How Hospitals Can Mitigate Financial, Legal, and Compliance Risks 

By Geoff New 

Inadequate clinical documentation can lead to serious consequences.  

Historically, poor documentation has resulted in significant financial losses through penalties, damaged reputations, and even exclusion from federal programs like Medicare. Additionally, it increases the risks of overbilling, audits, and potential fraud accusations by CMS and other regulatory agencies. In legal cases, poor documentation can weaken a hospital’s defense, potentially leading to unfavorable outcomes and millions in lost revenue.  

Patients trust providers to deliver the best care possible, a trust that is partially built on accurate and thorough documentation. If health records do not reflect the patient’s condition and the care provided, everyone loses. A strong clinical documentation integrity (CDI) program corrects process errors, fills in documentation gaps, and ensures the patient care journey is accurately reflected. This accuracy supports continuity of care, enhances patient outcomes, and reduces the likelihood of financial, legal, or compliance issues.   

Challenges and Solutions for Hospital Leaders 

For hospital leaders, inadequate documentation often feels unavoidable due to constrained resources and the complexity of the process. Coordinating everyone involved can seem insurmountable, especially with constantly changing healthcare regulations. The burden placed on clinicians, who must document extensively while also providing patient care, often leads to longer work hours and an environment ripe for ongoing errors. 

So, how can a hospital establish and maintain a strong CDI program that addresses these persistent problems? 

A Strong CDI Program Is Strategic, Timely, Accurate, and Complete 

The following tactics can help hospitals improve their documentation practices and create a more streamlined workflow:  

• Integrated and Synergistic: Unifying utilization management (UM), CDI, and coding creates a cohesive approach to documentation. All teams should work from consistent definitions, expectations, and workflows, collaboratively ensuring documentation accuracy against patient care. 

• Timely and Concurrent: Prioritize concurrent documentation. Documentation specialists should collaborate in real-time with providers to ensure accurate and immediate record-keeping, reducing the risk of inaccuracies. Postponing documentation increases reliance on human memory, which can be unreliable. 

• AI Technology: Leverage AI-driven technology like VISION Clinical Validation Technology™ to improve team processes and productivity. This platform ensures documentation aligns with the appropriate DRGs for accurate reimbursement and compliance, highlighting any gaps or missing data for immediate rectification. 

• Data-Driven and Strategic: Use actionable analytics and data-driven strategies to focus on clinical cases that require the most attention, keeping resource use efficient and impactful. 

• Regular Audits and Feedback: Conduct frequent documentation audits to reveal gaps and areas for improvement. Providing feedback and training based on audit findings maintains high standards and continuous improvement. 

• Continuous Education and Training: Offer ongoing education and training sessions to help clinicians stay updated on best practices and regulations, keeping them engaged in the CDI program. 

• Measure and Optimize: Focus on metrics aligned with the hospital’s goals, not just query counts. Formulate metrics that help uncover the root causes of process issues and revenue losses.  

The Value of Partnership in CDI 

Investing in a robust CDI program safeguards provider interests and enhances patient care quality. While many vendors offer CDI technology and services, true partners who address current issues and plan for future challenges are rare. 

At CorroHealth, our CDI team acts as an extension of your hospital’s staff, providing expert support for both inpatient and outpatient CDI. We alleviate the burdens of critical administrative processes from your clinical and care teams, ensuring every patient’s journey is accurately documented and ready for coding and billing. Utilizing VISION Clinical Validation Technology™, we streamline decision-making, enhance DRG integrity, and optimize revenue opportunities compliantly. Combining a people-first approach with advanced technology, CorroHealth delivers tangible improvements in financial and clinical outcomes, fostering revenue integrity and reducing noncompliance and litigation risks. 

Comprehensive CDI Solution 

The CorroHealth CDI Program is data-driven, strategic, and is tailored to solve your specific issues and can be offered as end-to-end services: 

Consulting: Holistic assessment to uncover pain points 

Education and Program Development: Customized training and development 

Outsourced CDI Services: Inpatient and outpatient 

Technology: VISION Clinical Validation Technology ™ for DRG integrity (Full Staffed, SaaS, Hybrid) 

Staff Augmentation: Providing CDI specialists for inpatient and outpatient services 

Auditing: CDI query auditing for educational and financial opportunities 

Risk Adjustment: HEDIS Abstraction and HCC 

Take the next step in strengthening your hospital’s documentation practices. Read our CDI Playbook, “Six Proven Strategies to Optimize Your Hospital’s CDI Program,” and transform your CDI program into a strategic powerhouse.