The Hospital Finance Podcast®

Surviving the Wave of Seasonal Audits [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Sue Chamberlin, Vice President of Compliance and Education for RRS Medical who will take us through some tips for surviving the increasing volume of payor audits.

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Highlights of this episode include:

  • Why the number of audits are increasing
  • Types of audits that providers could expect to receive
  • Common issues around clinical documentation
  • Tips to get through audit season
  • How a provider can prepare year-around

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance podcast. Audit requests put an enormous amount of pressure on hospitals and physician practices. With the amount of audits increasing, what can you do to ensure your team manages their current workload while meeting the demands of audit requests? Joining me today is Sue Chamberlin, Vice President of compliance and Education for RRS Medical and an avid HIM and PHI Evangelist. Sue even has her own podcast called Talking About PHI with Catherine Valyi Talking About PHI. Sue will take us through some tips for surviving the increasing volume of payor audits. Sue, welcome to the show.

Sue Chamberlin: Thank you very much for having me. I greatly appreciate it.

Mike: So, Sue, why don’t you start out by telling us why you think the number of audits are increasing?

Sue: Well, the biggest reason seems to be the fact that this whole country is heading more towards a quality-based system. We’re kind of stuck in the middle between the fee-for-service and the quality. And, again, some of this my own opinion from my 30-plus years in the field of kind of watching what’s going on is the more data we can get, the more data that can be gathered and reviewed and try to figure out kind of what’s going on can somewhat set the standards. But more importantly, what it’s doing is looking at the quality of care and the outcomes of all the providers, both from a facilities’ standpoint as well as individual health care providers, what their quality of care is and their outcomes to determine in time what their pay may be, and currently what kind of bonuses they may or may not get. We’ve kind of talked about for a while that they’re putting out a lot of carrots right now, but the sticks are starting to come as well with trying to get those outcomes and that data of how good is Doctor A compared to Doctor B?

Mike: Right. And as we know, there’s not just one type of audit. So why don’t you take us through the types of audits that providers could expect to receive?

Sue: Okay. So there is a lot. So the ones that you’re going to see a lot right now that we see coming often is, of course, we’ve got the big one in the physician side in primary care only at this point, which is the heat of the audit. And that is where they’re looking at the quality of care given in over 90 different categories. Now, that tends to hit a lot of physician divisions really tough when those come in, and they start asking for all the that. But you’re not going to see that in a lot of settings. So it’s important that everybody recognizes where that’s going to hit. Your specialists may not see it, but you’re going to see that in your family medicine, your internal medicine, that type of thing. You’re also going to see risk adjustment audits and your HCC audits, where they’re basically trying to determine how sick the patients are. So keep in mind that you’re sub-contractors for all of Medicare. The sicker the patients are, the more money they’re going to get per patient, per head kind of thing. So what they’re trying to do is look for any kind of additional diagnoses that may indicate that the patient’s sicker so that they can get additional income on that. Now, that tends to come a certain time of the year. But I have to make a little side note here to kind of keep in mind on this because it’s a frustration from an HIM, health information management standpoint, where we sit with the coding team on a regular basis and have to deal with DRG audits, which is the other type of audit to talk about is payment audits, where they’re looking at whether or not that DRG is at the appropriate level if that comorbid condition is really justified. And what a lot of the payment audits will do is they will come back and say, “Yeah, the patient may have this comorbid condition, but we really don’t think that is enough to really justify those higher DRGs. So we’re denying it. And we’re going to take you down the DRG, and we want you to remove that diagnosis.” Then a few months later, we get our risk adjustment audit where they’re coming back, and they’re looking for any of these comorbid conditions and might put that condition right back on so that they are getting additional money. So that’s the frustration that we get and that the going back and forth where we may get one thing happening because of the payment denials, and the wanting to try to look for ways to pay the organizations less, but then turn around to try to pull it in so that they can get paid more. So I will say those are kind of the big ones you’re going to see on a regular basis coming at you. However, what I also recommend is that we have a lot of things coming with MIPS and all kinds of other programs that are coming into place. So all of these different types of audits, I would recommend that you keep an eye in your contracting as they talk about what they’re going to expect from each of the payors for different types of audits that they may be doing and where all that is going to come together and come at all the organizations.

Mike: Sue, what are some common issues around clinical documentation that can trigger audits?

Sue: So there’s several different things that– and some of it has been occurring even along the lines of the electronic health record. So the electronic health record has been a really great thing in some aspects. It makes the exchange of information between providers so much better, and there’s a lot of laws coming down the pike around that. But one of the things that – other than sometimes physicians will complain that it takes them a lot longer – but with that, there tends to sometimes be a lot of cloning of documentation or templated documentation where they pull in the same note that says basically the same thing over and over and over again. And with that, they may not get the specificity in there for the documentation of what’s needed. So documentation may be missing. It may be that the same thing said over and over again. But the gut of what’s really going on with that patient and the justification of what’s specific to that patient is not always there. And that can cause not only an audit possibly if they see that that’s happening regularly with certain providers, but it could also then decrease the payment. Another thing that I have seen a lot in the years– and again, my experience has been about half my career on the hospital side and half my career on the physician division side or combination of it. And so looking at what’s impacted by documentation from the office and how it impacts the hospital and vice versa. So another thing I see a lot in the physician office is they may pull in the history and maybe do the exam, but they’re missing the true assessment. They may just come up with the diagnosis, but it’s not pulling in what the thought process is, what that assessment is, and what they plan to do about it. Sometimes we may see it that it’s just put on a problem list, but there’s nothing anywhere to justify that diagnosis except it being popped only on a problem list. And that can cause some issues as far as poor documentation. But let’s just hit– we talked about HEDIS there for a second.

So HEDIS with what they’re specifically looking for in some of the problems you might have with that. It’s not necessarily going to trigger on it, but when they come in and they look at the quality of care that a provider is giving, the provider may be doing all the elements that they need to about diagnoses and being addressing the diagnoses. But if they’re missing one little tiny thing, not recognizing what needs to be in there, that can cause a lower quality indication of that provider. So, for example, a BMI, a lot of times the doctors will write the BMI of 40 per person. But if they don’t put the height and the weight as well as the calculated BMI, it doesn’t count. And it’s kind of silly, not necessarily silly, things like that, but things like that that are showing not only the elements, but kind of what’s behind it. So another thing we see with diabetes care, did you not only get the A1C, but did you also make sure you got the blood pressures, the foot check? Did they send them for a dilated eye exam? Did you document that or just refer them? So there’s over 90 measures that require different elements and that they all need to be there, and that can cause some issues if the providers are not well aware of what’s required for each of these elements. And to make it a little harder, we got to give what’s due to the providers. They’re being asked for so many conflicting things and asked to see more patients and asked to make sure their documentation is perfect and try to remember that plus all the new drugs, plus all the other things that are going on. It is very, very difficult to set up everything to make sure that they’re getting all these tiny little areas. So I will say one of the things that they do push, especially for HCC, is, for example, is to use the MEAT documentation. So in that part it’s basically is monitor, evaluate, assess and treat, very similar to SOAP. But it’s making sure that you’ve got the elements that you need when you’re documenting and trying to support what you’re doing with that patient. What I tell a lot of providers is just say what you do. I know it’s simple, but make sure that if you were passing care to somebody else because you’re taken off quick, what are the things you want them to know? It doesn’t have to be copious, but document really quickly what you need this other provider to know to take over care for you. Don’t assume that you’re just writing for yourself. I don’t know if that helped, but with everything here.

Mike: Oh, yeah. No. It’s great advice, too. And I’m going to ask you for some more because I know you’ve written extensively about how to get through audit season. So do you have any tips for people that are managing through the audit season?

Sue: Oh, I’ve got lots of tips. So, again, a lot of the tips I have are based off of things that I’ve tried, talking to, players that I’ve done in my own offices with the divisions and the hospital, and that type of thing. So several things to consider. So when you’re looking at any kind of audit that’s coming in, the big thing is to make sure you know what’s going out. If you’ve got any kind of denial that comes in, you want to know how was that record sent? Was that record sent as part of a risk adjustment audit? Because technically, it shouldn’t be going for a payment denial records, that type of thing. So you need to track your denial. And if it’s a full documentation denial, how did they get the records? What are they denying, and why? And that’s where you may want to talk to your CDI team in the hospital. And hopefully, you have some kind of a clinical documentation improvement expert that can help on the physician division side as well to help identify exactly what is missing, what’s going on. When a full audit’s done, ask for those reports. Ask for the findings and the audit is done when you’ve got your HCCs. When you’ve got any kind of audit coming back, ask for more specific detail. That’s not always easy to do. And so I will say at some point too, you’re going to want to bring in your contract team and kind of talk to them about some of this as well. So when you’re looking at things, for example, a payment audit that’s done, keep in mind that if they’re doing a random one and they find something, they may come back and ask for a whole lot more records. If they’re asking for a bunch of records, somebody should be looking at those records to see what’s the same here. So like Sesame Street, which one belongs and which ones kind of match up, not match up, that kind of thing. And try to do some detective work to see what they’re looking for. Sometimes it can give you a heads-up of a problem that may have been identified. And now you can go back and put some things in place to make sure that what they need is actually being documented in the record. So sometimes that missing documentation, which literally could be one word that was not added in could take away thousands and thousands of dollars.

So I’m not sure that everybody understands, especially in the C-suite and sometimes on the finance side, just the impact of simple documentation and the coding and CCs and MCCs and DRGs and all that fun stuff. And once somebody’s coming back who is incentivized to find a reason to take that off, how that can impact the finances of the organization. So the other part I’ll throw out is that I started seeing more and more where some of the documentation that did not support, so even pre-cert’s done in the physician office before surgery or documentation in the physician office could, after the fact, lead to a denial of the surgery to the hospital. So documentation, documentation, documentation, but not more. Make sure that it’s the right type. Okay? Some of the other things that are just kind of some basic things is– and keep in mind, you may not know why some of these reviews are coming in. So if you’re getting a request with multiple patients on there from a payor, try to identify what it is. The other part is sometimes you’re going to get where the due dates for audits of any sort are really short. Now, the frustrating part that I find for some of the payment audits is they basically say that you have this many days to respond with the records, and if you did not meet it in time or you didn’t send everything, that’s your problem. It’s not a reason for an appeal. And that’s made it really, really tough on a lot of cases. So keep in mind that a lot of times these due dates are short. So make sure that you’ve got a good process to turn around those records. However, if that request came to you via snail mail, make sure you keep the envelope. So this is a big one for all of you. Keep the envelopes, because what you may notice is that the mark on the envelope – why am I blanking here – the postmark on the envelope may be a week after the date on the letter or more. I’ve had it sometimes where it’s over two weeks more. And by the time I actually get the letter, I have one day or no days to get the records.

Sue: That is a reason to push back. That is a reason to appeal. Keep that envelope as the documentation that you didn’t get it in a timely manner, and therefore, you have a right to appeal and to get those records submitted. So make sure you have that. Ask to submit records electronically for any of these audits when at all possible. A lot of these organizations have portals that you can download to. And that’s going to give you an indication that it went. Faxing By the way, a lot of systems will have a page limit for faxing, and you may not realize that. And so you need to make sure that when you are faxing, all the pages have gone through. Like I said, they won’t let you resubmit a lot of times if you didn’t send everything. Let me think. Another thing to keep in mind is that sometimes each payor, especially when they’re doing these big audits, they will hire several subcontractors. So you will find that you’re getting the same records request multiple times. Now, what a lot of people don’t realize is just how impactful the huge numbers of record requests coming into the usually HIM department or even the physician offices, that is a lot of work to get all of those records pulled. And sometimes the requests are thousands of records that are coming in at once. So if you are getting requests, you need to find a way to track it. Figure out who is requesting it, who the main player is? And what I used to do is if I’d get– if I decided I was going through this subcontractor, then any other contractors that would call me or send me records, I’d just call them up and say, “I’m working with this other subcontractor.” And they’d say, “Okay,” and take me off the list, which was awesome because the phone calls that come in are astronomical. See exactly what they need. Ask to have reasonable limits. And the big thing is ask to get paid. And a lot of people don’t think they can for payor audits, and sometimes the payors will come back and say, “We have it in our contract, that we get all records requested.” Well, usually the contract’s talking about if they ask for records to look at the documentation that supports what’s being coded, that’s one thing.

But do we really have it in the contract that they get to ask for six, seven thousand records to review and that they may ask for the last two to three years, even though you sent them the last two years last year.” So make sure that you’re looking at your payor contracts. Make sure that you’re bringing in HIM, your HIM department for your medical record people. When you’re looking, have them, at least, just review these payor contracts to realize what the impact may be. It’s not just taking records and putting them on a copy machine and sending them out. That is not what this is about. So make sure that everybody is aware of what you’re doing. They can also help you get a feel for what this audit may be about and what some of the action plans might be that you need to do. So I also ask that when I have any at once– once I am working with a certain subcontractor, I ask them to give me one person that is a representative that I work with. Only talk to that one person, and they are responsible to go pull the list from– so say you’re working in a hospital system that has 150 physician divisions, physician offices. They will go and pull the request for each one of those 150 and put them together for you. Ideally, if you can get them to in an Excel spreadsheet so you can manipulate it as you need to. But otherwise, you’re going to be getting one or two or three or four requests onto every single one of those offices, and then they’re going to forward them to you. So ask for that. If you need more time, call them. You don’t have to meet the time limits that they say. This is a lot of times for their benefit. So if you need more time, let them know you need more time. Don’t pay overtime and all that type of thing to get the stuff out immediately when they’ve probably built in a lot of time on their side as well. So, yeah, those are some of the ones off the top of my head that I share a lot with people on making sure, again, and when you’re doing the contracting, the term I use a lot is you need to reduce the administrative burden. And that’s one of the things that at least the federal government talks about once in a while.

Mike: Great advice. So is there anything that you didn’t mention that you think a provider should be doing year-round to prepare for audits?

Sue: So, again, with making sure that you kind of know where your areas of weakness may be. And I shouldn’t say weakness, where there’s opportunities to improve based upon. So if you get the report back that says, “We’re seeing this happening.” So, for example, several years ago, there was an issue with knee replacement. And with the knee replacements, they wanted to see not only that the patient had PT, but how many sessions of PT, when were those sessions of PT, and how did the person respond to it? Same thing with injections into the knees. When did they have them? How many? So it went into a whole lot more detail like that because they wanted to make sure that the doctors just weren’t going directly to the cut. So it’s those types of things that you’re not going to be able to pick up on without starting to see what some of the issues are. Find out. Ask specifically why it’s being denied. And some of that then was you just needed to get the office notes to more specifically state exactly what happened to make sure that the external PT notes were included when the records were sent in for the pre-certification. Everybody knows to do that now, but there were a lot of denials for a while because you were trying to figure out what those are. So that’s where year-round continue to monitor every single denial to kind of get an idea of what they’re going to do and how to improve the documentation. And it could be simple things. If you’ve got a HEDIS audit, and you find out that the diabetics got denied, you didn’t see the care that you needed to for them then put your focus there and not necessarily catching a blood pressure reading where you missed it in this specific case three times. Now, focus on the diabetes. So get those reports. Figure out one or two or three things that you can do to improve the documentation in this quarter and then something else and something else. But again, just keep a real close look at where those denials are coming from and how those records were sent out, and then just keep responding from that. So that’s kind of more year-round. But keep an eye– keep an eye out also for your calendar. You know when the records are going to come or record requests are going to come to, so kind of monitor that. And there’s a lot of them out there. HEDIS now has a little bit. If you can work with your HCC contractors, your HEDIS contractors, sometimes they may be able to give you just the patients that they’re probably going to focus on in the next quarter. Start getting some of that ahead of time, too, so that they’re only asking for the ones that are missing something. So a few things like that.

Mike: Great stuff, Sue.

Sue: I hope that helps.

Mike: Absolutely. Absolutely did. If someone wanted to find out more about your work, where can they go?

Sue: Probably the best is to follow me on LinkedIn or follow me Sue Chamberlin as well as you can follow me on RRS Medical on LinkedIn, as well as on the website for that.

Mike: Excellent. Sue Chamberlin, thank you so much for joining us today on the hospital finance podcast.

Sue: All right. Thank you.

Mike: If you have a topic that you’d like us to discuss on the hospital finance podcast or if you’d like to be a guest, drop us a line at

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