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Physician Office Records Boost Audit Success

Posted on June 10, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

The following is a guest post from Dawn Crump, Vice President of Audit Management Solutions at HealthPort

Medicare Administrative Contractors (MACs) audit hospitals claims. They compare Part A and Part B claims and look for discrepancies. While these reviews have historically been performed post-discharge, the MACs also conduct pre-payment reviews. MACs ask for documentation to support claims—and hospitals are obliged to provide it. This is nothing new.

What is new is the detail of proof they are requesting. MACs are seeking deeper documentation than ever before. A typical request from the MACs might include language as follows: “We need any and all information to substantiate this treatment.” In many cases, this depth of information only resides within the physician office records.

MACs Seek More Detail

Many hospitals are continuing to respond to MAC requests as they always have—by submitting the appropriate portions of the hospital medical record. Typically, approvals have been granted. But there is smoke on the horizon.

Hospitals have reported receiving denials when they fail to submit physician office records that further substantiate every preventative and therapeutic effort taken prior to more aggressive, in-hospital care (e.g. surgery). And now word on the street is that the RACs are moving toward seeking similar levels of validation for certain medical procedures.

In the immortal words of Bob Dylan, “The times, they are a changin’.” There is no sense in denying the inevitability of deeper MAC (and ultimately RAC) requests. I can summarize my advice in two small words: Be proactive.

Six Steps to Prepare for the Inevitable

Follow these steps to begin incorporating physician office records into your MAC, RAC and other auditor responses. In doing so, you may mitigate the risk of more probing audit requests and prevent revenue take-backs.

  • §  Start now in providing the full extent of what the MACs may soon expect—detailed physician office records that substantiate cause and what preemptive treatment was provided.
  • §  Endeavor to create a process that proactively satisfies these new-style MAC requests. Train your team to include appropriate physician office records in submittal packets. Assume that the RACs will soon seek similar documentation.
  • Meet with your physician groups and their practice administrators as a matter of course to discuss issues, obtain consent and agreement to obtain their records for this purpose.
  • Gather all documents that demonstrate a history of prior conservative medical treatment; showing any time the patient had preventative therapy and indicating surgery was the last resort.
  • Develop internal documentation protocols and guidelines for high risk MAC procedures.
  • Once a MAC request is received, via email, paper, fax or hand-delivery, scan it in and merge it with hospital records.

Though these efforts are above and beyond what has been customary to this point, they’ll prepare you to satisfy the next generation of audit request, both from MACs and potentially RACs. And isn’t it always best to change with the times?

Dawn Crump - HealthPort
Dawn Crump is Vice President of Audit Management Solutions at HealthPort. She formerly served as Network Director of Audit and Compliance at a large regional healthcare system in Missouri. 

Level the Playing Field with RACs as They Enter Practice Settings

Posted on February 5, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

Lori-Brocato-Healthport
Lori Brocato is Director of Audit at HealthPort. With more than 15 years in health care technology, Lori serves as HealthPort’s resident government and third party audit expert, sharing educational information and best practices with health care facilities via Webinars, media interviews and industry articles. Additionally, she is the AudaPro product manager for HealthPort and authors her own blog, Audit Insights, on the HealthPort website. Lori is also a monthly contributor for RACMonitor, an online knowledge source for healthcare providers. She is RAC certified by the Medicare RAC summit and a member of HIMSS and HFMA.

In my most recent blog post here, I presented some helpful hints for reducing the impact of typical RAC audits. In a nutshell, I emphasized that moving toward a centralized, more fully automated, paper-free environment would soften the blow of the ever-increasing administrative burden of audits. Maximizing technology, I concluded, will bolster efficiency and enhance organization, the traditional keystones of corporate success.

But now, to complicate matters, RACs have widened their nets. Nearly all hospitals have deepened their relationships with physician practices, and the RACs have taken notice. Hospitals must now be vigilant of audit activity surrounding the physician practices and take appropriate steps to mitigate the interruptions and expense wrought by additional inquiries.

RACs Make First Move into Practices

Two RACs have already promised upcoming reviews focused at physician practices and medical groups. RACs have also promised to expand E/M coding, the most likely source of overbilling or duplicate billing as hospitals accustom themselves to working in concert with these new business partners. Additionally, RACs now often request physical copies of medical records. In the past, automated reviews based on data analysis of claims an remittance information were the norm. To make matters worse, long-standing, regional health plan auditors are also getting in on the action, requesting and reviewing patient records.

Obviously, RACs have made some game-changing enhancements to their efforts to locate and retrieve billing errors and overcharges.

Here are four ways hospitals can level the playing field with RACs as it relates to their owned or affiliated physician practices and medical groups; minimizing the impact these inquiries have on staff and budgets.

Knowledge is Power –Provide your physician practices with access to RAC managers, historical program information and revenue impact reports. Inform them of key RAC targets for medical groups and deliver real, practical tips on how to mitigate risk.

It’s a Team Effort – Interview each practice administrator to identify and track all RAC activity and record requests. Explain the importance of centralization and incorporate practice administrators into the organization’s overall audit program.

Connect the Dots — Create a specific workflow or use database and tracking technology that follows a specific process to manage audit requests across both inpatient and outpatient settings; including physician groups and medical practices.  Open the lines of communication with practice administrators to ensure all RAC requests are properly communicated, logged and processed.

Learn from Mistakes — Conduct internal audits and track and review the results regularly. Take educational action based on findings. And finally, use data from internal audits and key reports to validate that any and all vulnerability are identified and fixed.

Audits are disruptive and a real threat to your revenue, and they are growing in frequency. The trend towards stronger hospital-physician relationships enforces the need for hospitals to take action, bring physicians into their centralized RAC strategy, and ensure everyone’s revenue is protected.