Data’s vital role in effective compliance monitoring

When it comes to staying compliant with ever-evolving regulations and protocols that guide your organization in delivering safe, quality patient care, being proactive—not reactive—is crucial. To stay ahead of emerging guidelines and expand your compliance risk coverage, however, you need access to actionable insights. You need good data. 

Luckily, like most healthcare organizations today, you have data. And lots of it. But do you know how to leverage that data effectively to uncover your organization’s specific compliance risk areas? With so much data, and in the face of so many risks—coding, compliance, financial, and operational—how do you know what information you and your team need to review to get the full picture? 

 

Claims data’s role in effective compliance monitoring 

Ongoing monitoring of your organization’s claims data is essential to ensuring a strong risk mitigation strategy that reduces patient harm incidents, penalties due to noncompliance, and reputational damage. Analyzing the valuable claims data that already exists within your organization can give you insights into how your organization is performing within best practice quality guidelines such as those issued by the Department of Health and Human Services’ Office of Inspector General. 

 

Just like healthcare organizations’ quality journeys are ongoing, the monitoring of claims data also should be ongoing. With ongoing compliance monitoring, your team can analyze the data to see trends and patterns or outliers in the data that indicate the organization is not meeting its targeted goals related to compliance and quality, aiding your organization’s quality improvement efforts. 

 

A strong compliance program focuses on mitigation—reducing risks before they become problematic. To achieve proactive compliance management, accurately capturing data and using it for improvement efforts is essential. Your organization has that data in hand—you just need to do a deeper dive to reveal the information that can help identify what is causing the risks. 

 

For example, sepsis is a big concern for provider organizations and is definitely on the OIG’s and other regulatory agencies’ radars. An organization reviewing its claims data might find variations in its coding practices for sepsis. Digging deeper into the data, for example, they might see an increased trend in use of sepsis codes that may identify potential compliance issues with coding guidelines. This provides insights into the organization’s risk for poor care outcomes and lost reimbursement. 

 

Nurse executives, CMOs, and other clinical leaders can then review the information to see if clinical practices or other processes around sepsis need to be adjusted to prevent issues from occurring in the future. Perhaps more training is needed. Maybe there is a new group of providers in the organization who practice differently. Or maybe there are operational processes that need to be adjusted or improved. The data can guide your organization to the priority areas you need to address to limit risk. 

 

In addition, working with compliance monitoring experts like Kodiak, who can combine technology and years of clinical and coding expertise, can further help your organization take the valuable information gleaned from the data to make clinical practice changes needed to reduce risk and improve the quality of care your organization delivers. 

 

Data in action: Identifying risks and opportunities 

Severe malnutrition is another issue that has increasingly been on the OIG’s radar in recent years, meaning it is (or should be) on hospitals’ compliance radars, too. The following example shows how digging deep into claims data can help organizations uncover compliance risk areas and unveil opportunities for process improvements. 

 

The issue: OIG audits have reported that hospitals were overbilling Medicare by incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims. Severe malnutrition is classified as a major complication or comorbidity and therefore results in an increased reimbursement if the claim is moved to a higher-weighted DRG. If documentation does not support a diagnosis of severe malnutrition, however, hospitals must downgrade the DRG, which results in lower reimbursement. 

 

The process: Using claims data, hospitals can identify cases with severe malnutrition, review the documentation to see if it supports the diagnosis of severe malnutrition, and examine how severe malnutrition has been coded. This includes reviewing clinical documentation integrity programs and health information management and other related processes to identify improvement opportunities. 

 

The results: In addition to identifying areas for improvement so coding for severe malnutrition is correct moving forward, some hospitals experience revenue reimbursement increases when they have updated their coding processes with the correct DRGs. One health system Kodiak worked with had an increase of $465,000 in reimbursement following a deep dive of claims data related to severe malnutrition cases across its 10 hospitals and the coding improvements made as a result of that analysis. 

 

Cover more risk 

A strong compliance program focuses on mitigation—reducing risks before they become problematic. Data is an essential component in any healthcare organization’s ability to effectively identify, evaluate, and mitigate risk. Especially in today’s climate where resources are increasingly limited, being able to zero in on your organization’s highest priority risks is vital. 

 

Kodiak knows claims data—and you know your organization best. Contact us today to find out how our compliance monitoring experts can work with you to leverage your valuable claims data to proactively identify your organization’s greatest risks and keep up with what’s next on the ever-changing compliance horizon.