Data Stewardship as a Risk Strategy--Protecting Revenue in a Transparent Healthcare Market

In this episode, Konstantin Gorelik, HFMA Certified Healthcare Analytics and Operations Consultant, discusses how healthcare finance and revenue cycle leaders can use data stewardship and external benchmarking to proactively reduce compliance, reimbursement, and regulatory risk. Highlights of this episode include: What data stewardship means in the context of revenue cycle and compliance risk. How organizations think about the strategic value of internal and external data. What proactive monitoring looks like in practice. How strong data practices make a difference in a high-risk situation. How finance teams can use data to objectively evaluate issues. Practical steps toward building a more proactive, data-driven risk monitoring approach. Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Konstantin Gorelik. Konstantin is an HFMA certified healthcare analytics and operations consultant with over 10 years of experience advising hospitals and provider organizations on reimbursement strategy, compliance risk, and revenue cycle performance. He previously served as a managing consultant at BRG, where he led complex claims analysis, payor provider dispute engagements, regulatory assessments, and multi-hospital monitoring initiatives. Konstantin focuses on data stewardship as a strategic tool, helping healthcare leaders translate internal and public data into structured, proactive risk monitoring frameworks that protect revenue in an increasingly transparent and regulated healthcare market. In this episode, we discuss how healthcare finance and revenue cycle leaders can use data stewardship and external benchmarking to proactively reduce compliance, reimbursement, and regulatory risk. Welcome, and thank you for joining us, Konstantin. Konstantin Gorelik: Thanks so much, Kelly. It’s great to be here. Kelly: It’s great to have you. Well, let’s go ahead and jump in. So, when healthcare finance leaders hear data stewardship, it can sound abstract. So, what does it actually mean in the context of revenue cycle and compliance risk? Konstantin: That’s an excellent question, and it’s not the first time or the last time that I get that when I start pitching on what exactly the importance of all of this is. Data stewardship is synonymous in my mind and hopefully in the industry as well with intentional management of how data is collected, validated, stored, and used across the organization. So, to that light, it would allow you to connect your finance, compliance, your operations team, and even your clinical documentation team. It’s not just your IT and their analytics team anymore. In our day and age where everything is becoming more interconnected and interoperable and able to be assessed by not only yourselves internally, if you’re a hospital organization, but externally by any type of group that’s taking a look at you, it’s important to have strong stewardship. It ensures that your reports are defensible and not just informative because honestly, many times you’re going to want to get to the beef of why things are happening at an organization. Numbers work, but numbers also need to tell a good story. And poor stewardship office services during audits, litigation, investigations, which you touched upon when you introduced me, and that’s when it’s the most expensive to fix. A lot of organizations will balk at the fact that they might want to invest a little bit more than they probably should upfront. But then once one of those investigations does come down the line, it’s better that they have done this proactively. Kelly: Interesting. I really like what you said about intentional management of that. That was something I took down because it just kind of stuck with me. You talk about internal and external data. How should organizations think about the strategic value of each when it comes to mitigating financial and regulatory risk? Konstantin: So when you hear internal and external data, regardless of what type of organizational vertical you’re in within the healthcare space, so if you’re an RCM, if you are a hospital, if you’re a provider, if you’re a biller or a payer, internal data typically will mean what you have in-house and what you have at your fingertips. So that comes in to you and your organization based on your standard course of business. So hospitals have a little bit of a different flow than maybe a payer would, but the bread and butter of this for hospital finance leaders would be like your revenue cycle data, your claims analytics, all of your metrics that have to do with your dollars and your cents and your bed counts and all the utilization that you have there. It allows you, when you’re internally investigating, to contrast your claims and billing data with past trends and essentially live in a closed container. External data is everything that’s out there in today’s world that wasn’t something that was mainstream maybe 10, 15 years ago, but is now. That includes implementing CMS’s public data sets, which include cost report data. We now have transparency in coverage, which is the payer side of price transparency, which this administration has really flaunted as a way to get transparency for patients. You have hospital transparency data, which is the other side of that type of data, which is the hospitals posting their charges and how much things cost. And so you have these two juxtapositions of internal and external data, and risk emerges in the gap between your internal performance, which is that closed container of how am I doing this month? How am I doing this year? How many claims did I see this year versus last year? That internal performance, in comparison to external benchmarks is, like I just said, where the risk emerges because you might have a very good view of your own world and your own realm, but if you’re not conscious of everything around you and how you sit relative to peers in the market, you’ll end up in that risky pool, as I like to call it. And external data is particularly powerful for benchmarking, like I mentioned. So, figuring out where you sit as an organization, whether you’re a hospital, a provider, a smaller entity, a health center, whatever it is, versus peers in the market, whether that’s in your area or abroad, also helps you identify outliers. So, if you guys have some sort of– there’s so many outliers that I could probably name off. But for example, you’re identifying conditions that have higher complications than maybe others do in the market for the same one. Like your knee replacements for some reason are 10 times more likely to be complicated. Those are types of things that maybe internally you, as your organization, can contextualize and understand, but when an auditor or the government is looking at that, they’re going to have questions and those are going to come down the line for you. And when they start asking questions, you got to know how to defend yourself there. And the last piece that external data is very powerful for is, like I said, so it supports or defends your reimbursement position. So context is everything in today’s world, and data is amazing, and there’s so much of it, and it’s beautiful to be able to access all of it, but contextualizing it and marrying it up so that there’s a story to tell will be incredibly beneficial in the years to come as other organizations, namely the government, become more tech-savvy and more proactive with their monitoring and strategy into finding fraud, waste, and abuse. Kelly: That makes a lot of sense. Thank you for that explanation. Many organizations are still reactive, responding when an audit lawsuit or denial trend appears. What does proactive monitoring look like in practice? Konstantin: That’s a good question. So, to understand proactive monitoring, you have to also understand reactive monitoring, and reactive in the context of these investigations and things that I’ve been a part of are responding after your denials, for example. So, you have a way that you’ve been billing as an organization for five years, the policies change, you don’t change anything, and then all of your money is hung up in a denial pool. And then now you have to figure out, well, what’s going on here? That’s one way where the reaction comes in. You also have a whistleblower claim that could come in. So that’s your qui tams, for anyone listening who’s in the compliance side of hospital finance, as well as payer disputes that come in. So those are ones that we’ve seen publicly. I live in Massachusetts. We had a public article posted about a dispute between Blue Cross Blue Shield and UMass Memorial Hospital. And those disputes are something that could have been solved privately out of the view of the public if proactive monitoring took place, which sets me up nicely to tell you what proactive monitoring really is. So that involves routine monitoring of patterns that regulators and payers already analyze. So, I want to let that sink in for anyone listening here. Examples of that would be length-of-stay outliers, unusually high units or charges for certain services, services that frequently trigger outlier payments for anyone in the revenue cycle space. A lot of your contracts will be paid– or, sorry, excuse me, not a lot of your contracts, but generally, there are going to be contingencies in there where, if you have an outlier case, you get paid a certain different rate. We’re seeing in the market and over the past few years, at least in my work with other clients as well, that that triggering of an outlie...