8 steps to mastering a medicare_medicaid audit

8/7/2019 8 Steps to Mastering a Medicare_Medicaid Audit

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Eight Steps to Mastering

the Audit Process


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Audits can be time consuming and very costly i not managed properly. Being unprepared

is no longer an option. With the expansion and success o the Recovery Audit Contracto

(RAC) program audits and increased fnancial repercussions or audits that have been

around or years, audits are ramping up.Additionally, more and more entities are actively trying to identiy improper Medicare and Medicaid payments and recentlPresident Obama stressed the importance o recapture audits. Today, healthcare acilities are being inundated with audits romMACs and MICs as RAC audits continue to slowly trickle in. Additional audits rom CERT, ZPIC and OIG are not ar behindmaking the need or a systematic and consistent process more important then ever. Missteps related to ulfllment or misseddeadlines can be the cause or recoupment and missed opportunity or appeals.

With over 30 years o Health Inormation Management experience, our extensive knowledge o HIPAA regulation, and interviewswith various healthcare leaders, we have developed a list o best practices that we are certain will help you be more preparedor the onslaught o audits coming your way.

We believe that there are eight key actions that you need to put in place to ensure that each and every audit request is optimally

managed education, communication, workow creation and management, release o inormation, decision managementappeals management, revenue impact analysis, and the mitigation o uture denial issues. Putting a process in place thamanages all o these key unctions can eventually make audits just another task in your teams daily activities.

1. Educate Key StakeholdersProvide your key stakeholders with access to historical inormationabout the various types o audits so they can better understand howeach can potentially aect revenue. Introduce them to importantWeb sites to increase their level o awareness and understanding oederal and state audits. For additional insight, have stakeholderssign up to receive blog discussions hosted by industry thoughtleaders and experts. These tools can provide a orum or them toask specifc and targeted questions.

2. Identify a team and schedule regularly occurring

meetingsConsider the complete acility impact when creating your team(Health Inormation Management, Compliance, Revenue Integrity,Finance, Business Ofce, Medical Sta and Case Management).Audits aect many dierent areas o the hospital and diverseexpertise is needed or optimal management o medical recordrequests and appeals determination and management. It isimportant or team members to be accountable and understandeach step o the process. Their responsibilities should be linkedto deadlines.

Once your team has been established it is imperative that regular meetings are scheduled to discuss all audit related issuesMeetings should be a orum to share and discuss ideas and experiences as well as to analyze and plan ways to handleknown vulnerabilities. Subcommittees are also helpul to address parts o the auditing process like appeals or proactivereviews.

3. TrackingCreate a specifc workow or use database and tracking technology that ollows a specifc process, to manage auditrequests. Keeping track o various audits and their specifc due dates is almost impossible to do with a simple spreadshee

Blog Discussion Web Siteswww.cms.hhs.gove/rac

www.cms.hhs.gov/cert

www.cms.gov/medicaidintegrityprogram/

www.oig.hhs.gov/reports.html

www.aha.org/aha/content/2010/pd/10ractracvendors.pd

www.racpreparedness.com

www.healthport.com/secureroi


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Consider using tested sotware that tracks and trends inormation. Updating and sharing the inormation needs to be easyand requent. Seek out a technology that is intuitive and allows you to easily use your data to look or patterns and toprevent uture recoupment.

4. Request letter management processProper management o medical record requests is vital to optimal audit management. A process must be put in placethat will allow you to quickly launch the release o inormation activity immediately. An undefned process can causeunnecessary delays which could jeopardize your ability to appeal and avoid recoupment. It is important to realize that thefrst step in the audit process is eectively responding to requests or medical records. Consider working with a trustedrelease o inormation vendor that employs associates who are highly skilled in HIPAA regulation and records processingto manage the request ulfllment.

5. Decision letter management processThe decision letter must be reviewed and processed quickly.Ensure that the letter is attached to the matching records bycreating a fle that is complete and easily accessible. I you decideto appeal the results o the decision letter, easy access to the

complete fle signifcantly reduces the response time.

6. Appeals management processAppeals must be meticulously tracked to ensure that deadlines arenot missed. Concurrent appeals are inevitable and a process mustbe put in place to careully track and manage multiple requests,due dates and storage. The use o an automated tool thatprovides reminders and emails to trigger action is recommendedto properly track this complicated process. Look or technologythat includes preset audits, is easy to use and that is trusted byyour peers.

7. Establish real-time nancial management and a

dashboard review processTracking the dollars at risk is key to understanding the potentialimpact audits can have on your revenue. Invest in a tool that iseasy to read and will provide real-time reports. It should have adashboard view o dollars at risk as well as dollars won and lost.Data is power. Thereore, it is important to have reporting tools thatallow you to review your aected revenue, get a comprehensivesnapshot o the fnancial impact o all audits, identiy DRG trends,and more.

8. Establish a process and procedures to prevent denial

issues from reoccurring

Conduct internal audits and track and review the results regularly.Use data rom internal audits and key reports to validate that anyand all vulnerabilities are identifed and fxed. Consider workingwith clinical documentation experts to improve documentation.

Audits are disruptive and a real threat to your revenue. We recommend using the eight steps above as your guide, fnding andemploying trusted technology, implementing a workow and utilizing consistent reporting wil l help you take control o audits.

HealthPort AudaPro

HealthPort AudaPro

is a powerulcomprehensive audit management tool

designed to relieve the stress related to

managing the many audits that can negatively

aect your revenue. Our unique technology

acilitates the automation o medical record

request ulfllment, appeals management,

tracking, reporting and communication.

Additionally you have access to real-time

fnancial compliance and HIM dashboard

eatures to capture critical data.

HealthPort AudaPros intuitive workow is

designed to uidly walk you through an audit

request, ulfllment and distribution process.

Additionally it navigates you through all o the

possible levels o appeal. Detailed reports, and

dashboards along with the ability to deploy

internal audits and provide data will help you

fnd vulnerabilities to improve your processes.


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Audit Denitions

MIC Medicaid Integrity Contractors

Reviews provider claims, audits provider claims, identifes overpayments

and educates or trains Medicaid employees

Not involved in collections or over payments

PERM Payment Error Rate Measurement

Measures payment accuracy rate

Each state is reviewed once every three years

CERT Comprehensive Error Rate Testing

Calculates a national paid claims error rate or Medicare Fee-or-Service

program

Reports on Carriers, and Fiscal Intermediaries

OIG Ofce o the Inspector General

Oversees all programs

Conducts independent investigations, audits, inspections and special

reviews

MAC Medicare Administrative Contractor

New contract entitiy

Will eventually replace current payment contractors

QIO Quality Improvement Organization

Staed by healthcare proessionals trained to review medical care andimplement quality improvement

Contracts last or three years

8 steps to mastering a medicare_medicaid audit

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