THE CUSTOMER PROFILE
Nemours Children’s Health is one of the country’s largest integrated pediatric health systems and the only U.S.-based children’s health system with two freestanding hospitals—one in Wilmington, Delaware, and the other in Orlando, Florida—with outpatient centers in Delaware, New Jersey, Pennsylvania, and Florida.
Consistently ranked the highest in quality and safety by U.S. News and World Report, Nemours Children’s contributes more than $220 million annually to meet community health needs and is ranked 14th for National Institutes of Health research funding out of 150 freestanding children’s hospitals. The nonprofit health system cares for more than 480,000 children annually.
THE CHALLENGE
A coding integrity department with limited resources requires advanced technology to support an expanded auditing schedule and new reporting model.
The coding integrity department of eight auditors was tasked with auditing a set number of records per provider annually and re-educating providers based on findings. Nemours Children’s made a strategic decision to change its approach to a provider’s coding accuracy by shifting from auditing focused on case accuracy to payment error rate. Following a provider’s coding review, the provider receives a financial error rate score that is based on paid claims. The provider’s error rate determines if additional corrective education and continuous auditing will be required.
“The shift to a financial error rate model of auditing had been on our radar for some time. Our executive team saw it as a better measure of risk, as overpayments, in particular, could point to compliance issues,” said Marianne Lockwood, director of corporate coding integrity for Nemours Children’s Health.
In addition to introducing a new auditing model, the coding integrity department expanded its annual auditing load to 20 records per provider. Along with the expansion, the department was providing consulting expertise to the central business office, front-end billing, and revenue cycle teams — making it clear that advanced technology-enabled processes were needed to streamline workflows.
Users of MDaudit Professional since 2006, Lockwood and her team determined that moving to the more advanced MDaudit Enterprise platform would address many of their challenges. “The financial error rate is a more complex undertaking than case accuracy. Our previous auditing method was pretty simple and straightforward,” Lockwood said. “But when a provider’s coding accuracy is missing the mark, it is putting the organization at risk, and we needed to do deeper dives. MDaudit Enterprise’s existing scoring functionality and improper payment rate reporting mechanisms support what we wanted to do.”
The financial error rate is a more complex undertaking than case accuracy. Our previous auditing method was pretty simple and straightforward. But when a provider’s coding accuracy is missing the mark, it is putting the organization at risk, and we needed to do deeper dives. MDaudit’s existing scoring functionality and improper payment rate reporting mechanisms support what we wanted to do.
From an auditor’s perspective, it would be hard to find another product that can give you the ease of use and detail that MDaudit provides.
THE RESULTS
In the first year after the implementation of MDaudit, Nemours Children’s Health has audited $2.5M in charges, resulting in $195K compliance and revenue risk identified.
For 5/1/2021 – 5/1/2022:
