Financial health in today’s healthcare organizations is dependent on a revenue cycle that speeds claim approval and reimbursement. Amid tight operating margins, this means that revenue integrity teams need to take steps to ensure claims are submitted clean from the start to avoid denials that result in revenue cycle bottlenecks.
This is where prospective auditing comes into play.
Part of a holistic approach to revenue integrity, prospective auditing complements retrospective auditing by helping ensure claims are submitted right the first time. With the right technological framework, healthcare organizations can overcome the challenges of having limited resources to monitor and audit claims prior to submission.
Solutions like MDaudit Enterprise streamline prospective auditing practices by drawing on AI-based capabilities such as natural language search, anomaly detection and machine learning to catch billing or coding errors early. By automating processes and recording results in a single, closed-loop environment, the solution delivers instant access and visibility into all prospective data sources.
Healthcare organizations can leverage MDaudit to focus on five keys areas of prospective auditing to boost the bottom line.
1. Audit New Providers
Any time a healthcare organization brings in new clinicians, there is risk from a claims perspective. New providers have no track record and should be considered wild cards in terms of billing accuracy and compliance. The current consolidation and acquisition climate exacerbates the risk, especially when large numbers of new providers are brought in-house at once. Prospective auditing built around new providers safeguards healthcare organizations from the “unknown” and ensures timely capture of revenue.
2. Audit At-Risk Providers
Many hospitals and health systems employ retrospective auditing strategies to benchmark performance against peers and identify trends across providers. When issues present with a particular provider, process improvement then dictates the need for education to correct problem areas going forward. These are important strategies, but healthcare organizations should not stop there. Upon identification of an at-risk provider, prospective auditing can get out in front of potential issues while education is underway and new processes are put into place. This minimizes the potential for revenue gaps until the issue is rectified.
3. Audit High-Dollar Procedures
All claims are not made equal. Claims denials across certain procedures—such as transplants, endovascular and spine—can dramatically impact bottom line health. They are also complex from a documentation and billing compliance standpoint. Naturally, revenue integrity teams will want to design prospective auditing tactics that focus on these procedures to ensure clean claim submission from the outset. Healthcare executives can rest assured that payers will prioritize auditing of these claims.
4. Audit High-Volume Codes
It’s not unusual for a small percentage of procedures to account for the bulk of a provider organization’s revenue. For example, orthopedic and heart services account for as much as 80% of revenue in many hospitals. Ensuring the efficacy of claims from the outset will save many headaches from a revenue cycle perspective down the road.
5. Audit New ICD-10 and CPT Codes
New codes that are untested from a compliance standpoint can wreak havoc on denials and optimal revenue integrity practices. Between COVID-19, telehealth and the new 2021 E/M coding changes, there are more reasons than ever to be diligent about double-checking charges before they are submitted. Prospective audits that target specific codes can help you identify errors before they go out, ultimately increasing first pass pay rates and reducing the administrative burden associated with working denials.
Ultimately, you will want an approach that combines prospective and retrospective audits which will allow you to maximize the overall revenue cycle. Read our prior blog about retrospective vs prospective audits to learn more.
