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  • Writer's pictureEffy Healthcare

Using Technology to Demonstrate Compliance While Raising Revenue

Manage regulatory burdens and boost revenue with continuous monitoring and corrective actions.

As revenue cycle executives, ensuring day-in-day-out general medical billing compliance to avoid false claims is part of our daily scope of work. However, we all know there is a much larger framework of rules and regulations hospitals and health systems must follow. Healthcare organizations must abide by directives from the Department of Health and Human Services (HHS), Medicare Fraud Strike Force, Office of the Inspector General (OIG), as well as other government and state agencies. Also, healthcare groups must follow the contractual obligations of commercial payers. There are hundreds, if not thousands, of compliance standards to monitor to mitigate the risk of failure to comply with rules, laws, and regulations.

Fulfilling compliance requirements does not come cheap. A survey by the American Hospital Association (AHA) determined that 63% of total annual regulatory costs are dedicated to documenting CoP adherence and verifying the billing and coverage verification process – equivalent to two-thirds of FTEs devoted to regulatory activities.

Locating compliance risk

With so many rules and regulations governing billing activities (and the multiple systems used to capture patient information, generate claims, follow-up on adjudication, and generate patient billing), pinpointing and permanently correcting compliance issues can be challenging – like trying to remove the needle from the proverbial haystack.

Traditional business intelligence (BI) tools can be useful for retrospective analysis and finding weaknesses; approximately 90% of process auditing can be accomplished in EHR or EMR software. However, after-the-fact, traditional analysis finds problems but provides no ongoing process correction. Organizations must employ continuous monitoring and auditing to ensure compliance, leading to high administration costs.

Continuous monitoring, auditing, and corrective actions

With consequences such as astronomical fines, imprisonment, and possible payer exclusion, there is little room for error when correcting identified compliance issues. Effy Healthcare Business Assurance technology is a proven approach that fills the operational gaps which lead to compliance breaches.

Effy’s efficiency platform continuously monitors and audits data in real-time and triggers alarms when established criteria and business rules are not met. Once an alarm is triggered, comprehensive workflows implement corrective interventions with robust and embedded automation tools.

With Effy Healthcare solution layered on top of all existing technology, covering disparate patient medical systems, billing platforms, and multiple locations, corrective actions are taken before claims are generated – protecting your organization from compliance pitfalls.

Compliance management raises revenue

Automating compliance management with leading Business Assurance technology not only ensures your facility is protecting itself legally, but it can also improve revenue as the key element of a comprehensive revenue integrity program. According to an HFMA/Navigant survey, organizations that employed revenue integrity programs reported a 68% increase in net collections, a 61% increase in overall gross revenue capture, and a 61% decrease in compliance risk.

Compliance and revenue triggers

Countless scenarios may indicate compliance issues and at-risk revenue. Some common triggers include:

  • High percentage of medical necessity denials

  • High percentage of service not covered denials

  • Statistics indicating upcoding or downcoding probability

  • Statistics indicating incorrect ABN usage

  • Low patient copay collections

With Effy Healthcare Business Assurance and Intelligent Automation technology, virtually any data point in any system can be monitored, triggered for an alarm, and fall into a workflow for automatic corrective action through RPA tools – protecting your organization from unnecessary legal and financial risks.

Interested in learning how Effy Healthcare can help you monitor and audit the claims process to mitigate compliance risk and raise revenue? Contact us today at


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