In an ideal world, an audit response process would be as simple as receiving notice of the audit, sending back some paperwork and moving on with your work. But anyone who has ever worked on a healthcare audit response team knows this level of simplicity is wishful thinking.
Instead, success is in the details, and compliance is based heavily on your team's actions before, during and after the audit. There's always room to create systems that promote best practices starting before your hospital or health system is even audited. A lot of organization and a little elbow grease can set you up for successful audit responses far into
Best Practices Before An Audit Response
Before the audit even arrives on your doorstep, you can take steps to train your team and implement processes designed to simplify your response process.
• Build your team
Start by defining roles within the audit response process. A good team, at minimum, consists of:
- A documentation lead with access to medical records
- A project manager responsible for making sure all paperwork is sent on time
- A doctor or nurse who can provide a clinical perspective to create a complete picture, if needed
- A quality assurance team member to review all information before it's submitted
Of course, the team is not limited to four people. Include as many employees as your organization needs to send a timely, complete audit response.
• Set up appropriate technology
How can you leverage technology to facilitate communication between the team you've set up, and maintain predefined deadlines? Do you need triggers or automated checks to support your quality assurance process?
Some teams use several spreadsheets or offline systems for monitoring audit response procedures. We recommend investing in technology designed to handle tracking from day one. A good software package supports all team members and can make or break your success in responding to the audit on time and correctly.
• Opt-in electronically, if possible
Traditionally, initial audit notifications are notoriously tricky to keep track of. Government audits are sent via paper letters, and commercial audits are a mix of website posts, paper letters and electronic communication. Sometimes organizations have thousands of locations nationwide, but only handle audits through one or two central offices. The burden of simply organizing audits to get them in the right hands can be hefty, and time spent redirecting the audit notice can eat away at the time you have available to actually submit a response.
There are two ways to handle this. One, ensure all payers and government entities have updated contact information on where audit requests should be sent, including the point person's name, email, phone number and address.
The second, recommended way, is to opt into electronic notifications whenever possible. While electronic audit requests are relatively new in the world of healthcare, they are infinitely faster and more efficient than awaiting a paper letter. Engage with a health information handler to take advantage of electronic communication options
Best Practices During an Audit Response
You've set up your team, your processes and your technology. Now you receive notice you're being audited by Medicare Recovery Contractor, meaning it's time to implement the following best practices.
• Track audits as quickly as possible
If you were unable to opt into electronic communications or are still working on it, you may receive notice of the audit via a paper letter in the mail. Unfortunately, the clock starts ticking from the date the letter is printed. Meaning, the time it takes for the letter to get into the hands of the right person in your hospital or health system is time that could have been spent responding to the audit.
Whether you're using software or a spreadsheet system, make sure you're logging the audit and kicking off the response process as soon as possible. For letters, track the issue date, the date you received the letter initially and the date it is being entered into your tracking system. That way you can keep track of any time lost between issue, receipt and starting the process then work to cut that time down in the future.
• Take QA reviews seriously
Establish your QA review for a complete and thorough audit response. Skipping a review can mean spending extra money to appeal after a denial, so make sure your QA reviewer is capable of understanding and confirming that the audit response tells a complete story.
If possible, everyone on the team should have time to review all gathered documentation for the response with the designated QA reviewer checking last and working with the project manager to ensure all information is submitted in full and on time.
Best Practices After an Audit Response
At this point, pat yourself on the back. Responding to audits can be an expensive, exhausting process, and every one that is submitted on time is an accomplishment. But once you respond, the process is temporarily out of your hands. There's little to do until you receive the results of your audit, at which point, there are several end-of-the-line best practices your team can implement.
• Do your financial due diligence
Whatever the financial impact of your audit result, you will usually see it through your reimbursement for any given payer within that time period. If hundreds of accounts are reimbursed at once, it can be difficult to determine the impact of one small audit, but it's a critical piece of your response process.
The actions you should take to track audit results depend on the type of audit: Pre-pay, post-pay or denials. But with all three, you should track any submitted claims and dig through monthly reimbursements to uncover any audit adjustments.
It can be time-consuming to keep track of audit responses manually. It's helpful to have technology that can automatically monitor each outcome in connection with initiated audit activity and generate a report on audit results within a certain time period. With a complex manual system (or no tracking system at all) you can easily lose audit funds as they're rolled into monthly reimbursements.
• Track results for future audit response adjustments
The point of doing your financial due diligence and tracking everything from the audit letter issue date to the status of all denials is to gather data on your performance. Hard numbers are the best way to establish your performance and identify areas for improvement in future processes.
Software equipped with a great reporting tool can track your KPIs on a monthly basis and remind you to conduct a process review every quarter to implement any needed changes. Analyze your results on your own and within your team to adjust policies moving forward.
Remember, findings, even the negative ones, are an essential part of the audit process. Audits are established to ensure processes and regulations are adequately followed. A string of "lost" audits is not a judgment on your performance at work. Instead, it's useful data and information that can be used to quickly and efficiently button up your hospital or health system's day-to-day performance.
• Develop an appeals strategy
Finally, after your audit has been submitted, you should establish an appeals strategy. Treating every audit result as unique and taking the time to examine it and decide whether or not to appeal is a full-time job. To save time, many organizations establish criteria for audit appeals in advance.
Some of the strategies we've seen in place include:
- Appeal to every audit that doesn't go your way. Though you won't get every appeal in your favor, sometimes the math checks out on this strategy. If you consistently overturn a high percentage of results, it could make sense to appeal every one.
- Use a hybrid model based on the rationale to appeal only to certain types of denials based on the reason for adjustment, like prior authorization or standard of care.
- Use a hybrid model based on finances to appeal only to certain audit results that exceed a pre-established financial threshold.
Of course, you will always come across special cases or audit results out of the ordinary that need extra examination, but having an agreed-upon strategy in advance can save hours of time that would be otherwise spent poring over individual results.
Healthcare audit response software
The healthcare audit response process, overall, is complicated. Though the industry is moving toward tools that simplify the process, like electronic document submission and communication, things are still at a point where you simply can't afford to respond to audits without technology in place.
Looking for the best audit response software? Blueway Tracker is our clients' best defense against insurance audits. As one of only 15 software providers certified in electronic health information handling, Blueway Tracker is able to provide electronic communication while assisting with providing regular reports on success and setting triggers that ensure your team meets deadlines.
Protect your insurance dollars. Learn more about Blueway Tracker, now with Full Cycle esMD
In the world of healthcare financial software, we tend to default to speaking in terms of efficiency, productivity and dollars. After all, that's our business model. We help hospitals screen more patients, cover more medical bills and use technology to form long-term relationships with patients. It's easy to illustrate this in terms of dollars, percentages and decimal points.
But what if we told you that screening more patients and connecting them with available benefits can build strong communities? Or that covering one emergency room visit with Medicaid can change someone's life? When you put people at the forefront of the equation, the healthcare software industry is seen in an entirely new light.
The business of healthcare software
At Bluemark, our software's inherent value lies in making sure that individuals are connected to the right programs at the right time, making sure no one falls through the cracks and that hospitals can screen and enroll as many folks as possible. While getting screened for financial assistance provides an inherent benefit to the patient (we'll get to this in a moment), increased screening and program enrollment also has a significant impact in a hospital revenue setting that should not be overlooked.
Since our company was founded, our clients have utilized the MAPS platform to secure Medicaid approval for over 500,000 applications. Projecting forward we see that number growing by 100,000 plus approvals per year.
Our clients have also utilized the MAPS platform to approve over 500,000 in financial assistance applications. The Medicaid approvals have resulted in $2.5 billion in Medicaid reimbursement for our clients.
Over the years, we, like many of our peers, have found ourselves defaulting to the business approach to tell our story. We've focused on the what and how, but too often overlooked our why - and it's a shame, because the "why" is so powerful.
The "why" of healthcare software
If you sift through the numbers, data and billing statements, there's another side of the coin,which is the side that makes us and our peers in the industry want to get up in the morning and go to work: our impact on patients. With healthcare financial assistance software hospitals receive critical revenue, but a patient walks away enrolled in Medicaid or another type of financial assistance program. What does that mean?
Sometimes it means an entire family gets the healthcare they need on a regular basis. Other times it means someone who has lived in chronic pain for decades is able to afford the medication they need for relief. For some people, Medicaid programs allow for an independent lifestyle with open access to regular medical care.
Hospitals operate with basic business principles in mind, but they are not a business in the traditional sense. Hospitals aren't just driven by revenue, they're driven by their mission statements and core values. Helping the community is part of that mission.
What does Medicaid access mean for communities?
In the United States, one out of every five adult patients and one in three children receives health insurance through Medicaid. These patients are diverse in age, ethnicity and health, but all are able to receive the care they need without the burden of cost.
Medicaid especially protects middle-class families, children, the disabled community and senior citizens. In fact, 70% of nursing home residents pay through Medicaid. Medicaid and other financial assistance programs don't just protect the most vulnerable among us, either. Anyone can find themselves in a situation where the cost of necessary medical care seems overwhelming or impossible.
Financial assistance programs create healthy communities inhabited by people with proper access to care. It also helps hospitals keep up with expenses and strengthens the healthcare system for everyone by reducing the burden of cost and avoiding resource shortages.
The individual impact of financial assistance
If you have been fortunate enough to be able to afford medical care throughout your life, it can be difficult to truly understand the impact these programs have on both individual people and our communities as a whole.
There are countless stories from people who could be your friends, neighbors and peers who have benefited from financial assistance. Consider John from New York City, who left an abusive household at age 14 and enrolled in Medicaid after moving into a homeless shelter. Later in life, after working his way to a steady career and his own apartment, he was suddenly diagnosed with HIV, medication for which cost upwards of $4,000 per month.
Today, John is enrolled in Medicaid for his HIV as well as management for his diabetes, heart issues and lupus. With the burden of these costs handled, he is able to donate his time to an AIDS support organization while keeping his home.
Tom from Dayton, Ohio had a six-figure salary and job security before losing his sister and parents within the span of 16 days and suffering from a mental health crisis. Tom found himself homeless, jobless and in need of mental health treatment with no insurance. With Medicaid, Tom was able to get the help he needed and move back into his own apartment.
In Tom's words, "Because of Medicaid, for the first time in 20 years, I am happy." These are just two of thousands of stories from individuals across the U.S. whose lives have been changed by the impact of financial assistance. You can read more stories from your state and beyond from the Robert Johnson Wood Foundation
Quantifying the "why" of healthcare software
Of course, just because the "why" behind what we do can best be told in stories, that doesn't mean we can't quantify it the same way we can quantify our impact.
Since its founding in 2001, Bluemark solutions have facilitated the approval of over 500,000 applications impacting 1.25 million people. Recall that Medicaid benefits extend to the patient's entire family after approval. The average size of families eligible for Medicaid due to these approvals is 2.5 people, meaning our impact goes two-and-a-half times further on average.
Further, the average value of each approval is $5,000. Crunching the numbers, it can be conservatively estimated that our financial assistance efforts have generated over $1 billion in reimbursement revenue and community benefit.
Bluemark: Supporting communities nationwide
Over the years, we've focused on our core offering of healthcare financial assistance software, but we've also worked outside hospital walls with nonprofits on a mission to connect underinsured or uninsured families with public benefits. We've created a software platform designed to link working class families with food assistance programs.
Inside hospital walls, we've also created specific tools designed to benefit patients, including our MAPS-clear Patient Outreach Portal, which makes it simple for patients to connect with healthcare financial professionals online and submit documentation needed to push them through the application process. This software benefits both the hospital, which sees a reduced workflow, but also the patient, who receives a partial or full discount on their medical bills.
Our mission as a company goes beyond revenue and dollar signs. What we do is ultimately about helping the patients that need high-quality care. We have worked and will continue to work to strengthen the health of communities across the country.
Go beyond revenue and support your hospital's mission by bringing patients back into the equation. Learn more about Bluemark's patient-centric software tools like MAPS-Clear here.
Patient outreach is the process of establishing a financial relationship with your self-pay patient population. It works to position financial counselors as a resource to help patients with medical expenses the same way nurses, doctors and specialists assist with medical care. At the very least, outreach involves getting patient contact information and permission to contact them in the future regarding their medical payments.
The goal of patient outreach is to make contact with a patient as early as possible to facilitate future communication regarding the patient's account. The process must be done efficiently, but with immense tact for best results in establishing strong relationships. Each hospital or health system has established procedures and etiquette for outreach, but as with every process, there's always room for a little improvement!
Why is patient outreach important?
Building a relationship with your self-pay patient population is a key principle of success in healthcare finance. There are many misconceptions around medical financial assistance, and outreach can help demystify the process by educating patients.
One such misconception is the potentially negative stigma around Medicaid and charity care as a welfare program in the eyes of many patients. The Affordable Care Act attempted to destigmatize healthcare assistance programs by redefining programs like Medicaid as simply a subsidized program that covers medical costs for individuals and families. Outreach education continues with this repositioning by showing patients that Medicaid is simply a subsidized program based upon your family circumstances at the time of care.
Another misconception is that financial counseling is closely associated or overlapped with the collections department. Patients often falsely believe that anyone who contacts them in regard to medical payments is seeking to collect money. While hospitals may have financial counselors involved in collecting deductibles and copays, collections is generally not a task charged to the financial assistance department.
Finally, this is not necessarily a misconception, but another aspect of financial assistance patients don't often realize and may need educated on is that financial assistance is a win for both the hospital and the patient. The hospital's expenses are covered, as are the patients. Additionally, when one family member is enrolled in Medicaid, their entire family is typically enrolled and they may be eligible for coverage on future visits.
When is the best time to reach out to patients?
There are two times to reach out to patients: Either when they are still on hospital grounds or once they've gone home. Both circumstances require different outreach methods.
• Outreach while on hospital grounds
Ideally, patients should be approached for financial assistance enrollment as early as possible. However, there are certain sensitivities around the logistics of approaching a patient's bedside which must be considered when initiating the relationship.
To ensure your staff speaks to the patient without being insensitive, you may want to make financial assistance part of the discharge checklist. If a patient is set to leave, either assign a staff member to check in with them and start the enrollment process, or ask the patient to check in with the financial counseling office prior to leaving.
• Outreach from home
If you are unable to reach out to a patient while they are still in the hospital, you must move on to option two and attempt to contact them at home. This option is less ideal as you may be confused for collections or your outreach attempts ignored more easily than if you were at their bedside. But it is not impossible to establish a relationship after the patient's hospital visit.
There are two types of outreach at this point: direct and passive. Direct outreach is proactive and involves calling patients over the phone to engage them in the financial assistance enrollment process. Direct outreach works well for getting a patient's attention, but can be costly and time consuming. It is best to focus on high-dollar accounts first when making phone calls for outreach.
The second type of outreach is passive, which involves including information on medical bills or other correspondence directing the patient to the financial assistance office for help covering their payments. In this case, impetus is on the patient to reach out, not your staff. This method is not as effective and can be easily ignored, but it does allow you to target a larger number of accounts at once.
What are some best practices for patient outreach?
Outreach is a nuanced process that tends to be highly specific to the hospital or health system in which it takes place. However, there are several key best practices that can be followed universally.
1. Account for your patient population's evolving demographics.
Part of the population is still comfortable answering the phone or responding to persistent (not annoying!) voicemail messages. That part of the population tends to be older, and only makes up a portion of patients today.
Younger generations tend to prefer self-service tools that allow them to engage in the financial assistance process on their terms, when they want and in their desired communications channel. Instead of operating only through phone calls, branch out into using emails and texts in your outreach process to keep up with evolving demographics.
2. Make use of technology.
Even if the majority of your patient population is older or has been responding fairly well to phone calls for years, you may be able to capture and engage several other patients through emails and texts.
Technology doesn't just give you the means to send email and text communication. It also:
- Facilitates the use of electronic tools like program screening microapps
- Allows for self-service portals that can initiate the engagement process more effectively
- Automates workflows for increased time management
- Increases security for sensitive information communicated electronically.
Some processes have been done by hand for so long you may no longer notice. If snail mail, phone calls and manual spreadsheets are just the way you've always done it, it doesn't hurt to take a peek behind the curtain and explore the possibility of a tech upgrade in your outreach process.
3. Give patients freedom of choice.
Once you've found the channel in which a patient is most comfortable engaging with, let them choose how they wish to communicate after first contact. Provide 2-4 options and points of access and make note of which one they specify is best for connecting. From there, you can also ask which times of day they prefer to be contacted.
Not only does this increase the likelihood of regular patient response, it puts them behind the driver's seat and gives them some control over the situation. Freedom of choice is an underused tactic for patient cooperation that can set a solid foundation for the future of the relationship.
4. Prioritize education in your outreach.
This one is huge. Patients must understand the role you're playing is to help them, not send them to collections or ask for money. Be aware of phrasing, and know what conversation openers tend to elicit a positive response from patients. Then, train your employees on what words and phrases work and don't work.
The goal is to provide education without coming off as insincere or giving the patient a reason to cut off contact before the relationship is even established.
5. Always track outreach efforts.
Remember, a huge part of financial assistance write-offs are dependent upon demonstrating effective, proactive outreach activity. The best way to do this is to use a software or other electronic system that can track your team's efforts and ensure they are compliant with your internal rules as well as external tax regulations.
Many hospitals underestimate the value of tracking outreach internally, but this data is invaluable. Knowing how often people in different age groups respond to certain outreach efforts can help manage your staff's time and better segment calling lists. You can also track metrics to help determine the best times to call and how to open the conversation. When it comes to outreach, hard data is the best teacher.
Technology to improve patient outreach
Take your patient outreach process online with the MAPS-clear patient portal. This standalone portal works as a web-based application that supports proactive patient outreach activities, remote financial counseling, and new contactless engagement initiatives.
Learn more about Bluemark's MAPS-clear solution here.