Compliance Management
Because the details matter.
Identify and minimize revenue risks by establishing a proactive approach to payer contracts and payer audits.
Prioritize what’s often overlooked.
In an industry that has become increasingly demanding for healthcare providers, maintaining compliance across the revenue cycle is a critical task. This includes prioritizing contract management and audit management efforts—two aspects of the revenue cycle that can have significant financial impact if not handled appropriately. While error-prone manual processes were once the norm, today’s environment demands more sophisticated methods to tackle and track each of these items. By automating activities, health systems can improve accuracy, streamline interdepartmental workflows, and ensure third-party accountability.
Why compliance management efforts matter.
A typical health system receives 50-100 medical record reviews for Medicare or commercial audits every 45 days.
Many payers have a tendency to carve 3-5% out of each contract they negotiate, while providers often sign payer contracts without negotiating, leaving valuable dollars on the table.
Compliance Management Components
Audit Management
Benefits
- Quantify risk and gain insight into the root cause of problems–dollars at risk, win/loss percentages, denial trends, and more–via advanced reporting features
- Increase visibility with simplified tracking of all commercial payer, Medicaid and CMS Medicare audits
- Defend reimbursements by reviewing, responding to, and appealing all payer audit activity
- Protect revenue and reduce future take-backs of previously collected dollars
- Automate workflow to simplify compliance with audit requests
- Accelerate audit resolution by improving documentation requests and tracking documentation necessary for successful appeals
- Electronically submit medical documentation via esMD, including RAC, MAC, CERT, PERM, SMRC, TP&E, all Medicare review types, and all Medicare first and second level appeals
How It Works
Regulatory and commercial audits come in at the discretion of the issuing party, leaving providers overwhelmed by the resulting workload. But instead of merely worrying about the financial impact of payer audits and the resources they require, health systems can, and should, proactively monitor these items and develop a plan of attack to minimize their effect on revenue.
Integrated with all major health information systems, SSI’s audit management tool, Audit Director, enables providers to break down organizational silos and improve collaboration across the enterprise. Users can ensure timely filing by seamlessly tracking existing, and incoming, audits and protect revenue with complete visibility into audit-associated revenue risks. Audit requests can be moved electronically among departments for uninterrupted workflow, while supporting documents can be scanned and attached. Users also benefit from the appeals management tool which provides the ability to store payer-specific appeal letters and streamlines the appeal package process for tracking wins and losses.
Contract Management
Benefits
- Gain a thorough understanding of expected payments, based on contract terms
- Ensure proper payment from payers
- Strategize for more equitable contract negotiation, including measuring the quantitative impact of specific contract terms or proposed contract changes to secure favorable reimbursement conditions
- Measure and plan for the revenue impact of proposed contract changes
- Identify and recover underpaid reimbursements
- Net down accounts receivable based on expected reimbursement
- Build out hard copy contracts in a solution that accommodates both simple and complex contract terms
- Report on key factors that most significantly affect payer-provider contracts: variance analysis, adjudication analysis and payer comparisons
How It Works
Payment models have become more complex, as the industry has moved away from fee-for-service models to value-based care models–complete with bundled payments–in their place. Simple contracts are a thing of the past. Today, providers wrestle with convoluted contract terms, decreasing reimbursements, and payers’ sometimes cavalier approach to incorporate contract changes into their system.
Health systems must ease the overwhelming burden of manually reviewing claims and remits to ensure they are paid according to their contracted rates with payers. SSI’s contract management tool, Contract Director, provides a platform to easily manage and simplify revolving payer contracts. The robust solution automatically reviews for payment accuracy and updates, based on rules built into the system, with forecasting capabilities that allow clients to foresee the impact of proposed contract changes on their revenue. Users are equipped with the knowledge necessary to hold payers accountable for contractual obligations and enter into more equitable negotiations.
Springhill Medical Center recovered three quarters of a million dollars from a single payer using SSI’s contract management solution.
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Make your move toward stronger financial performance.
