Learn what some of the top IDNs in the country are doing to combat the onslaught of external audit requests and what their challenges are in doing so.
Managing external audits from either government or commercial payers and being efficient in our responses with the proper documentation support is of utmost importance in billing compliance. We’re challenged by staffing shortages, financial restraints, and compliance with constantly changing“ regulations, so it comes to reason that we need help.
MDaudit held a recent panel discussion with several of its esteemed customers from the top 50 Integrated Delivery Networks (IDNs) across the country gathering their input on what it takes to run external audit requests efficiently.
While perhaps most common from the country’s largest payer, CMS, and its review contractors (RAC, MAC, UPIC, TPE, SMRC, etc.), external audits come from government and private payers alike. Given that these payers have recently “upped” their game by leveraging technologies like AI and machine learning into their processes, we as healthcare organizations need to do the same to keep up.
Given that other teams aside from Compliance are roped into these external audits, organizations need to collaborate better to pull the right information and make sure we have all the pieces necessary to get it done on time and with transparency. With that said, let’s hear from our experts.
QUESTION 1: What are some of the internal factors driving your external audits within your organization?
“We needed to have a better way to track the volume, to ensure we have the quickest way to get those medical records to them. our team has been tasked with reviewing external audits, and we want to identify the possible issues and trends and provide education back to our providers on anything that we’re able to find. By using External Audit Workflow, we’ve been able to see certain procedures are being requested because the way we have our group set up by specialty. So, for example, we found that like Botox is being requested a lot, and we have that in multiple groups. Since we’re able to see that, we know we might be getting those for other groups if we haven’t already.”
“We’ve seen some trends for rehab services and things like that identified as well as medical necessity for a lot of those complex procedures, such as neurology or neurosurgery, and related procedures with high-dollar payments due to rehab post-surgery, which is what drove us to utilize External Audit Workflow. Today I read that the OIG’s work plan for October includes in-person reviews of the Medicare Fraud control unit so there’s a push for those investigations to occur. Our health care system is in Florida, with a high amount of fraud that occurs compared to some other states. We used to use manual tracking with Excel spreadsheets, and CMS has pushed for organizations to use more sophisticated data analytics. Leadership did not have easy access to the system, which also pushed us to look for a better tool.”
“We had both internal and external factors as a driving force. During Covid, we had a break from the onslaught of external audits. We also had a complete reorganization of our revenue cycle and HIM structure, which had previously been market-based; most of the external audits were done at a market level. When Covid was over, and things started to roll in again, we knew MDaudit to be really user-friendly, and External Audit Workflow is intuitive; the ease of being able to create reports made it effortless rather than having to track things down or use an unwieldy system.”
QUESTION 2: Describe some key challenges to managing external audits.
“We have a system of about twenty hospitals and nine clinics we have right now; it’s a huge system, and knowing where everything’s going and making sure you keep tabs on things is really the most daunting aspect. Trying to get everything in a central area is critical. Also, knowing who needs to be handling the workflow as things and people change, positions change, or structure changes is challenging as well.
“One of our main challenges is logistics, especially with government audits. A lot of notifications are paper-based and mail can often be misdelivered or delayed. They don’t respect that this delivery is archaic and extend those audits. So sometimes they can just default to a denial, and then we have to go into an appeals process. Another issue that we deal with is time and resource management. Audits usually have a short submission period and appeal windows, so it’s important for us to be as timely as possible, and with our limited resources that can be a challenge.”
With MDaudit’s External Audit Workflow, Electronic Submission of Medical Records (esMD) is built-in to the system, helping customers save time, money, and logistical challenges.
“One of the great benefits about submitting via esMD (electronic submission of medical records) as opposed to paper-based, is that if medical records are missing, or some portion of the record is missing, external auditors are willing to allow you to resubmit in good faith because you submitted the initial documentation, and they have proof that you’ve submitted.”
QUESTION 3: Tell us about your old processes before implementing External Audit Workflow; some of the good, bad and ugly things that came along with it and what the new process has done to change things for your organization.
“We manually added the information onto a spreadsheet. One of the main issues with that is there is nothing telling us what needs to be checked nor what happened with a particular external audit. Now, with MDaudit, we are able to use it for both internal and external audits so all data is in one place and we can track all documentation. Most of our staff used to save documents on their drives, but now, with a central repository, everyone has access.
“One of the goals we wanted was to report on how much work we were actually doing and to give more detail to the higher ups in terms of how much money we would be retaining, and track what happens after we get the letter. We didn’t have a lot of controls in place for that.”
“We also manually added information; I managed all government-related audits and the submission of medical records. But we do have an external department that manages the appeals process, so they’ll review any denials that occur and provide any recommendations. If we appealed, then I would go ahead and submit, based on their input. We were conducting those requests through email, and as we know, inboxes can get flooded, and some would fall off our radar. So, having a process that included a checklist separate from email was a huge benefit to us. Our goals were to consolidate our processes and workflows, reduce the time to respond and appeal to audits, and to increase tracking and trending capabilities to identify potential risk areas.”
QUESTION 4: What are some of the methods that your organization has been utilizing to submit documentation and get that documentation back?
“There’s quite a bit of paper going on still, especially with particular payer audits that are not more local. The rest go through esMD (Electronic Submission of Medical Documentation) with External Audit Workflow from MDaudit. Relying on electronic submission is becoming more critical.”
“We actually utilize an e-fax which has been useful in those circumstances where they don’t utilize electronic submission. But if any auditor has esMD, we always use that as the first resource to submit medical records. It’s the most reliable and beneficial resource we have and of course, if that’s not possible, then we’ll do fax, and then, as a last resort, we have a team member in the office print the records on our behalf and send them via mail if that’s required. It’s not as convenient and takes away from that employee’s time and resources.”
QUESTION 5: How many functions and teams are typically involved in managing an external audit?
“We try to get those who receive the letter to send them to us; sometimes, they get to the revenue cycle team. Then our compliance department works on getting the records, ensuring everything that’s needed is addressed, and then we usually submit those. We work with the revenue cycle team when we get responses back, and we also work with the coding team in cases where we find things were incorrectly coded.”
“We get letters from all over the organization, but now that our inpatient and outpatient organizations are on one consistent system, we have a realignment in regards to letter distribution. We’re now in the process of having HIM manage all the letters and distributions for all the audits with will help reduce delays. Our department manages the compliance-related audits related to government agencies, and the denials team manages most of the commercial audits. So, there’s a lot of collaboration.”
QUESTION 6: Are there any key metrics that come to mind from your leadership that you focus on when it comes to external audits?
“Being able to show how many dollars we’ve defended.”
“Many people see audit work as not being revenue-producing nor easily measurable. But there are definite financial impacts of the work that we do, and in compliance; we need to be able to share with leadership the financial impact of our audit submissions and appeals. We look at denial amounts and the amounts we recouped in appeals. This is an important piece so we can identify potential areas of risk. Being able to do further investigation based on those increases in audits to ensure we’re complying and if there are any trends or any increases in audits, so we can warn leadership that there may be an increase in take-back amounts not due to us being out of compliance, but because of the sheer increase in audits.”
To learn more about MDaudit’s External Audit Workflow and how you can better manage incoming audit requests from commercial and government payers, talk to an expert today.
