Audit Manager Uncover Hidden Value in HIM

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Original story posted on: September 4, 2013

For decades, health information management (HIM) departments have handled requests for records, validated patient consents, prepared documents, and ensured their safe delivery to verified requesters. The process is called release of information (ROI). It is labor-intensive and regulation-driven.

Recovery Auditors Contractors (RACs) are just one of many external requesters of medical records. Five years ago, when RAC pilots began, ROI was one of the first areas impacted. It remains an area of intense workflow demand.

Hospitals have two options when considering how to respond to RAC requests for additional documentation. They can opt to receive auditor additional documentation requests (ADRs) within audit director or RAC coordinator offices, where ADRs are received and processed by the audit team. Alternately, they can utilize internal ROI staff (or outsourced services) to receive and process RAC requests.

While both options have proven effective, most hospitals find the use of ROI experts to be more efficient and economical. This article explains how to integrate ROI professionals into your audit management processing, which improves RAC results at lower operational costs.

Did You Know?

Medicare’s fee-for-service RAC program is one of the most active requesters of hospital medical records. According to the most recent American Hospital Association (AHA) RACTrac survey, RACs have requested more than a million records through the first quarter of 2013.These requests represent more than $8 million in Medicare payments, a 53 percent increase over the cumulative total reported in the third quarter of 2012.[i]

Furthermore, while electronic processing for ADRs is progressing (the first use of esMD for initial ADR requests began in September 2011, for select government auditors), appeals still are not being accepted through electronic submission. Much paper remains in the process, and all this record-shuffling carries operational cost. In fact, 55 percent of hospitals say administrative costs have increased due to the RAC program, according to RACTrac.

For 29 percent of RACTrac hospitals, the cost to receive, validate, prepare and submit records in response to RAC ADRs is eliminated by using an outside ROI service. These organizations save record-production dollars and mitigate their risk of technical denials. Saint Barnabas Health is one of these organizations.

Subhead: Tackling Audit Problems Together

Barnabas Health is a six-hospital, 4,600-physician, integrated delivery network in New Jersey. Newark Beth Israel Medical Center alone treats more than 25,000 inpatients and 300,000 outpatients annually. Maria Muscarella, RHIA, assistant vice president of HIM and EMR for Newark Beth Israel Medical Center, decided early in the RAC game to integrate her ROI and audit management teams.

Audit management at Newark Beth Israel is centralized, ROI processing is outsourced, and RAC tracking/audit management software is used. To make her audit management process more efficient, Muscarella identified eight steps within the audit lifecycle that required an exchange of information of paper files, electronic files, or both.

  • Repayment requested (demand)
  • Appeal initiated/re-bill initiated
  • Appeal decision communicated
  • Final exchange of dollars based on appeal outcome
  • Payor review identified
  • ADR request issued
  • Record submitted for review
  • Result communicated

Across these steps, Muscarella combines RAC audit management software with outsourced ROI professional services to streamline the process and reduce operational outlay. “All steps within the audit management process are easier to accomplish when our ROI services partner assists,” Muscarella said. “Technology plus people yields the best audit outcome at the lowest organizational cost.”

The Benefits Add Up

The integration of ROI professionals within the audit management process removes several days from the RAC process and ensures that deadlines are met. Technical denials are virtually eliminated and staffing costs dramatically reduced when outsourced ROI staff are involved (versus in-house resources). Other benefits of integrating ROI experts into the audit management process include:

  • ROI service providers (also called health information handlers) facilitate easier electronic submission of documentation to the RACs.
  • An electronic copy of all records submitted typically is stored within the RAC audit management software, thereby facilitating fast reproduction of documents.
  • Paper is eliminated throughout the audit management process.
  • Postage costs are reduced.
  • Turnaround time is reduced.

If your organization has not integrated ROI experts into your audit management team, now is the time to do so. These professionals, whether in-house or outsourced, bring a wealth of knowledge and expertise to RAC processing. Make them a part of your RAC team today!

About the Author

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.

To comment on this article please go to editor@racmonitor.com


[i] AHA RACTrac Survey. 1st Quarter 2013. June 4, 2013. Available online at: http://www.aha.org/content/13/13q1ractracresults.pdf

 

Dawn Crump

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