a high-pressure environment with increased demands on limited staff. Currently, the organization’s compliance and HIM de- partments are handling all audit requests. Collaboration and teamwork are more important than ever before. “They have become creative in communicating, coordinating and track- ing the work,” affirms Wheeler. “The effort has required the reallocation of employees and help from the business office and other areas.”
New audit threats to watch The first major new audit is coming from the Medicaid
RACs. These were launched at the beginning of 2012, but are not expected to reach full swing until 2013. While some states are still selecting their contractors, others are already seeing increasing volumes in Medicaid RAC audits. Many states were waiting to hear the final decision on the
Affordable Care Act (ACA) before proceeding with their recovery audit programs. Now that the Supreme Court has held ACA to be constitutional, more states are picking up their Medicaid RAC activity. Medicaid RACs are looking at many of the same targets as the Medicare RACs. Current activity indicates a large num- ber of automated reviews for
Lori Brocato is audit product manager, HealthPort. For more on HealthPort: www.rsleads.com/210ht-211
coding and billing errors versus complex reviews involving complete medical record requests. Providers can also expect more prepayment reviews com- ing from CMS for Medicare. These are the RAC prepayment reviews designed to supplement – not replace – the MAC payment reviews. They were scheduled to start at the begin- ning of 2012, but the uproar forced a delay until early June, 2012. And due to further delay, these prepayment reviews were scheduled to go live on Aug. 27, 2012. Medicare Prepayment Reviews are a CMS demonstration project, initially affecting only 11 states. Seven of those states (Florida, California, Michigan, Texas, New York, Louisiana and Illinois) are targeted as having high populations of fraud and error-prone providers. The other four states (Pennsyl- vania, Ohio, North Carolina and Missouri) are targeted as having high claims volumes of short inpatient hospital stays. The initial round of audits will involve only eight DRGs.
For organizations located in the designated states, preparation should include a pre-emptive internal audit of these DRGs to determine the status of clinical documentation regarding medical necessity justification, coding and billing. By targeting the initial DRGs, case managers can ensure the appropriate level of care and test for billing errors. At St. Vincent’s, a probe audit was performed by CMS in the spring of 2012 in which five cases from each of the eight DRGs were audited. According to Wheeler, “The probe audit was a black hole, since we have received no feedback or follow-up communication.”
Duplicate audits under investigation
Congress is looking into the overlap in healthcare recovery audits being conducted nationwide, and by multiple contractors. A bipartisan group of legislators has requested that the General Accounting Office (GAO) initiate a study of the various audits being conducted on behalf of Medicare. The goal is to effect change that requires a coordinated effort among auditors to eliminate duplicate and/or unnecessary requests.
Practical workflow strategies to cope
Wheeler recommends proactive workflow strategies to cope with the heightened audit demand: • Prompt action. In a paper-based environment, it is espe- cially difficult to assemble the entire record and respond promptly to auditor demands. Wheeler’s staff responds to auditor requests for medical record documents im- mediately upon receipt to ensure the organization meets the 45-day deadline and avoids technical denials.
• Executive awareness. Payments will slow down. Cash flow will be impacted. Therefore, executives and management teams must be informed of audit activity on a regular basis. Education and awareness training serve this purpose while also justifying necessity for additional resources and staffing reallocations.
• Staffing adjustments. St. Vincent’s now has a business office representative in their HIM department. This staff member works with a coding manager to assist with prepayment reviews. Any audit requests received by the business office are centralized in HIM.
• Benefits of centralization. Centralized audit processing streamlines audit workflow and minimizes duplicative work/cost. A centralized database to capture and monitor every audit, regardless of type, is necessary to identify duplicate audits.
At St. Vincent’s, nearly every chart is now being audited, creating a high-pressure environment with increased demands on limited staff.
Though it seems obvious, providers should track all audit requests. Some auditing bodies have targeted the same rev- enue/encounter. Ideally, returning reimbursement already received is something to avoid altogether, and you certainly want to avoid duplicate payback. Returning money to a payer is something you should only have to do once.
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