Q&A: Outsourcing CDI work overseas

Q: Are any healthcare organizations outsourcing their CDI department with foreign workers? If the department is remote anyway, what benefits and drawbacks are there to utilizing foreign CDI team members at a lower cost?

A: Some hospitals are very strict about not outsourcing to foreign coders or CDI specialists. Generally, there are extra difficulties and concerns about things such as communication, education, licensing, cyber security, and compliance. Being familiar with providers and helping engagement is also a much more difficult task for outsourced staff. Outsourcing using foreign coders is a bit more common practice, but many have found the time distance poses a challenge in answering provider questions—for CDI specialists who have a role hinging on provider education and engagement, this could create an even bigger issue. Contracting out often makes it harder to establish trust and cultivate relationships with providers, and outsourced staff may not have a vested interest in the organization and its mission and success.

Another hurdle to consider is privacy. “Compliance” 42 Code of Federal Regulations (CFR) part 2 prohibits unauthorized disclosure of information, and therefore consent and sanctions apply. Federal statutes of HIPAA also are in harmony with CFR 42 part 2. Under the law a “lawful holder” of a patient’s protected health information (PHI) is an individual or entity who has received such information as the result of a part 2 compliant patient consent (along with notice of probation on re-disclosure). The law also elaborates on proper processes for release of information (ROI), such as cases of subpoenas. Any penetration to the CFR is a violation to federally mandated requirements. Hospitals and healthcare organizations would need to tread very carefully in this area when sharing data overseas.

Despite the potential challenges some organizations have attempted to use oversees outsourcing for their CDI staffing. For example, one CDI department did a trial overseas outsourcing five of their 30 CDI positions for about a year. The trial was deemed unsuccessful due to audit performance and productivity and the contract was ended. Here are some insights to consider provided from that CDI department:

• Time zones: The time difference was challenging, mostly regarding training and communication. The contracted team was extremely accommodating, but that resulted in them often working absurd hours.
• Cultural: In the country where the contracted team worked, certified coders had a higher salary range than nurses. So, all the contracted staff were RNs and certified coders, but while they had coding experience, they did not have any or very limited clinical experience. This inhibited their ability to identify clinical documentation opportunities. Also, there were internet restrictions in the country that gave them only limited access to online resources. The contracted employees were absolutely kind, respectful, receptive to feedback, and incredibly hard working.
• Support: The contracting agency committed to provide a subject matter expert to directly support the contracted employees, but this never came to fruition. The CDI department was given the impression that all the contracted employees would have “CDI experience”—but the contracting agency didn’t seem to have a clear understanding of the difference between coding and CDI roles. The contracted team needed more support than the CDI department had the bandwidth to provide.

While the CDI profession has transitioned to remote work in many aspects, it’s unclear whether the nature of the work could allow for foreign outsourcing now or in the future without risking lower performance, due to its current extra difficulties. Results from additional trials may provide further insight.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council.