The Customer Profile
University of Utah Health is the Mountain West’s only academic healthcare system, combining excellence in patient care, the latest in medical research, and teaching to provide leading-edge medicine in a caring and personal setting. The care system’s reach covers five surrounding states in a referral area encompassing more than 10% of the continental United States. It offers the latest technology and advancements in more than 200 medical specialties, including some services that are not available anywhere else in the region.
Part of this system, University Hospitals and Clinics relies on more than 1,400 board-certified physicians and more than 5,000 healthcare professionals who staff five hospitals—University Hospital, Huntsman Cancer Institute, Neilsen Rehabilitation Hospital, University Orthopaedic Center, and University Neuropsychiatric Institute. This group also features 12 community clinics and several specialty centers. Consistently ranked #1 in quality nationally among academic medical centers, the University of Utah’s internationally regarded academic partners include a School of Medicine and Dentistry and Colleges of Nursing, Pharmacy and Health.
We were doing everything through Excel spreadsheets, and it was time consuming to manually fill in all the detail. We couldn’t run comparisons or trending reports, without the support of the data analytics team nor could we
drill down into exactly the data we needed to perform audits. We also had to
build our own scores, which could sometimes result in inconsistencies.
We had really just gotten up and running when COVID-19 hit and threw a hatchet into our auditing program. Account volumes skyrocketed due to patients being tested, seen and treated in the five hospitals, so our team was pulled off their normal jobs to help support coding for COVID accounts to keep things flowing and to keep money coming in.
With COVID-19, everything changed multiple times, so we had to correct and rebuild accounts. The new platform contained a number of built-in templates for COVID that we were able to quickly run to see where we were, which helped quite a bit.
The Challenge
Manual Look-Backs
Even before the COVID-19 pandemic dealt a significant blow to their bottom lines, hospitals and health systems nationwide were already operating under razor-thin margins and ongoing operational losses. A study commissioned by the American Hospital Association (AHA) found that the median hospital margin overall was just 3.5% and projected margins to stay in the red for at least half of the nation’s hospitals post pandemic. Further exacerbating the situation is an expected increase in denials as healthcare organizations navigate a fluid regulatory environment and learn how to interpret new guidance around coding and billing for COVID-19 related care.
These elements have combined to create a landscape in which healthcare organizations need to capitalize on all appropriate reimbursement opportunities and avoid the revenue cycle bottlenecks that can result from denied or delayed claims. They must also quickly and proactively identify and address compliance issues to avoid the potential for bottom-line losses down the road when auditors come knocking to ensure appropriate use of stimulus dollars.
Like many healthcare organizations, University of Utah Health sought to enhance the agility of its 5-person Quality and Compliance Support team and accelerate key aspects of the revenue cycle process through automation. The team is tasked with internal and external audits, such as those conducted by the region’s Medicare Administrative Contractor, that could sometimes pull two members off daily duties to respond.
Retrospective audits were particularly complex and cumbersome, according to Sheri McPhee, CPC CPC-I, Quality Assurance and Compliance Manager for Revenue Cycle Support Services at University of Utah Health.
That reliance on the health system’s analytics team occasionally resulted in unavoidable delays, adds Brittanie Draper, OP Coding Auditor, Revenue Cycle Support Services, University of Utah Health.
“For example, if I realized I need different information to populate a report, or if I got the sample size and realized there was an issue, I had to go back to the analytics team and say ‘this is great, but I need one more component.’ Then I had to wait for the additional data,” she said.
What was needed was a way to automate many of the manual processes involved with retrospective reviews to support expedient responses to denials and audits. They turned to MDaudit Enterprise from Hayes to make that happen.
The Solution
Automation and Analytics
MDaudit Enterprise is a cloud based (SaaS) healthcare compliance and revenue integrity platform which enables healthcare providers to audit physicians and coders to mitigate compliance and revenue risks. It integrates Augmented Intelligence (AI) based capabilities such as natural language search (NLS) and machine learning within its analytics modules for anomaly detection to help organizations increase productivity by predicting and planning strategies for the future.
The platform brings together compliance and revenue cycle departments within a system’s healthcare organization—two critical areas that have traditionally operated in silos, creating a fragmented approach to revenue integrity. Compliance professionals leverage the platform to audit entities and perform corrective actions to mitigate compliance risks, while revenue cycle professionals leverage the analytics modules to identify revenue risks and take further actions. Workflow engines and analytics are tightly integrated to empower organizations to take action on the insights in a collaborative manner that produces better outcomes.
The Results
Accelerated Processes, Recouped Revenues
Implementation of MDaudit Enterprise was completed just ahead of the COVID-19 pandemic, timing that provided an early glimpse of the value the platform brings to the table.
Beyond pandemic response, MDaudit Enterprise has ramped up efficiencies in the department with its easy access to information needed for effective retrospective auditing. For example, the compliance team had undertaken an audit of billings related to Botox cases to ensure facility coding. They sent over a spreadsheet for McPhee’s team to complete, but they instead were able to quickly pull the same information from MDaudit, including every patient with the specific coding and charges.
“It was a much cleaner, smoother process,” said McPhee, adding that the reporting functionality and user-friendly dashboard are personal favorites “because I can see everything that’s going on; who’s doing what and where audits are in the process.”
MDaudit Enterprise also simplifies audit build—something that previously could take a full, frustrating day just to pull the needed accounts, notes McPhee. “This new program is a lot easier and we’re not spending a full day trying to build an audit.”
Draper, the department’s MDaudit superuser, also points to builds as her favorite aspect of the platform, noting that previously there were multiple steps to get an audit going. “This platform has cut down the workload because we can set up and get going in the same day. We just need to plug in the information. So, for me, enterprise productivity has improved big time.”
She adds: “As a team, we need to show how much revenue was saved or recaptured as a result of audits. MDaudit can do all that and how it’s in the university’s and employees’ best interest to have it.”
For the University of Utah Health, MDaudit Enterprise has aided in the recapture of a combined total of nearly $60 million in at-risk charges and revenues, including for COVID-19 related services.
Looking Ahead
A Prospective Approach
Based on the success of MDaudit’s retrospective auditing capabilities, University of Utah Health hopes to expand its use of the platform to also cover prospective audits—which will aid in the health system’s ability to detect errors during pre-bill. Prospective audits also show regulators that the organization is proactive with its billing processes.
“We want to be proactive in everything we do with revenue cycle processes, whether that is identifying opportunities for improvement or getting clean claims out the door from the start,” said McPhee. “MDaudit provides the automation and analytics capabilities that empower us to make that happen. It simply could not be done with manual processes alone.”
