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Healthcare Providers Use UC to Combat Aggressive Third-Party Auditors


October 11, 2016

While electronic medical records (EMRs) have gone a long way toward protecting patients’ privacy and rights along with providing a digital paper trail of diagnoses and care, they have a very definite downside. During a time when all vertical markets are under pressure to cut costs and improve efficiencies, the healthcare sector has been undeniably slowed down and made less efficient because of the EMR and HIPAA mandates.

The widespread use of EMRs in the healthcare industry has brought with it a host of third-party players, and many of them employ aggressive and sometimes fraudulent tactics to satisfy their goals. Unfortunately, this type of behavior is often against the best interests of patients and healthcare providers and can make it even more difficult for organizations to meet HIPAA and other requirements.

Third-party auditors often encourage healthcare providers to maximize the severity of illness to boost quality scores and are also known to practice clinical validation, second-guessing diagnoses by using what are often outdated or faulty standards. Finally, while technology is certainly moving toward automation and analytics, third-party companies often use analytics and algorithms to issue huge volumes of denials. That means hospitals are losing revenue from nonpayment, and lack the time and resources to fight a mounting number of denials.

The problem is epidemic, according to a recent ICD10 Monitor article, which claims the number of Medicare audits nationally has grown by 936 percent. Fortunately, there are a few steps healthcare providers can take to prevent and combat audits and fraudulent denials. Having a unified system in place to address denials can be a major asset, as well as putting together an audit response team. The group would handle coding, compliance, utilization/case management and physician representation. Healthcare providers would be involved throughout the entire process and given feedback at the end of the cycle, to ensure they don’t continue to make the same documentation mistakes that triggered the initial denial.

Unified communications (UC) can be an extremely valuable asset in this process, enabling audit response teams to communicate and collaborate with healthcare personnel about the entire process. Since multiple healthcare providers are often involved on a single claim and denial process, UC solutions can offer a centralized way to manage the entire auditing process and ensure all the correct players remain involved and engaged.

By utilizing what is in many cases existing technology solutions, healthcare providers can help offset the hassle and lost revenue brought about by EMRs and aggressive third-party audits. Failure to fight back against increasingly cutthroat third party companies and technology will only lead to more lost revenues and greater challenges for providers.




Edited by Alicia Young

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