Slideshow: Revenue Cycle Reckoning

There’s a right way and a wrong way to audit your revenue cycle. Take it from the experts.

What NOT to Do During an Audit

It can be difficult to bring out the best in your employees if you hastily announce that they are about to undergo an audit. Even when your organization is not the IRS and the “audit” is a coding and documentation review of the revenue cycle, it’s common for people to imagine the worst, according to coding auditors. “They associate it with the government—coming in in suits. Powerful people that can change their lives. Even though you know you’re not going to do that, you don’t have the ability, it’s still a perception that they get,” says Tammy Ree, RHIT, CCS-P, PCS, CHC, CPC, senior HIM consultant at UASI. “But if you go in and say ‘This is being done, there’s no punitive damages that will occur because of it, it’s an opportunity to find out what’s going on, to improve process and patient care,’ then people buy into it more.”

A Case of Mistaken Identity

A thorough revenue cycle audit means auditing every single part of the revenue process, from the minute a patient walks through the doors of an emergency room or doctor’s office. “I have been involved with more focused audits around the registration validation portion of the encounter of the patient. So making sure that the insurance is being entering correctly, that they’re validating that the patient has the right insurance. If you’re using the wrong insurance information you’re essentially giving away free services,” Ree says.

The Chaotic Mail Room

One facility discovered that they were losing money simply because mail was not directed to the right employees, and they were missing deadlines to submit appeals because the paperwork got lost in the mail room. To prevent this from happening the facility’s staff made sure mail room workers knew exactly who in their department received the most time-sensitive mail, and that their location in the office was clearly identified. They also provided education about properly labeling envelopes, return addresses, their shape and color. So, for example, key documents might be in a manila envelope rather than just a standard envelope that looks like it contains a bill. Or thick envelopes are more important than slim ones.

Leaving Money on the Table

One tactic providers are using to ensure they’re not “leaving money on the table” is using data analytics programs to identify trends, such as which diagnoses are the most expensive and thus require a closer look, or which codes are drawing the most denials for lack of clinical documentation. Stacey Upton, RHIT, CCS, a quality assurance manager at TrustHCS, says data analytics can be used to identify trends that need to be addressed through coder education and training. “Every facility should determine the areas they want be audited.  This could be based on denials and claims issues, a lot of times facilities utilize that information to determine what direction they need to go with their audits—is it BMI, sepsis, OIG work plan, etc.,” Upton says.

Fighting for Every Dollar

An effective audit is one that is thorough. And for many providers that includes re-examining the rates that insurance companies are paying for visits and procedures, even when they are contracted to pay predetermined rates. Ree says she likes to go back and look at a payer’s payment history to see if they are actually meeting the requirements of the contract. “Typically you don’t think about auditing payments, you just assume that you’re getting what you’re expecting to get. But when we did a review on payers we found out they were paying less than the contracted rate and that became a big issue. They were supposed to pay an 80 percent charge, but they had implemented an internal process that downcoded [a service] without letting anybody know,” Ree says. “…I wouldn’t care to look at Medicare or anyone that’s paying me for service. But any time you have a contract where you’re paid on a percentage charge for services or whatever amount I would look at those occasionally.”

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