How Analytics Can Benefit 4 Key Members of the Compliance Team

robert-freedmanBy Robert Freedman, Hayes Management Consulting
Twitter: @HayesManagement

As healthcare organizations have reached near universal adoption of EHR and practice management systems, the amount of available billing and claims data has grown exponentially. This data has the potential to offer insight to issues that can adversely affect the organization both from a regulatory and financial standpoint. Compliance and revenue cycle leaders are both coming to realize the benefits of collecting and analyzing this valuable information.

However, as compliance teams move from static auditing schedules to proactive risk-based programs to help identify and manage risks, it has become clear that it’s not just managers and supervisors who can benefit from data analytics. A robust analytics program can provide valuable insight that can help every member of the compliance team perform his or her job better.

In particular, use of analytics can significantly improve communication between the compliance team and other departments in the organization. There can often be friction between an auditor and those being audited, but focusing on data and providing a bigger picture view for both parties helps foster better working relationships and more effective issue resolution.

Using actual data instead of hypothetical situations can diffuse disputes and make audit finding discussions positive and more productive. It can also provide a wider view of a potential issue that can aid in instituting effective corrective action, both huge benefits for the compliance team.

For example, an auditor may find an instance of an incorrect E&M billing. It can easily be written off by the physician as a one-time error. However, analytics can reveal a pattern and show it was not an isolated instance. The auditor and physician can then rationally discuss the issue backed by data. That can be a tremendous advantage for compliance teams and helps take the emotion out of findings discussions.

Here are four key members of the compliance team that can get significant value from an organization’s analytics program.

Compliance Officer
Analytics gives the compliance officers a global view of the entire organization. The increased use of analytics provides the compliance officer with the tools to spot variances and shifts that may be indicative of emerging risks, allowing him or her to address them proactively. Analytics provide the opportunity for additional reviews or deep dives into specific data points.

The tools boost the effectiveness of the compliance program by allowing the compliance officer to access data directly rather than relying on other groups to provide it. This greatly aids the rest of the team when they need to conduct more in-depth investigations.

An analytics program allows the compliance officer to help create dashboards that incorporate specific areas of potential risks. Dashboards provide operational and action-oriented data by providing alerts to predefined tolerance levels, opportunities for rapid drill down to pinpoint specific claims and the ability to facilitate mitigation and resolution of issues.

Analytics tools and rapid access to additional data frees up the compliance officer to spend more time on uncovering issues and potential risks rather than struggling to obtain the data needed to do his or her job.

The routine audit function often consists of reviewing samples of ten or twenty cases devoid of other context. This process leaves the auditor with a limited view of the actual activity in that particular area. With an analytics program, the audit doesn’t have to end with a simple review of sample cases. Once the review is complete, auditors can use analytics to do a deeper investigation by looking at the physician profile and reviewing activity bell curves to get a better understanding of the physician’s billings and claims over the past year.

This more in-depth review can help reveal new issues or provide evidence of existing ones. An auditor can then take this history and match it to the audit just conducted to see if they align. This type of extended review can also uncover other issues that can be brought up with the physician during the meeting to discuss the results of the audit. This analytics-based approach makes the auditing process much more comprehensive and efficient. It also provides auditors with a more global view of organizational activity instead of being focused only on a particular slice of time or limited sample of audited claims.

Reviewing bigger picture analytics can also provide significant benefits for trainers. Using analytics, the trainer can gain a wider scope when doing ad hoc training or individual training with physicians.

Analytics data can also be helpful when training new physicians from specialty departments. Trainers are able to research the specialty beforehand, familiarize themselves with the different procedures and services involved and identify how each is billed. This information can be invaluable to a trainer. It can provide him or her with a common language that will improve communication when the trainer meets with a physician, a practice or a department to begin or follow up on a training sessions.

Issues will inevitably arise and when they do, it will be helpful for the investigator to review the data from a global point of view and get a better understanding and a wider frame of reference. Similar to auditors, investigators are often focused on singular events such as potential violations of laws or regulations. Reviewing data collected in an analytics program allows the investigators to view these individual instances within the context of the area involved or the organization as a whole.

If the OIG is involved, the investigator is required to conduct a thorough investigation complete with a written report of all potential violations that describes in detail the targeted conduct. Having access to detailed information as a result of a robust analytics program will help the investigator get to the heart of the issue quickly to help mitigate penalties.

Use of analytics in healthcare is proving to be significant in helping to reduce and often avoid risks. It is also becoming an important component in helping individual members of the compliance team and making the compliance program stronger and more effective. In the end, that will greatly benefit the organization as a whole.

This article was originally published on Hayes Management Consulting and is republished here with permission.