Revenue Cycle Release of Information Presents Challenges and Opportunities

It’s time to consider the use of artificial intelligence to respond to requests for copies of records.

When we hear “release of information,” we usually think of a provider’s health information management (HIM) department. However, the release of information is done by other entities throughout the revenue cycle. Access (registration) may release information to payers to secure eligibility and service authorizations. Case management (utilization review) releases information to payers to obtain authorizations for continued stays and to secure placement for patients who need to be transferred to skilled nursing facilities. Patient financial services (PFS, or patient billing) may release information to support a claim or an appeal of a denial. Nursing may release information to provider offices and to a facility when a patient is transferred. The common denominator among these examples is an exchange between covered entities for treatment and billing purposes. Often, these are not logged, even though they are disclosures, usually without patient authorizations.

Although organizations attempt to centralize all releases of information within HIM, it’s not always possible or practical to do so. If HIM isn’t staffed 24-7, will we delay the transfer of a patient to another facility from 7 p.m. until the next morning? No. A nurse or some other designated person needs to process the request. 

Some options that healthcare organizations can consider to address release-of-information demands are the following:

• Expanding staffing coverage in HIM (not likely to happen)
• Training someone in registration, bed management, or nursing to handle release-of-information requests when HIM is closed
• Creating predefined packets of documents in the electronic health record (EHR) to simplify release by nursing after hours
  • The predefined packet might be labeled “transfer file” and include the H&P, ED report, outpatient report (if any), physician orders, medications, nursing assessment, and transfer note. The goal for developing this packet is for it to contain key documents and be easy for the nursing staff to access. The contents may already be defined in your EHR as the clinical summary of care or your UCSDI (United States Core Data for Interoperability), in response to interoperability and information blocking initiatives. Ensure that staff tasked with releasing information are aware of this predefined set of documents, to ease their efforts.
• Ensuring that individuals releasing information are properly educated about patient restrictions, minimum necessary metrics, and any conditions restricted for release.

PFS is a function that needs to address multiple requests from payers for copies of records to evaluate claims. Some payers require copies for each claim, such as worker’s compensation, while others may require copies for claims of a certain value, such as for claims of over $50,000. Expecting HIM to deal with each of these is quite a burden, creating a workflow challenge, and they may not be completed in a timely fashion. Allowing PFS to release documents to support claims or appeals of payer denials makes sense, from an efficiency perspective. 

Annually, insurers conduct Healthcare Effectiveness Data and Information Set (HEDIS) reviews. These reviewers came on-site and reviewed records to abstract the various HEDIS measures in the past. However, now, some organizations queue the electronic records requested for remote access by the HEDIS reviewers. A similar approach is used for other auditors as well. This approach negates the need for HIM to send the records to the reviewer/auditor.

Another unique option is one in which some organizations have extended to payers the right to access records of their insured patients. Typically, certain designated payer employees are authorized to directly access insured individuals’ records without requesting PFS or HIM. Structuring this access requires tailoring the access rights to only those patients insured by the payer, excluding other encounters, and automatically logging the access. The tailored access route may also need to exclude access to certain test results or conditions, which makes this approach challenging, but doing so can lift a significant burden from PFS and/or HIM. If this option is being considered, be certain to check your state regulations to ensure that there are no restrictions to doing so.

Finally, extending access rights to physician offices that have providers on your medical staff will facilitate patient care and reduce requests by physician office billing staff for copies of records. Typically, this option is offered to physicians who are not already on your networked EHR system. Again, the access should be restricted to patients who have been treated by a provider in the practice, with access for disclosure purposes automatically logged.

However, it’s also time for organizations to expand the documents available on their portals, and to consider the use of artificial intelligence to respond to requests for copies of records.

During these times when many organizations are finding it difficult to fill vacancies, consideration of alternatives is necessary to allow all of us to do more with less, yet continue to comply with federal and state regulations.

Programming Note: Listen to Rose Dunn report this story live today during Talk Ten Tuesdays at 10 Eastern with Chuck Buck and Dr. Erica Remer.