The Medical Audit Common Reviews and their Risk

The Healthcare Industry (both Payers and Providers) has always had a measure of audits and their “ripple effect” carries down the line whether it be workload i.e. record retrieval, desk auditing, refund request, data validation, or the many other facets of audit usage. Today, these audits represent a much broader scope of interplay between Payers and Providers and that interplay can be seen in sharper relief in the “Healthcare Audit Season”.

The Season(s) and their Impact

  • DRG Validation – The most common request seen by providers these reviews have mostly replaced line item auditing. DRG or Diagnosis Related Grouping audits are a serious matter having implications across several of the audit types mentioned above. These audits deserve a team approach, and educational feedback component and a team meeting to discuss error, education, appeals and the like. This is coding done at its best or not.
  • MRR – Risk Adjustment and Medical Record Reviews are primarily driven by payers to prove co-morbidities, chronic conditions, and risks that may have not been identified in the original claim. These can be a double-edged sword for providers who should be reporting this data with their original claim and when this request comes they are often re-paid with a one-sided (payer only) DRG Validation audit resulting in a refund request. This is a lot of work for both the payer and the provider often in ending up in a multi appeal process. It should be noted here that capture of requests by a government entity or a representative of a government agency is important in terms of RAC reviews because once a record has been audited for one purpose, it excludes it from a RAC review.
  • RADV – Medicare Advantage Risk Adjustment Data Validation can be a second level of risk for a provider when responding to a RADV review initiated randomly by CMS. In these audits, the health plan has just 45 days to provide CMS a “best scenario” record substantiating all submissions by the plan at this point. The point is that the payer is managing CMS expense to their best ability. RADV audits are a response from payers to the Initial Validation Audit (IVA) begun by CMS. The claims requested are then compared to the claims submitted to CMS for accuracy. It should be noted here that capture of requests by a government entity or a representative of a government agency is important in terms of RAC reviews because once a record has been audited for one purpose, it excludes it from a RAC review. 
  • HEDIS – Health Effectiveness Data & Information Set is a burdensome season for providers in terms of the volume of records requests. These can be overwhelming in the months between December and May which is the typical HEDIS Season. In our experience on just one HEDIS retrieval project we did in January to May 2018 we retrieved more than 50,000 records for a payer client. HEDIS retrievals should be used to capture HEDIS measures only and any other use should not be tolerated such as retrospective auditing of any kind.
  • Care and Quality Improvement Audits – These requests for records are the toughest for providers to address. These reviews are intended to identify “high risk, chronic care patients” for internal programs such as preventive care and so on. Properly used this could be a real win-win for payers, providers, patients, and taxpayers. The problem is that Third Party Audit Firms hired by payers have turned these requests for records, not into a quality search but a search for dollars instead. This means payers, via their third-party audit vendor, pull records for Care and Quality Improvement Audits only to push that claim through a DRG Validation Audit prompting appeals and workloads which distracts from the good the program was intended to do.
  • Five Star Program (Medicare Advantage) – This program has real dollars for providers who demonstrate for CMS and NCQA the matter by which the prover is improving the delivery of care. These are measured in fewer patient complaints, improved patient experience, and so on. Focus here will improve your bottom line.

Managing Audit Data

Ask most providers leadership “what are your total audit risks in terms of dollars?” and you get a variety of responses. The short answer is “I’m not exactly sure.” This is because typically audit responsibilities are fractured across a provider. The DRG is handled by coding, many of the others are split or shared by HIM and the business office. Many of these groups never discuss outcomes, data analytics, communication and the rest. Without audit consolidation via software, a committee approach, or other avenues your leadership will never truly comprehend what’s at risk.

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Healthcare Audit Tracker

Medlinks Cost Containment, Inc. has since 1997 provided payers and providers with medical auditing using their proprietary tool The Healthcare Audit Tracker.

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