Data inaccuracies have always posed a risk of litigation and penalties, particularly when they come in the form of bad data in a patient chart that compromises patient safety.
However, the new rules around price and coverage transparency introduced by the Centers for Medicare and Medicaid Services add a new layer of risk involving patient data and patient interactions for both providers and payers.
Russ Thomas, CEO of Availity –which just this week announced its acquisition of Diameter Health – spoke with Healthcare IT News to discuss how inaccuracies put hospitals and health systems at greater risk of litigation, government penalties and investigations and significant administrative costs associated with correcting errors.
Q. How do data inaccuracies put healthcare provider organizations at greater risk?
A. The new CMS regulations require providers and payers to keep patients informed about the costs of care and their personal financial responsibility throughout the care journey. Furthermore, they require providers and plans to receive patient consent for the services and associated expenses.
The costs reflected in the final bill must also align with those quoted prior to the encounter or procedure. Under these new rules, if patients aren't informed or are informed inaccurately, the provider could end up being responsible from a financial standpoint.
These regulations add a layer of complexity for providers and payers when it comes to tracking and reporting financial data. For example, this practice is straightforward when it comes to a standard procedure, such as an annual visit (for example, the cost of the appointment is X, the patient co-pay is Y).
However, it becomes more complex when new needs are uncovered during a patient encounter. For example, if a patient presents in the ED in terrible pain, and a series of tests must be performed to diagnose the cause. Or, during a colonoscopy, if a physician finds several polyps that must be removed and tested. These costs can range wildly, and it is not always possible to inform the patient beforehand.
Accurate provider data is important to ensuring alignment between the provider and the health plan on specific members. The more complex the event, the more risk involved and the more difficult it will be to pinpoint an expected expense for the member.
Hospitals face the greatest level of exposure in this environment because of the number of unplanned medical activities they manage, but risk has increased across the board.
Q. There can be significant administrative costs associated with correcting errors. Why is this?
A. If you think about provider data specifically, there are certain elements that are easy to validate. For example, it is easy to know if Dr. Smith is a male or female or whether she is an internal medicine physician or osteopathic specialist.
However, there are other elements that are difficult to verify, especially when it comes to resource allocation in large, complex health systems. Tracking the locations where Dr. Smith is contractually able to see and treat patients is one of those elements.
This is becoming an increasing problem as health systems continue to expand their service offerings via acquisition. For example, if a hospital acquires Dr. Smith's standalone practice, her office is now one of multiple facilities in the hospital network. Dr. Smith's contract may change as a result, enabling her to see and treat patients at other hospital-owned locations outside of her own practice.
Keeping track of where Dr. Smith will show up and provide services is tricky in these instances because the healthcare industry currently doesn't have a standard way to communicate the difference between contractually able to see patients versus actually seeing patients.
For example, Dr. Smith may primarily see patients in location A, but is also contractually able to see patients in locations B, C, D and E.
