In the world of being an expert it can take careful observation as to what is occurring in your area of expertise. This has become especially true in the world of auditing. It is true in the realm of RAC as CMS offers loads of grey areas, and an ever moving target of rules. It’s also true in the realm of commercial audits. Many payers are struggling with increased requests from payers in the area of commercial reviews. Instead of the standard hospital bill audit sites are seeing a rapid increase in “Medical Necessity”, “Level of Care, and other specialty audits. Many facilities are perplexed as to how to handle these audits. Here are a few tips and the sooner the better because these audits are intended to rack up savings for the payers.

1. Your Audit Losses begin with Medical Record Requests – Audit losses in most facilities begin with a medical records or release of information clerk. Every good director, C-Suite exec, V-Suite exec should go spend 2 hours with this individual. It will open your eyes to the many sly, confusing, and incredibly voluminous number of requests. This person is making decisions, “do I send these records or don’t I”? In many, many cases no decision making exists, the record is merely sent. That’s a mistake. Many of your “letters of intent” to audit begin right here. Many requests ask for multiple visits and every page of the record. Besides the high cost of copying and sending the record you have just facilitated a “desk audit’. If your facility is on the ball, you don’t allow for desk audits and every audit must be done on site. Next, many requests need an interpretation and that interpretation should be defined this way. “Will this release of records affect the bottom line”? The answer in a large number is “possibly yes”. This includes DRG Validation requests, Risk Assessment requests, APC requests, confirmation requests, review of services requests. All of these and many, many more are intended to remove dollars from the bottom line. This is done in the form of rev code denials such as with supplies. It is done with desk audits. It is done with misinterpretation of contract rules. All these take backs start right at the records requests.

2. Records Request or retrospective Utilization Review – One of the sites where we service their audit needs recently started recieving Medical Records and audit requests for Medical Necessity and level of care auditing. Here is some of the objections we sighted in a letter to them:

These audit “types” are considered Utilization Reviews that could and should have been done during the patient’s inpatient stay. These reviews retrospectively done must require a set of criteria that you would use to determine your findings. We would need a complete understanding of the process, criteria, reviewers, and any other components used to make these decisions. We further object to a retrospective review that usurps the physician and practitioner’s experience “at the bedside” and “during the events” where decisions are made in the patients interest for best care practices. It is our belief that a retrospective review such as you propose is unfairly weighted in your favor.

These reviews would further burden our site in that they have the distinct ring of a CMS RAC audit. As (Payer name here) is no doubt aware this type of review has cost providers millions of dollars in that these reviews require massive internal man hours to review, respond, appeal, and adjudicate. These cause further financial delays to both parties. They would require us to formulate a team, use untold resources, and create an entirely new set of individuals to review and respond to an unknown number of requests.

3. No request approved until reviewed – In our audit expert practice here at Medlinks we encourage our clients to allow us to review these requests and we do so daily. A request that fails the litmus test is considered an audit and the firm is thus notified with an audit policy. If the request id deemed OK, than we release records. The most important factor is that we record all these transactions so the facility has an idea of the onslaught of requests and the savings incurred by refusals. Savings are calculated by the hourly wage divided by 3-4 requests equals the site savings. I can tell you at our clients this savings is substantial.

4. Audit must do’s –

1. You must enact and strictly enforce an internal audit policy

2. You must charge a fee for every audit, including DRG/APC/Risk Assessment

3. Never allow an off site audit. Make them spend money on a fee, a third party firm, travel expenses and etc. This will dramatically lower their motivation

4. Always require the audit firms written and signed findings

5. Never agree if you don’t agree

6. Always appeal disputed items. This costs them time and money and makes you the standout

7. Always vigorously defend your audits

8. Be nice and be firm

9. If an auditor is inappropriate, uncooperative, or obnoxious kick them and their firm out of your site permanently

10. Ask to see the auditors pictures of their grandchildren. This makes everyone happy!

Medlinks Cost Containment, Inc. does outsourced audit departments for US Hospitals. Our employees, and subcontractors are all based in the USA. We perform all types of medical audits including RAC audits, nurse auditing, and etc. We offer the Healthcare Audit Tracker, the industry’s best audit tracking software. We are HIPAA compliant and offer other services such as HEDIS placement, and Trauma Abstraction.

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