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Readers Write: Compliance Reimagined: Transforming the Value Proposition of a Traditional Cost Center

October 27, 2021 Readers Write No Comments

Compliance Reimagined: Transforming the Value Proposition of a Traditional Cost Center
By Peter Butler

Peter Butler is president and CEO of Hayes of Wellesley, MA.


Compliance has gotten a bad rap in healthcare. Traditionally viewed as a necessary cost center, this department is too often viewed as the police force of a health system.

A lot is missing from this simplistic view of the processes that ensure hospitals and health systems aren’t hit with avoidable penalties when the auditors come knocking. Within a rapidly evolving regulatory framework that includes more than a year of fluctuating COVID and telehealth guidance (among other changes), compliance in essence becomes the safeguard to a healthy, sustainable bottom line.

In truth, there is a distinct opportunity for health systems to reimagine a department that has long operated in a silo by embracing forward-thinking revenue integrity models. These innovative strategies bring together billing and compliance teams in a collaborative way to accurately identify, track, and capture all monies owed, transforming the value proposition of compliance in terms of bottom-line impact.

With the right technology-enabled processes, these revenue integrity teams can proactively identify revenue breakdowns on both the front and back end of claim lifecycles and significantly improve revenue capture and financial health.

Compliance is a cost-constrained function inside today’s healthcare systems. While addressing it is a necessary evil, healthcare organizations often struggle to justify allocating extra dollars to optimize this area when faced with so many competing priorities. Yet the business case for investing in the infrastructures and strategies necessary for a technology-enabled revenue integrity model can be an easy one to make in terms of return on investment. Revenue integrity teams can both protect an institution from risk and improve revenue retention. Often, they can also identify dollars that might otherwise be left on the table.

For example, a recent report from the HHS Office of the Inspector General (OIG) pointed to a notable rise in inpatient hospital stays where upcoding was believed to be the culprit, a significant liability for health systems on the compliance front. Revenue integrity processes that integrate systems to create strong partnerships between revenue cycle, billing, and compliance teams can improve this outlook through shared internal monitoring and auditing.

But because revenue integrity is inherently a data-hungry undertaking, manual processes of combing through claims data will not provide the timely insights needed to get ahead of issues. That’s where automation and artificial intelligence becomes a game-changer. Revenue integrity teams equipped with the right tools can conduct real-time monitoring of upcoding risks associated with billing around costly, high-severity cases, significantly minimizing compliance risks that could impact the bottom line.

Compliance professionals are well acquainted with internal auditing practices. On the revenue integrity front, holistic strategies marry the strengths of prospective (front end) and retrospective (back end) auditing. Collaboration between compliance and billing teams can draw on these techniques to make sure claims leave a health system clean from the start. When faced with denials, revenue integrity processes rapidly drill down into root causes to inform process improvement.

From a technology standpoint, here’s how it works:

  • AI-backed prospective auditing. Augmented intelligence and natural language search can help healthcare organizations get ahead of potential problems by detecting anomalies in at-risk claims in near real-time. For example, when considering upcoding risks as mentioned earlier, health systems can automatically flag high-dollar claims, and potential problematic cases can be identified and audited from the outset.
  • Technology-enabled retrospective auditing. Manual efforts to mine thousands upon thousands of claims lines across denials and identify problematic trends for process improvement are typically a non-starter for most resource-strapped compliance departments. Advanced analytics discovery tools exist that can’t comb through denials within minutes and deliver actionable insights.

It’s time for hospitals and health systems to reimagine how they view compliance in terms of impact to the bottom line. With the right revenue integrity strategy, this traditional cost center has the potential to bring real value to financial health and sustainability.

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