What would a billing compliance auditor’s job look like if they weren’t constantly overwhelmed by manual tasks and mountains of unwieldy claims data? It would probably be less reactive and more proactive, focused on educating providers and protecting against future external audits. To minimize billing risks and maximize claim reimbursements, adopting an aggressive strategy for coding and auditing is a critical way to have your teams working smarter, not harder.
Adopting such a strategy has never been more critical as it is today. Healthcare billing compliance requirements are becoming more extensive, resulting in greater scrutiny over providers and facilities. This increase in oversight is prompting organizations to thoroughly examine their billing compliance, auditing, and revenue integrity in an effort to limit compliance risks. By taking a proactive rather than a reactive approach organizations can preempt any expensive coding errors and billing compliance risks.
Heightened Third-Party Scrutiny
Auditing agencies have expanded their oversight, leading to more penalties and takebacks that can be financially crippling for any organization. The Office of Inspector General (OIG) investigates fraud and abuse, Recovery Audit Contractors (RACs) monitor hospitals for billing errors, Medicaid Integrity Contractors (MICs) look for Medicaid overpayments, and Zone Program Integrity Contractors (ZPICs) track Medicare fraud and abuse. The increased attention from these entities has compelled organizations to modify their strategies to ensure billing compliance and revenue integrity.
A proactive medical coding and auditing strategy has these core aspects:
- A risk-based auditing approach using technology to identify anomalous billing trends
- Employing regular prospective audits to significantly decrease the recurrence of aberrative billing patterns — and an
- Emphasis on ongoing monitoring and education
A strategy that encompasses these can help auditors correct billing and coding errors prior to claim submissions, directly equating to significant decreases in denials and the maximization of reimbursements. Each one can support your compliance efforts and contribute to the revenue integrity of your organization.
The Risk-Based Approach
Risk-based audits are unscheduled and performed on a case-by-case basis. However, performing full chart review audits on every potential risk is not feasible. It would help if you had volumes of billing data to examine provider billing patterns that appear anomalous. To do that effectively, you must have the right technology. An integrated software solution allows for continuous monitoring and analysis of your billing and claims data. Without the use of an automated solution, your teams are unable to address issues as they arise.
Being ready for audits by third-party entities that may be scrutinizing your organization is essential for maintaining compliance and efficiency. Risked-based audits address potential problem areas preemptively, stopping them from snowballing into serious revenue and compliance issues. This approach makes discovering and resolving issues less of a chore, saving your organization time and money. When combined with ongoing monitoring, a risk-based approach becomes even more effective by directing audits toward known anomalies and risks.
By taking this approach, compliance awareness becomes imperative throughout your organization, with education playing a central role in ensuring compliance. Risk-based auditing also provides for more frequent reporting than annual risk assessment programs, facilitating a proactive approach to your medical coding and auditing.
Prospective Auditing
With the insights gained using a risk-based approach, you can prospectively audit cases that carry a greater risk of denial. The OIG guidelines can help you identify these cases, as can RAC and Medicare Administrative Contractor (MAC) work plans. You may also detect high-risk areas during external audits that could be targeted for prospective auditing. Proactive medical coding and auditing strategies employ prospective auditing to correct any billing and coding errors on your claims before payers can deny them.
Although retrospective auditing offers the benefit of an expanded time frame allowing for more claims to be audited, prospective auditing can help reduce your denial rate since it catches errors in advance of claim submission. Both prospective and retrospective auditing become tremendously easier with the help of an integrated software solution. Audit software lets you automate auditing functions so your team can concentrate on data analysis and coding quality, saving your organization time and resources.
Ongoing Monitoring and Education
To ensure your organization’s compliance throughout its revenue cycle and promote revenue integrity, continuous monitoring and internal auditing are essential. This is another aspect of the proactive coding and auditing approach that may be enhanced with audit software. With the time that can be saved by introducing automation to your audit processes, auditors can not only conduct more audits but also provide educational resources to coders and providers that help them improve the quality of their coding.
Coding errors and claim denials decrease when auditors can sit down with providers and coders to educate them on coding quality and its importance to revenue integrity. Providers (and coders) who receive the educational resources they need to maintain a high coding quality place considerable value on those resources, which ultimately leads to fewer errors and a greater opportunity to focus on the patient experience. Ongoing monitoring and continuing education are key components of proactive medical coding and auditing.
Implementing Your Medical Coding and Auditing Strategy
Finding the best strategy for your organization involves the consideration of several factors, time and cost being chief among them. A lack of human resources and confining dependence on outdated processes have held many providers back from implementing risk-based auditing and other techniques that characterize the proactive approach.
However, new processes and technologies have given these organizations hope. There’s an extensive range of software platforms that have been developed to help them improve auditing efficiency and reliability. By employing new methods and tools, your auditors and compliance teams can deploy their resources effectively to minimize risk and maximize reimbursement. To do this, you’ll want to keep a few points in mind.
Shedding Manual Processes
Most auditing processes have not undergone the dramatic changes that digital transformation has brought to other areas of healthcare. Despite many recent technological advancements, organizations still rely on paperwork to run their operations. However, with medical audit software, you can significantly reduce the amount of paperwork that your company has to manage.
One of the key advantages offered by audit software is workflow automation. By automating the audit process, continuous risk monitoring and anomaly detection are built into your medical coding and auditing strategy. This enables you to detect risks, identify the root causes of claim denials and take corrective action to avoid them. You can invest the time your organization saves through automation in ongoing monitoring, education, and improving data quality.
Sifting Through the Data
Auditors spend much of their time simply gathering the data they need so they can review it. This leaves only a small portion of their schedules free for them to do what they should be doing: auditing. However, in a perfect world, that critical data would be processed by the time the auditors even begin their work. This would create the perfect opportunity for coding quality reviews, a primary feature of proactive medical coding and auditing strategies.
In addition to providing workflow automation, audit software gives auditors the indispensable advantage of analytics. Software platforms that compare billing data with PEPPER reports can help identify anomalies and narrow down areas of focus based on what’s above or below normative ranges. Billing compliance departments typically lack the resources to analyze dense PEPPER reports and OIG work plans, making these platforms a critical tool for ensuring compliance.
The volumes of data that are available to healthcare providers are enough to overwhelm even the most experienced auditors. Cloud-based audit software, powered by artificial intelligence and machine learning, can guide auditors to the most relevant data so they know where to concentrate their efforts. The right software platform helps them spot trends and identify any coders whose work deviates from normative ranges. Having anomaly detection as a feature of your audit software will ultimately allow for a greater patient experience.
Focusing on the Patient
Healthcare providers face increasing pressure to provide high-quality services quickly, not just for the sake of their bottom lines but for the convenience and well-being of their patients, who often need urgent care. Billing compliance and revenue integrity are the guide rails for your medical coding and auditing strategy, but the best possible patient experience is always your destination.
Healthcare organizations today must be proactive to stay compliant and strengthen revenue integrity. A proactive medical coding and auditing strategy typically entails taking a risk-based auditing approach, holding routine prospective audits, and investing in ongoing monitoring and education. Building these core elements into your organization’s strategy helps ensure that coders and auditors can correct billing and coding errors before they result in denials. By employing a proactive coding and auditing strategy, your teams can effectively reduce claim denials, minimize risk, and maximize reimbursement.
To learn how MDaudit can help you support your billing compliance efforts and bolster the revenue integrity of your organization, contact our team.
