The New World of Auditing

By
Original story posted on: February 26, 2020

  • Product Headline: WEBCAST
  • Product Image: Product Image
  • Product Description:

    Billing Observation Services Correctly: Keys to Avoid Denials

What’s next for auditing professionals?

The first thing to note here is that I am not an auditor. 

So, for me to write an article on auditing tips might seem a bit unusual. But this is not an article on auditing compliance, but rather on being an auditor – and while my “tips,” so to speak, are not geared toward the technical aspects of coding and auditing, they do apply to future career opportunities for auditors.

I have spent the last six years heavily involved in artificial intelligence (AI)-type research and development in the non-clinical areas of healthcare, often referred to as administrative support systems. This includes work in predictive analytics, machine learning, and text recognition systems. And while I will never be worried about AI taking over the world, there are specific skills within specific industries that will be affected. For example, we have already seen how automated check-in and verification systems have replaced the need for many front-office staff. And we have seen how claims checkers have resulted in a reduction in back-office staff by identifying billing and coding errors prior to claims submission. 

What we are now seeing, with progress in text recognition and natural language processing (NLP), is the need for coders at the basic coding level beginning (or continuing) to decline. Those who have progressed their education and skills to become auditors made a wise decision, because while coding, which is comprised of algorithmic processes, is easily automated, auditing, which is an oversight function, is not. Auditors review the work of coders, and auditors will review the work of automated coding engines. In either case, auditors are far less replaceable in this world of technology than are coders.

So, here you are. An auditor. What’s next? Well, it is my opinion that there is a three-way demarcation of needs for auditors: analytics, litigation, and revenue cycle. And with the need for experts comes the need for expert training. Let’s look at each of these areas, one at a time.

Analytics
I believe that we are all in agreement that compliance risk is increasing – and along with that, there has been an increase in the number and intensity of compliance audits. These types of audits can be external, such as a Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), or U.S. Department of Health and Human Services Office of Inspector General (OIG) audits, or internal, such as the need to conduct regular coding and billing audits, as well as repayment and self-disclosure audits. In both cases, there needs to be someone with a reasonable understanding of basic statistics and compliance analytics to move the ball forward. In some cases, whether it is defending an external audit or initiating an internal review, the organization might engage a statistician, like me, which is expensive and a bit time-consuming. In most cases, however, I find that they try to work through it themselves, often without the requisite training or experience, resulting in poor outcomes. An auditor is a natural to fill this need, because half of the issue with an audit is understanding the underlying issues, which are almost always tied to some coding and billing concern. An auditor with training in compliance analytics would be in a perfect position to satisfy the basic needs for reviewing and contesting an external audit (at least for the first two levels of appeal) and designing internal reviews for compliance strategies and repayment issues. 

Litigation
Along with an increase in the aggressiveness of outside audits, there is a need for auditing professionals with basic litigation support skills. There are three types of experts: witnesses, consulting experts, and testifying experts. The difference between the first and the last is intent. Basically, if you are involved in an investigation, maybe just because you work for the organization, you may very well be called to testify. You may not want to; you may not feel qualified to, and you may not be ready to, but getting subpoenaed trumps all of those “nots.” The fact is, experts, such as coders and auditors, get subpoenaed to testify all the time, and being trained in the basics of testimonial skills and know-how can mean the difference between winning and losing a case. Some of you may want to move into this area willingly. After all, it is a bit exciting, and it can be quite profitable. Consulting experts are hired by attorneys to assist them with, for example, understanding the foundational aspects of coding and billing for a specific case, or assisting with preparing interrogatories for an upcoming deposition or trial. Or maybe they want you to render your opinion on the testimony from another expert, which requires that you write an expert report or a submit a sworn affidavit. Testifying experts go one step further, providing their written opinion of their findings, as well as testifying to such, in both depositions and hearings. Willing or not, it is my opinion, based on my years of experience in litigation support, that auditors are going to become more and more involved in litigation surrounding recovery audits and fraud investigations. And if we accept that this is the case, then getting prepared now is the best way to ensure success in the future.

Revenue Cycle
We often think that RCA-type engagements are left to the financial and operational folks, but that is just not the case. I know of many organizations that are utilizing the skills of their auditors to assist with things like denial analysis. I conducted a study some 10 years ago and was shocked to learn that the overwhelming majority of providers simply write off denied claims, rather than appealing them. The sad thing is that, when appealed, the findings are reversed in favor of the provider a majority of the time.

The problem is that many organizations treat denials as technical problems, when in fact they are more qualitative problems. I have watched qualified auditors with experience in analyzing and reviewing denied claims grab back huge amounts of money for their organizations. And when a pattern of wrongful denials has been identified, their value as analysts (and sometimes, experts) goes through the roof.

In summary, it is my opinion that there is a huge opportunity for auditors to become specialized in more than just different medical specialties. And with this opportunity comes the need for training. I know that groups like the National Alliance of Medical Accreditation Specialists (NAMAS) are in the process of creating training and certification programs for auditors in this area, and I wouldn’t be surprised to see more folks jump on this bandwagon. So fasten your seatbelts, and prepare to be trained! 

And that’s the world according to Frank.

Frank D. Cohen, MPA, MBB

Frank Cohen is the director of analytics and business Intelligence for DoctorsManagement, a Knoxville, Tenn. consulting firm. He specializes in data mining, applied statistics, practice analytics, decision support, and process improvement. He is a member of the RACmonitor editorial board and a popular contributor on Monitor Monday.

This email address is being protected from spambots. You need JavaScript enabled to view it.

Related Articles

  • For Audits, Emphasize Preparation, Not Panic
    Now is the time to prepare, assess time frames and provider requirements, and ensure a proper compliance plan is in place. On March 30, the Centers for Medicare & Medicaid Services (CMS) provided a temporary respite on audit activities due…
  • Provider Relief Funds: The Hottest RAC Audit Subject
    Reporting the use of PRFs will be an ongoing issue due to the fraud and abuse implications of misusing PRFs. The federal Provider Relief Fund (PRF) was created under the provisions of the Coronavirus Aid, Relief, and Economic Security (CARES)…
  • IRF Care Again in Audit Crosshairs
    OIG determines admissions to inpatient rehab not appropriate. Last week, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an audit of OSF Saint Francis Medical Center in Peoria, Ill. In this audit, the…