Lori Brocato, Audit Product Manager at HealthPort outlines 4 tips to avoid audits, reduce costs, and minimize revenue disruptions in 2013
Over the past twelve months, the volume of Medicare claim review audits has grown. And other payers are following suit. Audits tax your human resources and increase operational expense. To reduce costs and minimize revenue disruptions, I’ve pulled together four tips to help prevent audits in 2013.
1. Know the target areas.
Medicare administrative contractors (MACs) and recovery audit contractors (RACs) are focusing on certain DRGs. Some MACs may focus on different DRGs specific to their geographical areas if they feel that these DRGs are prone to overpayment issues. (See Cahaba Government Benefit Administrators LLC for an easy online reference.) For RACs, respiratory DRGs and stroke DRGs seem to be some of the main targets.
A second trigger for review is the coding of secondary ICD-9 codes not related to the principal diagnosis. Though these non-related codes may be perfectly legitimate, they may also signal billing for duplicate services, non-covered services, or services not considered necessary and reasonable.
One-day and short stays are another target for Medicare claims review audits.
2. Watch your EHR and cloned codes.
Recent concerns have risen over the use of EHRs and Medicare billing. The federal government has paid out billions of dollars to hospitals and physicians, incenting them to use EHRs, with the goal of reducing healthcare costs. However, an unintended consequence of EHR use appears to be heightened volumes of billing codes, triggering a spike in Medicare reimbursements to providers.
At this point, CMS is unclear if the problem is fraud-driven by upcoding, cloning of notes, and gaming of the system. It may be that EHRs simply allow for the capture of more relevant information and automatically correct previous undercoding and underpayment problems.
CMS is already increasing its fraud detection efforts. One MAC recently notified providers that it will be denying claims based on cloned notes. The RACTrac survey found millions of dollars in underpayments by the RACs, an indication that undercoding and underpayment is occurring.
3. Better documentation cures all ills.
Denials are usually due to lack of documentation, insufficient documentation, or non-specific documentation. Therefore, the number one way to mitigate denials is to launch an in-depth clinical documentation improvement (CDI) program. Identify audit targets or those cases that cost the most in human resources and revenue loss. Next, conduct internal self-audits to review documentation and check records of targeted DRGs. This process helps hospitals and health systems to correct deficiencies upfront rather than spending time and resources on a formal audit.
4. Centralize audit management.
A centralized audit function supported by tracking software allows for optimum management of the audit and appeals process and minimizes the risk of technical denials because of missing dates. Duplicate audits are easily identified and curbed.
Taking these preventive steps will not stop audits, but it will decrease denials and mitigate revenue risk. Welcome to another year of protecting your revenue stream.
Featured image credit: http://allhealthcare.monster.com
