Reducing the Compliance Burden

As healthcare payment models evolve, it’s more important than ever to protect your revenue. Yet the number of audits—recovery, government and commercial—continues to rise. The effects of these audits have both financial and human capital implications.

In its semiannual report to congress, the HHS OIG reported that $3.35 billion was recovered in 2015. The first half of the year saw $1.8 billion in take-backs. Compare that to the first half of 2016 where $2.77 billion was recovered. This means that in just the first half of this year, the government has recovered nearly the full amount recovered for all of 2015.

As if that weren’t enough to keep providers awake at night, these audits are requiring significant human capital investments. The time and expertise required to manage audits and appeal processes have become a real burden.

How are providers to overcome this challenge? Data.

“With so much effort expended on audits, how can providers reap a return on their human capital investment? The answer lies in data,” said Dawn Crump, vice president of audit management solutions at CIOX Health, in an article for Health Data Management. 

Data—and the ability to analyze that data—is crucial to reducing the financial impact of audits and streamline the workflows and manual processes associated with those audits. Additionally, predicting audits and proactively addressing revenue cycle red flags—rather than reacting to audits—is essential.

In a recent webinar, Ed Reyes, senior compliance auditor from Sutter Health discussed how he has leveraged his data to improve compliance efficiency and proactively prepare for audits.

With self-service analytics, Reyes and his team proactively monitor audit risk, pinpoint the root causes of audits and boost efficiency by streamlining audits and appeals across the organization. “Our department needed to mature our data analytics process from a risk perspective,” said Reyes. “Having the ability to aggregate, analyze and assess data has provided tremendous opportunity.”

Analytics enable Sutter and many others to improve their compliance efforts by:

  • Proactively identifying audit target areas to reduce take-backs
  • Mitigating audit risk and uncovering opportunities to improve coding and documentation
  • Automating the audit and appeal process to increase compliance efficiency
  • Improving appeal success by managing appeal workflows, organizing documentation, and managing deadlines
  • Maximizing compliance resources and pinpointing claims likely to result in take-backs
  • Comparing compliance performance with benchmarking data
  • Standardizing compliance through a centralized analytics platform

Data must be actionable to successfully manage compliance efforts. With data analytics, you can regain power—as you reduce both the financial impact and the human capital expense in compliance.

Learn more about MedeAnalytics compliance capabilities and watch the webinar recording to learn more about Sutter Health and how they use data analytics to mitigate risk and protect revenue. 

Posted in


MedeAnalytics is a leader in healthcare analytics, providing innovative solutions that enable measurable impact for healthcare payers and providers. With the most advanced data orchestration in healthcare, payers and providers count on us to deliver actionable insights that improve financial, operational, and clinical outcomes. To date, we’ve helped uncover millions of dollars in savings annually.

Leave a Comment

Get our take on industry trends

Why Health Plans and Employers Need Stop Loss Reporting

September 10, 2019

Due to rising healthcare costs and the Affordable Care Act removing the ban on capitated benefits coverage, numerous employers with self-insured health plans often purchase stop loss coverage. This coverage is not medical insurance; but rather, it’s a financial and risk management tool that protects the employer from excessive claims.

Read on...

Bridge the Payer/Provider Data Gap

August 23, 2019

Every patient has a plethora of data associated with their health record, which can include decades of enrollments, claims, accounts and charges. Much of this data is not housed within the same institutional, facility or provider database…

Read on...

Digging deeper: Leveraging analytics to boost service line profitability

June 19, 2019

Regardless of the size of the hospital or health system, you need to look beyond traditional operational metrics to fully understand your organization’s performance. Insights into revenue, volume, cost, quality and variation across service lines are key to improving both performance and profitability.

Read on...