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Tag Archives: Just

What do you do when the auditor just will not respond?

I work at a Substance Abuse Rehab and Cigna has been doing audits of all of their out of network providers. I have not heard of a single facility that has passed the audit. We recently had our audit completed and predictably failed (even though a retrospective audit from Optum BH came up with 0 problems during the same time span). We now have a no payment flag placed on our facility and we are forced to refer patients that come in with Cigna to other facilities.

I have been trying to contact our auditor since the day we found out the flag was placed on our facility. She sent me one email that was very terse and stated a letter would be sent out later that week……that was 6 weeks ago and we have yet to receive the letter. Since then I have called and or emailed 2 or 3 times per week and I have gotten nothing. I have no idea why we even failed the audit and at this point all we are doing is turning patients away.

Personally I believe ignoring me is purposeful on the auditors part. I also believe that the audit itself is punitive and is meant to drive out of network providers away from accepting Cigna patients rather than to improve care for their patients. Basically, the longer the auditor ignores me, the longer any appeal process will take. I am wondering if I have any legal recourse in this matter. If the auditor will not respond to me, who do I talk to? Almost all of Cignas plans are self funded, so they are under ERISA, which I believe rules out state insurance commissioners. I am completely lost here and any direction will help a great deal.

Medical Billing and Coding Forum – Payer/Health Plan

HIM Reimagined: Just the facts

HIM Reimagined: Just the facts

by Sheila Carlon, Ph.D., RHIA, FAHIMA; Mary Beth Haugen, MS, RHIA; Connie Renda, MA, RHIA, CHDA; Linda Sorensen, MPA, RHIA, CHPS  

The Health Information Management Reimagined (HIMR) taskforce is charged with envisioning for the HIM profession in 10 years. The HIMR vision was created to ensure current and future professionals are prepared for the future of HIM in the rapidly changing environment resulting from changes in healthcare, technology, and education. Under the direction of the Council for Excellence in Education (CEE), the taskforce comprises educators from all academic levels (associate, baccalaureate, and graduate) as well as HIM practitioners. The CEE oversight body comprises educators and practitioners who hold a variety of HIM credentials including Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and other specialty credentials.

When working to shape the future of the HIM profession, the HIMR taskforce worked (and continues to work) diligently to seek input from a variety of stakeholders. Members of the taskforce presented the HIMR recommendations to the boards of AHIMA and the Commission on Certification for Health Informatics and Information Management (CCHIIM) and at the AHIMA leadership symposium, Component State Association meetings, and Assembly on Education. In addition, HIMR sought direct comments from CAHIIM, external stakeholders (employers and professional associations), and the AHIMA membership at large.

Through the comment and discussion period, the taskforce received direct comments from 60 AHIMA members and interested stakeholders. The passion and commitment of those that commented has been acknowledged as well as the commitment and leadership of the HIMR taskforce as they seek to advance the HIM profession through this innovative vision. Members of the taskforce would like to take this opportunity to clarify the recommendations and address some of these comments.


HIMR fact and fiction

One noted interpretation of HIMR is the elimination of associate degree programs.

  • Fact (as taken from the draft HIMR white paper, available at Program accreditation at the associate level continues, as does the associate level degree, but it is based on a condensed set of HIM core content and deeper specialty content.
    • Rationale: The taskforce recognizes the critical importance of associate degree programs to the HIM profession. HIMR demonstrates commitment to this academic level through the plan to create specializations at the associate level in response to industry need.


Another common response to HIMR is that the industry changes noted in the white paper will not impact HIM professionals as significantly as suggested.

  • Fact: While we cannot predict the future, we can look to the past, the experiences of similar industries, and to the well recognized changes proposed for the future by experts in healthcare and technology. All indicators point to significant changes in healthcare and health information technology that will impact the work of HIM professionals. The recommendations in HIMR are intended to reflect healthcare in 10 years and beyond, not healthcare today. Moreover, healthcare and other industries are requiring higher levels of academic preparation, particularly for key leadership roles. HIMR supports creating clear pathways for academic advancement to position HIM professionals for future success in the workplace.


In response to the HIM white paper, some have expressed concern with the notion of specialization, particularly with the impact on rural communities.

  • Fact: The specialty tracks proposed in HIMR will include a HIM core curriculum that represents the HIM body of knowledge. This proposed core curriculum would cover content related to the existing HIM domains of knowledge while affording academic programs the flexibility to meet their local needs. It is the firm belief of the HIMR taskforce that having specialties at the associate degree level demonstrates the diversity of the HIM profession today and creates a multitude of opportunities for HIM professionals tomorrow.


Some have interpreted HIMR as promoting a reduction or elimination of the clinical knowledge component of HIM curricula.

  • Fact: HIMR does not make any mention of reducing or eliminating the need for clinical knowledge among graduates of HIM academic programs. While HIMR reflects a transition in the roles associated with HIM practice, the members of the taskforce recognize, celebrate, and support the clinical knowledge that HIM professionals bring to managing health information. The taskforce also recognizes that the diversification of the HIM profession requires a balance of clinical knowledge based on specialty, academic level, and domain of practice. Clearly, the HIM professional’s ability to communicate effectively in any healthcare-related role is enhanced by a strong clinical knowledge base. Future curriculum development activities will continue to include clinical content requirements as appropriate for the academic level and specialty.


Respondents have expressed concern with the sunsetting of the RHIT credential at the end of the 10-year HIMR plan.

  • Fact: HIMR includes a recommendation to phase in specialty programs and associated specialty credentials. At the end of the proposed 10-year implementation plan, the recommendation is to sunset the RHIT credential and replace it with specialty credentials. The intent is to also use the associate programs as a building block to baccalaureate programs and the baccalaureate programs as a building block to master’s programs, since the knowledge required in HIM continues to become more advanced and complex.
    • When HIMR was introduced, it was as a draft document with the specific intent of gathering feedback and input. Input received during the comment period and ongoing discussion about the value of a strong RHIT brand has prompted ongoing dialogue on this topic with the HIMR taskforce. The taskforce members are currently considering options to retain the RHIT brand in combination with academic specializations. Feedback and discussion is planned for the House of Delegates at AHIMA’s annual convention in October 2016 and will serve as a sounding board related to this topic with final revisions to HIMR planned before the end of 2016.


Respondents have interpreted HIMR to allow individuals with less than a baccalaureate degree to earn the RHIA credential.

  • Fact: This is in no way stated or implied by HIMR. However, HIMR includes a recommendation for individuals who hold a baccalaureate degree or higher who also hold a RHIT credential?a window of opportunity to attain the RHIA credential. A similar 1999?2004 initiative was instrumental in positioning HIM professionals with advanced degrees for recognition of their HIM knowledge and higher level education. Comments have been received about the need for more granular eligibility criteria should such an initiative be undertaken as part of the HIMR plan. The taskforce continues to discuss eligibility criteria around this recommendation based on feedback received to date.


Respondents have interpreted HIMR to downplay the importance of coding of health information.

  • Fact: Coded health information has never been more important. HIMR recognizes this in multiple ways, such as coded data being a source of data that will offer increased opportunity for HIM professionals with analytics and other associated skills. In addition, HIMR also recognizes that coding knowledge and leadership will continue to be a pillar of the HIM profession. However, we anticipate the role of traditional coder will continue to evolve, requiring additional skills and education to be able to engage in higher level roles, such as auditing, compliance, and other coding related leadership roles.


Leading is not always easy, because if it is done right it almost certainly requires change. Change is difficult, and the story of HIM is a story of change. We can collaborate to construct a future for HIM that is different, hopeful, and innovative. John F. Kennedy said ‘And those who look only to the past or present are certain to miss the future.’ This message seems as appropriate today as when the words were first spoken. This journey will require leadership, political will, and compromise from all stakeholders to push the profession forward. Only through our joint willingness to accept this challenge can we succeed as united HIM professionals.


Editor’s note

Carlon is the HIM department director for CC & IS/Regis University in Denver. Haugen is the president and CEO of The Haugen Consulting Group, Inc., in Denver. Renda is the assistant professor and program director of health information technology at San Diego Mesa College. Sorensen is the department chair for the health information management department and Allied Health College of Health Professions at Davenport University in Grand Rapids, Michigan. Opinions expressed are that of the author(s) and do not represent HCPro or ACDIS. – HIM Briefings

Healthcare Outsourcing Services Is Not Just Medical Billing And Medical Coding

A while back, when you heard someone refer to healthcare outsourcing, you knew they were speaking about medical billing outsourcing and coding services. Now however, healthcare outsourcing can refer to a myriad of different fields. Healthcare outsourcing companies have diversified their offerings in order to be able to fit into the sometimes overstretched budgets of healthcare providers creating solutions suited specifically for the healthcare industry.

But while medical coding and billing are not the sole areas of focus in the healthcare outsourcing, it is certainly one that requires the most attention among healthcare providers because of the healthcare reform. On the 4th of October, consulting firm, Navigant (NYSE:NCI), acquired healthcare consulting company, EthosPartners Healthcare Management Group (EthosPartners). EthosPartners specializes in physician and hospital alignment, physician practice operations management and physician revenue cycle management. The company cites the need to prepare for the demands of health reform while delivering high quality care, a need that is certainly echoed by many healthcare providers.

Many medical billing and coding companies are preparing for the influx of business in relation to the reform and some are choosing to diversify and expand their offerings in order to cover numerous areas in the space. One such company is outsourcing company and subsidiary of Xerox (NYSE:XRX), ACS, who announced on the 15th of October that they are acquiring healthcare teleservices company, TMS Health from Palm Beach Capital. The Florida based company provides customer care services to pharmaceutical, biotech, and other healthcare-related industries. According to Connie Harvey, Group President of ACS Healthcare Payer and Insurance, ACS is helping pharmaceutical companies make every customer interaction count in a market that spends up to $ 12 billion per year on marketing to its stakeholders, TMS brings strong communication capabilities to the deal. Together, we will save clients money and help them more effectively reach constituents. TMS is the healthcare teleservices provider of seven of the top ten pharmaceutical companies, and who, only four years before had been acquired by Palm Beach Capital for $ 10.5 million. TMS Health counted companies such as AstraZeneca (NYSE:AZN), Merck (NSE:MERCK), and Novartis (NYSE:NVS) as some of its clients during that acquisition.

Indian company Aditya Birla Minacs on the other hand, is going into similar paths as ACS when they advised on that they are also looking for acquisitions in the healthcare space, as well in the public sector. But while ACS acquisition was for a US based company, Birla Minacs is looking towards Europe for its expansion plans. According to Deepak Patel, Aditya Birla Minacs CEO, At the moment, our priority is to build capabilities in core business process in the healthcare and public sector verticals. If we get a firm with a European base it would be an added advantage.

Meanwhile, in the healthcare information technology (IT) space, CACI International was awarded by the Centers for Disease Control (CDC) with a $ 1 billion multi-year indefinite delivery/indefinite quantity (IDIQ) contract on the 19th of October. The contract will focus on providing close to real-time gathering of health information, development of analytic tools, and public health and community collaboration. According to Bill Fairl, CACIs President of US Operations, the contract will allow CACI to, provide credible health information and better protect the health of the public.

It is interesting to see that while outsourcing urges companies to specialize, the outsourcing industry itself, and outsourcing companies as well, are being pushed to diversify their offerings to address the needs of companies. Healthcare is only one industry but certainly, it presents a multitude of opportunities as well.

Audrey B is a Strategic Solutions Group Executive of Infinit Outsourcing, a medical billing outsourcing and medical coding outsourcing provider that puts together a boutique approach to give small to medium and large companies a long-term competitive advantage.