No matter what job you have, producing measurable results is an expectation. A CEO is measured by the value of a company. A physician is measured by their quality patient outcomes. However, measuring the results of your auditing team and program may be a little more difficult to figure out.
Goals and Benchmarks
Before we dive into 5 key performance metrics (KPIs) you should be watching, it is important to mention the importance of having clear goals and metrics for your team. Be transparent in your expectations and be sure the goals align with those of the broader organizational compliance mandates, revenue integrity leaders and the c-suite expectations.
For example, if the organization is focused on improving overall billing compliance and first pass pay rates, an increased focus on prospective audits and increased provider education will help support those broader goals.
While MDaudit can provide some standard auditing benchmarks to use for comparison, the reality is that your results may vary based on your organization. The size of your team, the type of charges being audited (professional vs hospital), the experience of your team and the approach to auditing you are taking (planned, risk-based, prospective vs retrospective) all affect the volume and outcomes expected. The best approach is to make an educated guess about where you should be and then after collecting measurable results for 3-6 months, go back and adjust your benchmarks based on experience.
5 Key Metrics to Watch
Auditor Productivity Measures
Cases Completed
• Number of cases completed in the last week/4 weeks/12 weeks.
• Average cases completed weekly per auditor can be calculated and used as a benchmark.
This will help you understand if the auditors are meeting their goals for number of cases and may indicate the team will be behind if they are not keeping up, or perhaps their performance may need a QA review if they are completing significantly more than expected (to ensure there is both quantity and quality).
Line Items Completed
• Number of the line items completed.
• Of the number of line items evaluated, how many are E&Ms?
• Of the number of line items evaluated, how many are non-E&Ms – like procedural based services, modifier utilization, high risk DRGs, etc?
• Of the number of line items reviewed, how many originated from more straightforward office-based visits and how many tie back to long inpatient stays where the patient had multiple services and comorbidities?
By looking at the count of lines items in addition to the complexity of said line items and the place of service, you are able to have full visibility into your auditors and the level of intricacy of the cases they are working.
Quality Measures
“Audit the Auditor” aka QA Results
• Ensure you have instituted a QA program for your auditing team.
Effective ‘Auditing the Auditor’ sessions with constructive dialogues have proven to help common mistakes and significantly improve overall quality. These QA sessions can be led by your more seasoned and experienced auditors or managers. Hold retrospectively with your auditing team to share feedback on both successful and unsuccessful outcomes.
Accuracy of the audited services/procedures over time
As a start, take a look back at the last 6 months of auditing activity and assess the following:
• Top 10 codes (e.g. E&Ms, DRGs, etc.) with disagree findings and why
• Top 10 codes/services resulting in the highest overpayments/underpayments and why
• Top 10 modifiers with disagree findings and why
• Top 10 diagnosis codes with disagree findings and why
• Rendering provider groups and rendering providers with the lowest overall accuracy rates and why
• Of those providers educated, are their subsequent outcomes improving and/or favorable?
Trending the aforementioned is a critical way to observe if your program is making a difference for the organization over time. You should see the overall accuracy of coding on services/procedures increase over time if you are focused on education and corrective action. Expect minor fluctuation but if the accuracy starts declining, there is a need to dig further to understand why. Perhaps a new provider/coder has started or something new (such as the influx of telehealth in 2020) would indicate a risk.
Identification of Lost Revenues
• Number of Missed Services/Procedures and the corresponding financial impact
• Trending Number of Missed Services/Procedures
Make sure to document the top 10 missed procedures unearthed during your auditing efforts. Hospitals are losing critical revenues when high-dollar procedures/services are well documented but never billed or are billed with lower levels of specificity resulting in missed reimbursements and denials.
This should be a critical part of your auditing program. With shrinking budgets and pesky payer policies, finding every dollar for your organization counts and helps your compliance and auditing program show how they are revenue generating.
While these KPI are a good start to measuring the productivity and output of your auditing program, there are countless metrics you can use to help improve efficiency of your program.
MDaudit Enterprise offers advanced reporting which enables you to measure your auditor productivity and quality, along with minimizing billing risk, detecting anomalies, and maximizing your revenue opportunities. Request a demo to learn more.
