Customer Profile
Integrated healthcare delivery system with an academic medical center, regional hospital network, ambulatory and community healthcare network, and accountable care organization.
Affiliation: Two world-class medical schools offering access to ground-breaking research and innovative, patient-centered clinical care.
Patient Population: Draws millions of patients from across the globe.
The Challenge: Manual Processes Limit Audit Impacts
Healthcare organizations nationwide are under pressure to eradicate issues impacting claims accuracy, not only because of the damage they can do to the bottom line, but also because the Centers for Medicare and Medicaid Services (CMS) continues to ratchet up its scrutiny.
In response to the evolving regulatory and reimbursement landscapes, this world-class integrated health system sought to minimize billing errors, mitigate risk, enhance compliance, and speed its revenue cycle by establishing a prospective auditing program for outpatient professional claims generated across four of its seven hospital campuses. The goal was to identify and track trends that impact denial rates, delay claims submissions, and slow reimbursement and cash flow.
However, the billing compliance team soon discovered that manual workflows restricted the scope of the new audit program. Because audits were performed using spreadsheets and paper documents, the team was limited in the types of reviews they could conduct and trends they could track. Strategizing and conducting risk-based audits were also impacted, as trends tracking was limited to color-coded spreadsheets.
Manual workflows also made it more difficult to track audit meetings and record and share discussion topics, schedule and complete annual audits of 1,100 active providers, and organize and manage billing and compliance vendors. While best practices point to annual audits of providers, time and resource constraints only allowed these reviews to take place every 18-24 months—and still required support from outside vendors and additional internal resources to complete.
Notes the Manager of Physician Billing Compliance: “I would get a spreadsheet from a vendor, put a hold into the system, create a spreadsheet audit template, and manually create the report I’d then have to generate using spreadsheets and word processing. We were plagued by the confines of paper-based processes, even with our vendors.”
The onset of the COVID-19 pandemic further complicated progress under the new prospective auditing program as the team was redeployed to support other departments. Upon their return to billing compliance, the team had three months’ worth of work to make up, which would easily stretch into the following year.
To optimize prospective audits, the compliance department needed to automate manual workflows and enhance processes to expand the scope and reach of the program. For that, they turned to MDaudit Enterprise from Hayes.
The Solution: Automating Audit Workflows
MDaudit Enterprise is a cloud based (SaaS) healthcare compliance and revenue integrity platform which enables healthcare providers to audit physicians, hospitals, and coders to mitigate compliance and revenue risks. It integrates AI-based capabilities such as natural language search (NLS), anomaly detection and machine learning models (time series forecasting) with analytics modules to help organizations to be productive and predict and plan strategies for the future.
The platform brings together compliance and revenue cycle departments within the system’s healthcare organizations—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 action to capture revenue. Workflow engines and analytics are tightly integrated to empower organizations to act on the insights in a collaborative manner that produces better outcomes.
MDaudit Enterprise Prospective Workflow, part of the MDaudit platform, automates the claims audit process and enables healthcare organizations to focus on reviewing specific, targeted cases to catch billing or coding errors before submission. The module dramatically improves productivity by automating processes and recording results in a single, closed-loop environment. It does this by automatically ingesting charge and payment data and delivering instant access and visibility into all prospective data sources.
Workflow tools allow for easy creation of audits by simply choosing the audit criteria or conditions to be evaluated. Built-in features help pull sample cases, investigate claim details and record findings. It also features the Scheduled Audit Planner, which features a robust set of tools to streamline and automate audit scheduling processes. Audits can be created in bulk and pathways assigned to existing audits to leverage the automated outcome and next audit assignment.
Total Net Financial Impact
$119,000
In Five Months
The Results: Optimized Prospective Auditing
One of the earliest benefits the health system realized after implementing MDaudit Enterprise Prospective Workflow was a significant uptick in efficiency and productivity. Eliminating the manual aspects allowed auditing processes to be streamlined, which in turn enabled the department to identify and track a broader array of trends.
For example, the team can quickly create a customized review order to search for COVID-related patients with discharge order after Sept. 1, 2020, which makes them subject to CMS’s new “positive test” documentation policy. Another example involves the approximately 35% of audit results that revolve around re-coding or under-coding, which impacts revenues. Based on the trends identified by MDaudit, the team can provide feedback or education for physicians on appropriate code selection and documentation for more efficient and accurate billing.
The team can also mitigate the risk of over-coding or bundling issues or claims that go out without proper supporting documentation. MDaudit allows the team to identify those types of trends and then provide feedback and different educational support for different guidelines.
One of the top trends identified by prospective audits relates to split/shared E/M services on two campuses with a significant number of physician assistants (PAs). When an E/M service is shared between a physician and PA, it can be billed as split/shared using either the physicians or PA’s identification number. When those claims come in, they are now evaluated for issues that can be corrected with some form of provider education.
Overall, the financial impact of MDaudit Enterprise was rapid and significant. In a five-month period alone, prospective auditing of professional outpatient services on just four of the hospital campuses resulted in a Total Net Financial Impact of nearly $119,000. The billing compliance team was also able to clear the three-month backlog far faster than anticipated.
With our prospective audits, we are now able to identify more trends throughout the data. We can look at different scenarios or deficiencies and map them across the four campuses for which we are conducting prospective audits,” the manager said. “We can look at the trends and set up different risk-based audits or create education programs based on what the audits show. MDaudit lets us streamline our processes and points us in the right direction based on the different findings.
Just from a productivity and management standpoint, everything is much easier. We are more efficient, and we can conduct all our reviews” in a timely manner.
A Push in the Right Direction
Among the future plans with MDaudit Enterprise are the addition of the Quality Assurance (QA) Review Module. Plans also call for configuring metrics to monitor risk areas specific to the health system as well as those identified as annual priorities by the OIG.
MDaudit, said the manager, “has pushed us in the right direction and helped us focus on more risk areas in addition to our routine prospective reviews.”
