New rules and different roles mean HIM pros can chart new career paths

The rise of compliance opens doors to opportunities

The federal government's growing emphasis on Medicare compliance has opened up a host of opportunities for health information professionals skilled in keeping up with new rules, requirements, and regulations that affect not only the medical records department but the entire health care system.

Have you thought about working for the federal government as a fraud and abuse investigator? Plenty of coders and reimbursement specialists have entertained the idea, and it's not far-fetched. The research, record reviews, and documentation that form the foundation of health care coding and reimbursement are exactly the skills needed to understand legitimate Medicare reimbursement claims and red-flag fraudulent ones.

"Because of our understanding of documentation and HCFA [Health Care Financing Administration] regulations and coding, we are the ones who can look at records and see if something was appropriately billed," says Sue Prophet, RRA, CCS, director of classification and coding for Chicago-based American Health Information Management Association (AHIMA). Many coders "want to work for the FBI; they think that would be fun. And AHIMA members that have been working in insurance companies already have the investigative skills," she adds.

With frequent announcements by HCFA and other federal agencies of stepped-up efforts to stamp out Medicare fraud and abuse, it seems that Uncle Sam wants you. For coders and reimbursement professionals, "There are a lot of opportunities because a lot of government investigative agencies don't have the knowledge of coding issues," Prophet says.

"I recommend that HIM professionals who are interested pursue those job opportunities. The fraud investigations are going to happen. It would be better to have people who know what they're doing. They're going to investigate these cases with or without us. I'd rather have people looking at the records who know what they're doing."

But investigating Medicare fraud is just the tip of the iceberg. The growing issue of compliance is providing plenty of fertile ground for health information professionals who want to position themselves for new career opportunities and broaden significantly the scope of their responsibilities.

Consider the position of corporate compliance officer. "A lot of HIM professionals do have a lot of the skills needed for those positions," Prophet says. "They understand multiple third-party payer requirements, and interpreting and implementing regulations, standards, and legal requirements. They already have a rapport with physicians from working on other implementation issues. They usually have leadership, interpersonal, and team-building skills."

Legal training or background is not required for corporate compliance officer positions, Prophet says, since the position does not replace in-house counsel. What's more important is "knowledge of regulations and what you're trying to comply with - and a great deal of it is focused on the documentation area, which is certainly an area that HIM people are qualified in."

HIM professionals already have a head start for corporate compliance officer positions because of their knowledge of standards, policies, regulations, Joint Commission requirements, and HCFA requirements, she adds.

That background and knowledge has helped Sister M. Nika Lee, RRA, with the Order of Saint Francis, prepare for her new role as corporate compliance officer at St. Anthony's Health Center in Alton, IL. After working in the medical records department since 1990, she was tapped to become the health center's risk manager in 1996. Last fall, she was given her new responsibilities - and a job that is still evolving.

"Based on my responsibilities as risk manager and my experience in medical records, it was proposed that I would be the most appropriate person to take on the role of corporate compliance officer," she says, "because I already had experience as an ART with documentation and coding issues and had some training in legal issues and communications skills.

"Also my role reporting directly to the CEO - I was already reporting to the board," she adds, was useful experience for the corporate compliance officer job.

If such a high profile position in your organization doesn't appeal to you, why not set your career course for the position of coding compliance officer?

"I would definitely want in our program an HIM professional, as far as coding compliance goes - and reporting to me," Lee says. "They're going to have that knowledge. I need to be able to rely on people who have that background and knowledge."

There may be different titles for the position, such as HIM compliance coordinator or HIM compliance specialist, but it requires someone with detailed knowledge of the coding component of corporate compliance plans. This includes ensuring coding accuracy in reimbursement claims and making sure your organization's coders have the necessary knowledge and training, are kept apprised of new and revised coding guidelines, and receive ongoing education.

"Some of the duties may have been done by coding supervisors [previously], but a lot of places have made this an entirely different position outside the coding department so there's no supervisory relationship to the coders," Prophet says. This allows coders to be more open about what's going on than they might be with their immediate supervisor. In addition, the coding compliance officer commonly reports to the corporate compliance officer rather than the HIM director to emphasize the separation between departments.

There are other ways that HIM professionals can use their skills and knowledge as a springboard into new career opportunities. As hospitals gear up their compliance efforts, internal auditing and monitoring of coding and reimbursement claims will likely play a more prominent role. And although it's something that has been done all along as part of the coding and reimbursement process, it could become the basis for a new career direction.

"Auditing and monitoring is something our profession has been doing for years, so it's not exactly a new thing," Prophet says. "[However], we could take that skill a step further and maybe look at areas that are outside the HIM department. This could include looking at reports from accounting or financial systems and analyzing trends over time, case mix over time, the percentage of cases within certain DRGs and whether they've increased or decreased over time, and the reasons behind these trends, she adds. Such a position would result in "a more organizationwide look and taking a step back," she says.

"Financial personnel might look for weeks at a figure, and maybe it's as simple as they created a new code for that disease so now that disease moved into this DRG. Without a coding background and understanding, it might take a long time to realize the reason for that change," Prophet continues.

In 1996, AHIMA identified a host of new career paths for health information management professionals as part of its Vision 2006 initiative. (See box, at left.) Many of them require knowledge of a more in-depth use of health data, such as data modeling and mining, or a more "big picture" look at health information, such as data flow and re-engineering, or data risk assessment for the entire enterprise rather than just the medical records department.

Health information professionals can carve out a stronger role for themselves in the broader arena of data mining and analysis. "An area where there is great synergy and a lot of opportunity [for the HIM professional] is a real understanding of confidentiality and privacy laws related to patient data," says Deborah Krau, FHIMSS. Krau is the director of the HIMSS Board of Directors and vice president of Information Services and CIO for Main Line Health System in Berwyn, PA.

Medical records directors "can have a very significant role in shaping the clinical data repository. Access and security issues are really critical. Their understanding of state laws and regulations is extremely important [in relation to] access and the appropriate use of the automated clinical record," she explains.

One problem researchers encounter: When data are automated, their "idiosyncrasies" are automated as well, Krau says. "The role that medical records [professionals] could play in that as we automate data is understanding the data history, its idiosyncrasies and the coding systems that are utilized for reimbursement. They understand those coding mechanisms. I think they have a great role to play in assisting in the interpretation of some of the data that's mined."

As computerization of patient information grows, the position of data administrator will play a stronger role, and the key to success is understanding the data model of the organization, says Krau. "Knowing how the data are defined and how the data flow through the organization enables you to be very good at mining it." That includes understanding the data history, definition standards, idiosyncrasies, and timing of data input.

The important thing to keep in mind in setting your sights on new jobs or career paths is to think globally, health information professionals say.

"A lot of the focus in HIM has been directing or managing a department," Lee says. "One of the things that we need to do in order to progress in our role is take a step back and get the big picture. HIM professionals can fill a more global role."

And in the final analysis, she adds, responsibility for finding new ways to use your skills sits squarely on your own shoulders. "We need to be more flexible and be able to take risks. I've noticed it takes a lot of hard work. It means defining new roles, and I don't have any models to follow. I have got to be able to define that for myself."