Inaccurate data always carries the risk of lawsuits and penalties, especially when they come in the form of bad data in patient charts, jeopardizing patient safety.
However, new rules on price and coverage transparency introduced by the Centers for Medicare and Medicaid Services have increased concerns about patients New layers of risk for data and patient interactions between providers and payers.
Availity CEO Russ Thomas – announced the acquisition of Diameter Health just this week – with Healthcare IT News discusses how inaccuracy puts hospitals and health systems at greater risk of litigation, government penalties and investigations, and related to correcting mistakes substantial administrative costs.
Q. How does inaccurate data put healthcare provider organizations at greater risk?
A . New CMS regulations require providers and payers to keep patients informed about the cost of care and their personal financial responsibilities throughout the care process. Additionally, they require providers and plans to obtain patient consent for services and associated fees.
The charges reflected in the final bill must also be consistent with the quoted price prior to the encounter or procedure. Under these new rules, providers could end up being financially responsible if patients are not informed or are told inaccurately.
These regulations add a layer of complexity to providers and payers when tracking and reporting financial data. For example, this practice is simple when it comes to standard procedures, such as annual visits (eg, appointment costs X, patient copays Y).
However, the situation becomes more complicated when new needs are identified when encountering patients. For example, if a patient presents in the emergency room with severe pain, a series of tests must be performed to diagnose the cause. Or, during a colonoscopy, if the doctor finds multiple polyps that must be removed and tested. These costs can range widely, and it is not always possible to notify patients in advance.
Accurate provider data is essential to ensure provider alignment with a particular member’s health plan. The more complex the event, the greater the risk involved and the more difficult it is to determine the expected cost of a member.
Hospitals face maximum exposure in this setting due to the number of unplanned medical activities the hospital manages, but Risk increases across the board.
ask. Correcting errors can incur substantial administrative costs. why is it like this?
A . Some elements are easy to validate if you’re specifically thinking about provider data. For example, it is easy to know if Dr. Smith is male or female, or whether she is a physician or an orthopedic specialist.
However, there are other factors that are difficult to verify, especially with regard to resource allocation in large, complex health systems. Tracking where Dr. Smith is contractually able to see and treat patients is one of those elements.
This is becoming a growing problem as health systems continue to expand their services through acquisitions. For example, if a hospital acquired Dr. Smith’s stand-alone practice, her office is now one of several facilities in the hospital’s network. This could change Dr. Smith’s contract, allowing her to see and treat patients at other hospital-owned locations outside of her own practice.
Tracking where Dr. Smith will appear and provide services in these cases is tricky because the healthcare industry There is currently no standard way to communicate the difference between a contract being able to see a patient and actually seeing a patient.
For example, Dr. Smith may see patients primarily at location A, but may also see patients B, C under contract at locations , D and E. The health plan’s system may not be able to distinguish between where Dr. Smith sees a doctor and where she sees a doctor.
If the health plan selection states that Dr. Smith is no longer contracted to see patients at locations B through E, and that Dr. Smith will one day be Location B serves the provider, then the incoming claim may be that I was mistakenly treated as a non-standard claim by the health plan, which is much more expensive.
These types of physician assignment errors can often be corrected on the back end, but new regulations state that patients should not be held responsible for resolving these question. Therefore, calibrating these data is often a very manual job performed by suppliers and payers.
For example, I was closest to a doctor’s office and they had an FTE whose sole responsibility was to secure their provider Contract data is aligned with the 10 insurance companies they work with for accurate cost estimates and price transparency.
Q. You say, as healthcare tries to comply with new regulations , it faces enormous operational challenges. What are these challenges?
A . One of the challenges is how differences in patient characteristics can greatly alter the costs associated with the same procedure. For example, healthy patients without comorbidities may undergo colonoscopy at an outpatient center.
However, patients with conditions such as hemophilia may undergo colonoscopy. Because of possible complications, the same colonoscopy needs to be performed in a more costly hospital setting. This variability complicates providing accurate estimates.
One way to solve this is to provide a best-case and worst-case scenario. case estimates. To the point where these estimates can be made in real-time so that in the event of complications, procedures can safely continue without fear of fines or inappropriate reimbursement.
Also, while these rules are well-intentioned, the reality is that it may not be necessary to set this for every encounter A certain level of price transparency. We need to focus on the most problematic events — the medical events that put people out of business because they don’t know what their out-of-pocket costs are.
It is easier for the healthcare community to rally around this work and remove the variability associated with addressing more routine situations many challenges.
Q. Given all these issues and challenges, healthcare providers What can organizations do to reduce risk and improve data management? How can they improve the accuracy and timeliness of their data?
A . Most supplier organizations have different types of contracts with each insurance company. Most of them are based on tradition. Supplier organizations must proactively manage and adjust their contracts. There is a lot of ambiguity in this area right now. The effects of variability can be reduced if providers understand the differences in each insurance contract and update them appropriately.
Provider organizations also need to understand the differences between their systems and the back-end systems that their contracted health plans utilize.
They need the ability to understand the payer’s processing intricacies, such as determining whether the provider is able to contract at each location See patients, and how providers are set up in their directory. They need to know whether the payer system will classify the claim as a face value or non-face value claim at any of these locations.
Finally, supplier organizations need to ensure that their own data is clean, accurate and up-to-date. One of CMS’ biggest complaints is that retired or deceased doctors still frequently appear on the directory. There are solutions on the market that can help automate data cleaning efforts.
These solutions can utilize transaction data and question prompts to ask if a specific doctor is still in a specific provider organization. If not, the solution can initiate a workflow to communicate this change to contracted health plans.
This feature is reducing the administrative burden required to comply with new price transparency regulations that focus on physician-site correlation and impact on cost.
Email the author: [email protected]
Healthcare IT News is a HIMSS media publication.