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