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A report issued in early 2021 by the US Department of Health and Human Services (HHS) Office of the Inspector General (OIG) raised a number of red flags that should be informing hospital and health system audit strategy for the foreseeable future. Covering fiscal year (FY) 2014 through FY2019, the OIG analysis points to a notable rise in costly inpatient hospital stays—many coded at the highest severity level.

The report, which cautioned its findings were based only on an analysis of claims data and not the medical record review necessary to determine appropriateness, found that the number of stays at the highest severity level increased almost 20 percent during the time frame examined and decreased for each of the other severity levels.

As we face the third year of the global pandemic, hospitals and health systems are desperate to shore up bottom lines that have been battered by ongoing financial losses projected to exceed $100 billion in 2021. The key to undoing some of the financial damage is optimizing revenue flow and reducing compliance risk, which requires an understanding of the exact driving forces behind the devastating losses.

For many healthcare organizations, the primary problem can be traced to bundling errors, COVID-19 claim denials, and a range of coding issues.

That’s according to Hayes’ inaugural auditing and revenue integrity report, Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report, which analyzed more than $100 billion worth of denials and $2.5 billion in audited claims. It found that bundling errors were the top culprit behind the 34% of inpatient hospital charge initially denied in 2021, each with an average value of $5,300. Internal auditors also identified a significant number of concerns centered around disagreements between procedure codes and diagnoses, contributing to 33% of all internal audits containing “disagree” findings.

As the Omicron variant spreads across the US and the delta variant continues to push COVID-19 cases higher, it’s a grim reminder that the COVID-19 pandemic is far from over. Although 60% of the country is vaccinated with multiple doses and many lessons were learned by the 2020 pandemic cycle, hospitals and health systems are preparing for a rough road ahead. They are bracing for higher utilization, staffing shortfalls, and an increase in demand for COVID-related services leading to an increase in the clinical and financial pressure in days and months ahead.

Since the advent of the pandemic in 2020, healthcare organizations are trying to mitigate compliance and revenue risks. We will continue to provide data-driven insights to healthcare organizations during and after the pandemic.

An exclusive Tech Tribune Q&A with Brad Bostic (co-founder, chairman, and CEO) of hc1, which was honored in our:

  2022 Best Tech Startups in Indianapolis

  2021 Best Tech Startups in Indiana

  2021 Best Tech Startups in Indianapolis

  2020 Best Tech Startups in Indiana

  2020 Best Tech Startups in Indianapolis

The senior care industry has had to navigate tremendous challenges over the past year. From staffing shortages to the demands of the COVID-19 pandemic, 2021 hasn’t been easy. While advancements like the COVID-19 vaccines have brought some relief to those challenges, the senior care industry will face many more challenges as we move into 2022.

We reached out to experts in the senior care field to learn their predictions about the coming year.

Accelerated adoption of digital health and health information technology (health IT) is well into the process of transforming access to and delivery of healthcare in the U.S. and across the globe – and their power has been on full display throughout the unprecedented global COVID-19 pandemic. From telehealth and information exchange to artificial intelligence and machine learning, optimizing the reach and utilization of health IT has brought safe, quality care to previously underserved areas while creating new opportunities that promise to make a lasting impact on patients and providers alike.

While advancements have been made, interoperability and comprehensive standards to support health information exchange are works in progress, and uncertainty over compliance with new and evolving regulatory mandates – such as those governing handling of patient data in the 21st Century Cures Act – persists. The good news is that collaborations between health IT developers, provider and payer organizations, industry associations and state and federal agencies continue to evolve and improve.

November 03, 2021 - Providers are having a difficult time billing for services related to COVID-19, with 40 precent of charges for coronavirus-related care initially winding up as claim denials in the first 10 months of 2021, according to a recent analysis of more than $100 billion worth of denials and $2.5 billion in audited claims.

The analysis performed by healthcare technology company Hayes also found that 40 percent of professional outpatient audits for COVID-19 and 20 percent of hospital inpatient audits for COVID-19 failed.

The Senate’s recent decision to repeal the ban on funding for the development of a unique patient identifier (UPI) marks a potential watershed moment in the development of what previously has been a hot third rail for privacy concerns.

This controversial possibility of developing a UPI provides a new opportunity to link a patient’s health records throughout the health ecosystem, but also highlights the inherent challenges of such a project.

The Senate’s recent decision to repeal the ban on funding for the development of a unique patient identifier (UPI) marks a potential watershed moment in the development of what previously has been a hot third rail for privacy concerns.

This controversial possibility of developing a UPI provides a new opportunity to link a patient’s health records throughout the health ecosystem, but also highlights the inherent challenges of such a project.

Accelerated adoption of digital health and health information technology (health IT) is well into the process of transforming access to and delivery of healthcare in the U.S. and across the globe – and their power has been on full display throughout the unprecedented global COVID-19 pandemic. From telehealth and information exchange to artificial intelligence and machine learning, optimizing the reach and utilization of health IT has brought safe, quality care to previously underserved areas while creating new opportunities that promise to make a lasting impact on patients and providers alike.

While advancements have been made, interoperability and comprehensive standards to support health information exchange are works in progress, and uncertainty over compliance with new and evolving regulatory mandates – such as those governing handling of patient data in the 21st Century Cures Act – persists. The good news is that collaborations between health IT developers, provider and payer organizations, industry associations and state and federal agencies continue to evolve and improve.

Wellesley, MA — October 28, 2021 –– Bundling errors continue to wreak havoc on hospital bottom lines in 2021, causing 34% of inpatient charge denials with an average value of $5,300 each. That’s according to an auditing and revenue integrity report analyzing more than $100 billion worth of denials and $2.5 billion in audited claims released today by Hayes, makers of MDaudit, the industry’s leading integrated auditing, billing compliance and revenue integrity platform for the nation’s premier healthcare organizations.

“Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report” shares the findings of Hayes’ review of professional and hospital claims audited in MDaudit Enterprise during the first 10 months of 2021. Internal auditors identified a significant number of concerns in the claims they reviewed, with approximately 33% of the audits resulting in “disagree” findings. The concerns centered primarily around disagreements between procedure codes and diagnoses.

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.

HISTalk»

As actors work to comply with the Cures Act Final Rule, it’s become clear that greater consensus is needed regarding the interpretation of the definition of electronic health information (EHI) and the designated record set (DRS). As many readers know, the Cures Act Final Rule includes interoperability requirements related to information blocking and health IT certification. Both rely on the definition of EHI, which is grounded in the definition of the DRS, as defined by HIPAA.

I’m proud my organization AHIMA has been able to collaborate with the American Medical Informatics Association (AMIA) and the Electronic Health Record Association (EHRA) on a taskforce to examine the relationship between specific aspects of the Cures Act Final Rule and the definitions of DRS and EHI.

As actors work to comply with the Cures Act Final Rule, it’s become clear that greater consensus is needed regarding the interpretation of the definition of electronic health information (EHI) and the designated record set (DRS). As many readers know, the Cures Act Final Rule includes interoperability requirements related to information blocking and health IT certification. Both rely on the definition of EHI, which is grounded in the definition of the DRS, as defined by HIPAA.

I’m proud my organization AHIMA has been able to collaborate with the American Medical Informatics Association (AMIA) and the Electronic Health Record Association (EHRA) on a taskforce to examine the relationship between specific aspects of the Cures Act Final Rule and the definitions of DRS and EHI.

The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.

As a part of this series, I had the pleasure to interview Brad Bostic, CEO of hc1.

Brad founded hc1 to bring the benefits of precision health to all patients after witnessing his mother lose her battle with cancer while being treated like a number. He created hc1 with a bold vision to bring the power of precise diagnostic and treatment insights into the care delivery process, believing that transforming lab data into personalized healthcare insights would empower healthcare organizations to ensure patients get optimal diagnostic lab tests and personalized prescriptions for the best possible outcomes. Today, hc1 is the bioinformatics leader in precision testing and prescribing and its hc1 Precision Health Cloud™ is live across more than 20,000 lab and health system locations.