This article sets the stage for hospital executives to successfully budget audit management efforts in 2016 while also exploring new ways to maximize intelligence gleaned from all their audit activities.
What’s expected in 2016
While governmental audits such as RAC were minimized in 2015, commercial audits remain on the rise. And providers can expect to see even more payer and health plan audit requests in 2016 due to increased enrollments through the health insurance exchange. Millions of previously uninsured people have now purchased health insurance and health plans are working to effectively evaluate them through data and record reviews.
Healthcare Effectiveness Data and Information Set volumes are also expected to swell in the year ahead. According to the National Committee for Quality Assurance, it is difficult to provide actual numbers for medical record reviews, but a higher number is predicted. Variations in the number of medical records reviewed by individual plans or for individual measures is due to the disparities in availability of administrative (claims data) and supplemental data (from other electronic systems). This variation in electronic data greatly impacts the number of medical records needed on a plan or measure basis according to the NCQA.
The larger need for medical record review in HEDIS 2016 is due to two factors: retirement of rotation strategy and marketplace quality reporting systems according to the NCQA. More information is included in Table 1.
There is, however, a bright side to increased audit activity. Proactively engaging commercial auditors means greater access to current, actionable data. Intelligence gleanded can be used to reduce auditor take-backs and proactively yield better efficiency when it comes to patient care.
Keep lines of communication open
According to Tressa Lyon, HIM director of Norman (O.K.) Regional Health System, “hospitals are not getting the volume of audit requests we are seeing on the clinic side, but I believe there will be a deluge for all care settings in 2016.”
Norman Regional Health System has 26 clinics comprising more than 60 physicians. Each clinic receives its own requests. Hospital commercial audits are not reaching the request volume of the clinic side, where the average is 60-70 patients per request and the largest was more than 340 patients on a single request. For example, from January through August 2014, UnitedHealthcare requested 730 patient cases from NRHS clinics.
Ms. Lyon says that keeping dialogue flowing back and forth is the key to successful audit management and better relationships between providers and health plans. “Health plans are pretty accommodating for due dates – they will usually extend our deadline another 30 days. But they are persistent! They call every day with a status update,” Ms. Lyon says. “We’ve learned to process the ones received first, especially on high-volume request days. We also take care of the squeaky wheels first.”
Audits provide an impetus for communication, and although the goals of plan and provider may be different, the results of improved communication and more accurate data ultimately benefit the patient.
Audit workflow basics
Third-party vendor HealthPort oversees NRHS’ audit management system with a detailed process for receieving and monitoring requests. NRHS only gets involved if there is an issue or the health plan won’t grant an extension. NRHS’ revenue integrity department also monitors cases that are audited for denials and subsequent approvals. The revenue integrity department monitors the types of requests, while the HIM department makes sure all requested and required information goes out in a timely fashion.
Payers and health plans outsource the request of documents to third-party companies, such as ECS, EMSI and Optum. There are four or five common third-party vendors that request information for payers and health plans. NRHS’ biggest requestor, UnitedHealthcare, uses ECS.
Centralized audit team, software become necessities
As providers continue to field more and more audit requests, disorganized, segregated audit management teams can be easily overwhelmed. The surge in audits underscores the need for a centralized audit team.
Centralizing audit management teams simplifies workflow and boosts productivity. This is of paramount importance, especially when healthcare facilities must often field simultaneous audits from multiple fronts. The more centralized your audit processes, the more efficient and lean they will be.
Ms. Lyon warns providers to watch out for duplicate requests. “United once sent a request including 131 patients with clinic visits,” she says. “A second list was sent with the same patients, but it was sorted differently.” Ms. Lyon recommends using tracking software, and ensuring that a system or process is in place to catch duplicates and know what the health plans are requesting.
Beyond software, Ms. Lyon also uses outsourced audit management services through HealthPort. Staff numbers, outsourcing options and accompanying vendor technologies should be evaluated to determine if they can be used to manage the higher request volumes. Staff may need to be augmented, and a new audit management solution may be required. Sometimes it’s simply impossible for providers to complete all requests.
Relieving audit pressure through outsourcing takes the workload, phone calls, communication, red tape and everything else off the provider’s plate. Programs are secure, HIPAA compliant and report back to the provider in a timely fashion, thereby increasing efficiency.
Finally, audit staff (or an outsourced vendor) must ensure everything that’s supposed to be in the patient record is indeed in the record. For example, some EHR solutions include provider-configured tables that are used to automatically determine what is missing from the patient’s record—documents, electronic signatures or any other required information.
Centralizing and outsourcing audit management is a 2015 trend that is expected to continue throughout 2016 as providers adjust to increasing audit volumes.
Be prepared for all situations
“It’s extremely important to know trends, work with the denials management team, and review and track what health plans are reviewing,” Ms. Lyon says. “It is like a teacher announcing an upcoming quiz – audit data gives you time to remediate.”
Ms. Lyon advises health systems to have processes and policies in place to address any contingencies or outlying issues. For example, when NRHS receives requests for physicians’ offices, policy is to notify both the requester and the physician’s office. “Practices are often behind in their awareness,” she says.
While executives are aware of commercial audits, Lyon says that they often need reminders on some key points:
- Ensure documentation is there (emphasize this with executives to help bolster support for CDI programs and initiatives)
- Manage volume and turn-around time pressures, often difficult to do with existing staff
- Measure amount of staffing and time it takes to fulfill requests
- Staff must physically look at every page of a medical record to ensure HIPAA compliance and protect privacy
- Staff must also translate variances in verbiage between payers and plans (different requesters may use different names to refer to the same documents)
- Use some type of software for data entry and tracking
Moving to a healthcare system that rewards for value
Facilitating the ongoing move toward patient-centric care requires the cooperation of both payers and providers. These mutually beneficial relationships will help providers get the attention they need in areas affecting direct reimbursement.
It makes good sense to conduct regular conference calls between providers and payers. Providers should do their homework and know which areas are being targeted by auditors. At the same time, health plans need clean data, especially in areas of managed care where quality ratings are needed to justify Medicare payments.
Data analytics can be used to drive reimbursement and revenue retention. Health plans can guide physicians toward proper documentation, which, held in check by audits, will result in improved patient care.
Table 1: Factors Impacting HEDIS 2016
Retiring Rotation Strategy
The NCQA recently notified health plans that it would retire the federal guidelines having to do with measure rotation. This means that providers can no longer substitute last year’s data in specific areas to improve reviews. All requested HEDIS data must now be current to garner more accurate results.
Marketplace QRS Reporting
Reporting began with HEDIS 2015 and was submitted for the first time this past June. There are a number of measures added to the measurement set and some are hybrid. Medical record requests and reviews are predicted to increase, but still remain focused on a handful of measures.
Best practices in audit management
- Revenue integrity department should monitor and track the types of requests.
- Have system in place to catch duplication resulting from multiple requests.
- Call auditor if request not understood or clarification needed (better than assuming wrong, providing incorrect information and getting denied).
- When information is needed directly from physicians’ offices (this is usually part of the physician record, not the hospital record) clearly spell out process in a policy.
- Physically look at every page of record to make sure the right info is being sent—correct patient and only the minimally necessary data.
- Know what areas are being targeted by the health plans.
- Educate and prepare clinical staff—physicians and nurses.
- Confirm that everything that needs to be in the record is there and sent to the health plan.
- Properly track audits, especially as they are increasingly coming from many different sources.
- Identify auditor trends and work with denials management team to discuss and track what plans are reviewing.
- Use information gleaned from audits to be better prepared, retain more revenue and proactively improve patient care.
