How do you arrive at your destination if you don’t know where you are and you have no idea where you are going?

You would never leave home for a road trip without Google Maps or GPS directions, yet many hospitals continue to react instead of move proactively as they embark on the journey of auditing. The result is that many often get lost somewhere along the way. Industry experts agree that government audits are not going away anytime soon, and predictions point to a continued increase in the types of audits as well as the quantity of records and claims reviewed. The audit alphabet soup list seems endless: PROBE, PERM, CERT, ZPIC, QIO, OIG, SMRC, automated, semi-automated, complex, prepayment, post-payment, RAC, MAC, QIC, ALJ. It is easy to get lost, as the audit journey can be long and winding, with many detours. So, how do you find your way through this maze? The following steps can help.

The first step in the audit journey is to figure out your current location. It is important to identify the top five DRGs that your facility has been (and is currently being) audited for. You will need to know the number of at-risk dollars, the “no-findings” rate, current appeal success rates, and discussion appeal success rates. The root causes of your denials also will need to be analyzed so you can see in what areas the auditing bodies are really placing their focus. The information collected will give you a very good idea of your successes and failures, and it will direct you to where your facility’s weaknesses lie.

The next step in the journey involves educating key stakeholders at your facility about audit outcomes. Select a system that allows you to track, compare, and improve outcomes, then share this information throughout your facility. A team approach is critical to the success of your journey – involve case management, clinical documentation specialists, physician advisors, compliance, and senior leadership. Meeting once a month to share up-to-date information with members of your team will help keep everyone focused.

Also look for road signs along the way that will help point you down the right path. These signs can be found in numerous areas; one of the first places to look is on the Internet for your Recovery Auditor (RAC) and Medicare Administrative Contractor (MAC) websites, as well as on the Centers for Medicare & Medicaid Services (CMS) website. These sites have a wealth of information regarding government audits as well as links to official documentation, including change request documents and coverage determinations. Another very good source of information is the “Ask the Contractor” meetings that the MACs offer on a regular basis. Chances are that during the calls, many of your questions will be asked and answered.

Keep a close eye on Comprehensive Error Rate Testing (CERT) findings for your region – if the results of a CERT study indicate that a certain area has a high error rate, then shortly thereafter, the issue will show up as RAC post-payment audits and MAC prepayment audits. Education is crucial and can be obtained in a variety of places: Internet listservs, RACMonitor, vendors, RACTrac surveys, etc. Professional organizations such as the ACMA (American Case Management Network), AHIMA (American Health Information Management Association), the AMA (American Hospital Association) and your state’s medical association all also can offer helpful information that can benefit your facility. Consider attending a conference if your facility’s budget allows. Networking with other facilities and sharing information enables you to learn how others in the industry are approaching audits.

Finally, you will need a high level of commitment by senior leadership and staff in order to adapt to the ever-changing landscape of audits. Chances are, you will find areas in your facility that will require improvement, and it is crucial to have input from everyone involved in the process in order to be successful.

Remember that the audit journey can be challenging, but with appropriate direction and oversight, your destination can be reached.

About the Author

Amy Shaffner, RN BSN PHN, is responsible for providing government guidance, support and oversight to acute care facilities at Optum360.  She ensures key stakeholders have the tools, knowledge and process to effectively manage the government audit responses and minimize the fiscal impact to the health system.  Amy counsels and educates appeal nurse writers in a variety of subjects relating to the denial process and appeals. She performs audits and promotes standardization of the audit process.

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