Health Plans & Provider Networks Seek Optimized “Channel to the Chart” – 08/30/2010

AUG 30

Our definition of Healthcare Compliance spans a variety of topics that include ICD-10 conversion, Meaningful Use, Medical Necessity, Clinical Auditing and others.

Relative to clinical auditing, the healthcare industry continues to rely on a payment system where coding needs to be compliant, accurate, and complete in order to maximize reimbursement.

Market forces and change in this arena abound.  The convergence of Healthcare Effectiveness Data and Information Set (HEDIS) – a set of standardized performance measures for managed care organizations – and risk adjustment – a Medicare Advantage plan reimbursement methodology based on the patient’s health acuity – has led to an emerging new sector, Clinical Auditing.

Mandated by National Committee for Quality Assurance (NCQA) and the Medicare Modernization Act (MMA) respectively, HEDIS and Medicare risk adjustment have legitimized clinical auditing as a new industry, creating opportunities for emerging tech-enabled outsourcers with a myriad of relevant solutions.

With Clinical Auditing top of mind, payers and providers must find an efficient, accurate, and scalable “channel to the chart” with a vendor who can effectively acquire, analyze, mobilize, and aggregate clinical data to improve payment integrity. While member targeting, chart extraction, data management reporting, and clinical coding are each critical to reimbursement for healthcare, the merging of these features into one suite provides an “one-stop-shop” solution for clinical auditing services.

Recently we announced that Parthenon Capital was investing in our client, The Coding Source, LLC a clinical auditing firm at the forefront of this emerging sector.

Health reform and an evolving set of challenges at Centers for Medicare & Medicaid Services (CMS) is causing the clinical auditing landscape to change. This change is evident as businesses like The Coding Source grow, and dynamics drive change across the marketplace with:

  • Technology firms seeking services businesses,
  • Services businesses seeking technology firms, and
  • The industry seeking a scalable, “full service” alternative to the mega-vendors like MedAssurant.

If your business is seeing a similar transformation thanks to healthcare compliance, let us know.

Have a great week!

Joanna Roth
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