As we evolve in 2017, the challenges have settled for Health Information Management (HIM) post implementation of ICD-10. Clinical Documentation Improvement (CDI) programs and Computer Assisted Coding (CAC) continue to bring value to data integrity. Larger healthcare systems continue to centralize revenue services while their auditing efforts have improved with technology and resources to conduct audits, analyze findings and implement corrective actions. Establishing a proactive, audit management process with a multidisciplinary team is key to a compliant revenue cycle.
So, what should smaller, community based hospitals do to establish strong, compliant denial prevention systems? The term “audit” probably does not emit the most positive of thoughts for most HIM professionals. No one wants to hear that there are deficiencies or lack of compliance with regulatory standards. Audits can be categorized as proactive, internal audits to assess coding accuracy, data integrity, charge master, charge capture, etc. Audits are also categorized as external payer audits whether Medicare, Medicaid or Commercial payers. In today’s environment, there is heightened scrutiny by governmental regulatory agencies and these are viewed as a compliance risk. In these scenarios, demonstrating a strong systematic audit approach will go a long way in mitigating risk and revenue loss.
A revenue cycle team collaborating on the denial prevention system includes HIM, Coding, CDI, Patient Financial Services (PFS), Charge Master Owner and Case Management. Others within the revenue cycle are included, such as Patient Access Services (PAS) based upon trends. Whether the audit process is internal or external from a payer, a systematic approach to audit management is crucial. Technology can offer many options to improve efficiencies with workflow improvements, front end claim editing on coding for DRG capture accuracy and a proactive approach to overall data integrity.
The first step is to understand the type of audit and the focus. Categorize the requests, track key due dates for the submission of the medical record/other documents and number of patients requested, to name a few. Does the documentation require a clinical review to ensure all requested documentation is present such as Medicare Additional Development Requests (ADRs) or medical necessity reviews? Based upon this clinical review, gathering the required data and validating the presence of the data before it is submitted is a key step knowing deadlines are stringent. Once the information is submitted, what is the outcome of the review? Managing the outcome, revenue take backs, opportunity to appeal findings are varied depending upon the audit type, federal or commercial payer.
The best approach is to understand the outcome of the audits, substantiate findings, trend findings, conduct root-cause analysis based upon trends and actively work as a team to implement corrective action plans. Tracking and data analysis of internal audit findings and external payer denials can provide valuable information for documentation improvement. Implement metrics to monitor performance and demonstrate improvements in the revenue integrity. The community based hospital needs to have a resource who understands the operational challenges of managing this critical component of the revenue cycle. Technology and expertise combined can yield savings and preserve the revenue so critically needed for patient care. Dedicating the education and training for internal resources or outsourcing a component or all of the audit management/denial prevention is another great option for smaller facilities.
In the end, the revenue cycle team, with strong leadership, technology support and a systematic approach will support data integrity, enhance revenue integrity and ultimately turn denial management into denial prevention.
Laureen A. Rimmer, RHIA, CPHQ, CHC
Vice President, Department Management