Compliance Risk Areas Within Revenue Cycle

From intake and registration to claim adjudication, there are several administrative and clinical functions that contribute to the timely capture and collection of patient service revenue. It is crucial for providers to identify compliance risk areas to realize revenue.

To ensure that the provisions of the regulations are met, organizations must implement a comprehensive compliance plan. The compliance plan should include regularly scheduled compliance reviews evaluating the organization’s compliance with its own policies and procedures and industry regulations. Implementing a comprehensive work plan will position a facility to actively respond to the ever-changing healthcare regulatory environment. Additionally, it will allow the facility to effectively communicate regulatory requirements to leadership and affected departments, allowing them to implement process changes to mitigate risk.

There are many compliance risk areas in each stage of the revenue cycle including: patient access, medical documentation, charge capture, and patient financial services. Patient access risk areas include: HIPPA and patient documentation retention. Medical documentation & charge capture risk areas include: medical necessity documentation, physician orders, and coding accuracy. Lastly, patient financial services risk areas include: proper billing, duplicate claim submission, denials and proper payment and refunds.

Below is a list of revenue cycle compliance reviews organizations should consider to mitigate risk and ensure compliance with industry regulations:

Patient Access Management

• Advance Beneficiary Notice Retention (ABN) review
• Medicare Secondary Payer Questionnaire review
• Emergency Medical Treatment and Labor Act (EMTALA) compliance
• Red Flags Rule compliance

Medical Documentation & Charge Capture

• Charge Description Master (CDM) review
• Medical Necessity reviews
• Patient status designation (Inpatient vs. Observation) reviews
• Physician Order Retention
• Hospital Discharge Appeal Notices (Important Message from Medicare) Retention

Patient Financial Services

• 501R compliance
• Medicare Overpayment and Refund policy review
• 72-hour rule billing review (Medicare Regulation)
• Claim denial processing review
• Self-pay collection practices review