermediaries OIG – Office of the Inspector General Oversees all programs Conducts independent investigations, audits, inspections and special reviews MAC – Medicare Administrative Contractor New contract entitiy Will eventually replace current payment contractors QIO – Quality Improvement Organization Staffed by healthcare professionals trained to review medical care and implement quality improvement Contracts last for three years

HealthPort is the authority on the compliant exchange of protected health information through comprehensive audit management and tracking technology that includes integrated release of information services. By automating, managing and tracking the entire audit process, this combination helps healthcare facilities successfully protect their revenue from the financial ravages of audit-take-backs and breach-related penalties.