Starting on Jan, 1, 2012, providers must transition current HIPAA transactions to a new 5010 criterion, which is designed to improve the workflow between healthcare providers, payers and clearinghouses. In turn, most healthcare organizations are in the process of providing education and establishing new protocols to ensure a seamless transition to the new standard. Given the approaching deadline, HIM departments must become familiar with the new modifications and conduct an internal impact analysis to determine how 5010 will affect business practices and systems. Months of training time is needed to ensure staff is able to successfully transition activities into the new system. Given the time and attention that is needed for this transition, ROI efforts might be better suited for outside professionals that have the workload and resources necessary to conduct this responsibility properly.
Economic Risk Management
Providers also need to weigh the financial burden that can occur when ROI violations happen. Heavy fines (starting at $50,000 to upwards of $1.5 million) can be levied against a healthcare provider who fails to adhere to HIPAA requirements. Given the economic risks associated with ROI, it may be a safer bet for providers to use an outsourcing company that maintains the experience and training necessary to prevent these violations from occurring, resulting in reducing the economic risks of healthcare organizations that are already on shaky ground economically.
"Alphabet Soup" of Audits
The quality of an organization's coding and billing processes can make the difference between thriving, surviving, or failing in these turbulent economic conditions. In the midst of this slow economic recovery, hospitals are facing an "alphabet soup" of audit programs as payers nationwide are following in the trail of the CMS Recovery Audit Contractors (RAC) program. Some of these audit programs that are increasing in frequency and scope across the country include: Medicare's Comprehensive Error Rate Testing (CERT), Zone Program Integrity Contractor (ZPIC), Medicare Administrative Contractor (MAC) audits, The Medicaid Integrity Plan (MIP) and commercial payer audits.
HIM departments in all corners of the country are faced with the increased burdens of complying with these audits. Consequently, this has left some HIM departments stretched too thin, which is a key reason why some providers are already outsourcing ROI work to alleviate HIM professionals' time and workload.
Another reason why providers should consider outsourcing the ROI process is because of the increasing number of privacy breaches reported. According to a recent study conducted by FairWarning, patient data continues to be breached month after month at an alarming rate. Today, an average 200-bed hospital has had 24 breaches per month; a 20 clinic physician practice has had an average of 29 breaches per month; and the top 50 health systems in the United States have had an average of 125 breaches per month.