Providers: Are you ready to be audited?

By Donna Kennedy

In 2020, regular audits conducted by CMS and other payers were paused or significantly reduced as the COVID-19 pandemic took priority. Though we are not entirely ‘out of the woods’ of this health crisis yet, regulatory compliance teams have begun experiencing the resurgence and ramping up of provider reviews. Importantly, these audits are focusing on areas that are different than they were pre-pandemic. In this blog post, we will explore how audits are changing, who is most affected and what providers can do to ensure success. 

What has changed?

Three key effects of the pandemic are influencing how providers are responding to audits and what payers find important.

  1. Codes, waivers, treatments, and processes directly related to COVID-19: Claims and encounters related to COVID patients will be a main focus as agencies look to ensure they remove any fraud, waste, and abuse that bad actors may have tried to take advantage of.
  2. Approval for telehealth as a covered benefit: Though telehealth is not new, the shift in how it is utilized and reimbursed includes nuances that will be scrutinized to ensure compliance across payers and geographical locations as possible expansion of use will be a key focus for payers moving forward.
  3. Persisting trend of remote work: Virtual work may not be an absolute necessity anymore, but its popularity has barely decreased. This perhaps permanent shift must be accompanied with adaptive ways to manage productivity and establish meaningful KPIs.

Additional significant industry developments that ultimately affect audit processes and compliance priorities are the legislative actions surrounding surprise billing and price transparency.

Who is affected?

Audits have always been an anxiety trigger for hospitals and health systems. Therefore it should come as no surprise that CMS’ decision to double the FY 2021 budget supporting medical reviews is one that will be deeply felt by nearly all U.S. providers. Compliance and audit teams must prepare for intense scrutiny and be more vigilant than ever during these proceedings.

How can providers be successful?

To navigate the uptick in audits and new priorities of CMS and other payers, providers must channel immense focus and flexibility in the following four ways:

  1. Invest in comprehensive data and powerful analytics capabilities. These are imperative to substantiating both the need for the operational requirements to manage external audits and the financial return of successfully appealing audits.
  2. Embrace technology, even if it is intimidating. Providers’ ability to adopt new tools that support communication across disparate teams as well as geographies are needed in a remote working environment that will not quickly go away.
  3. Institute a strong review process to identify financial risks of audits and planning for future audits. Performing well on external audits requires that providers set up comprehensive internal reviews and assessments that identify risks, augment workflows, and elevate best practices.
  4. Pour time and effort into clinicians. Under unfathomable pressure, clinical teams need more than thanks and appreciation. They need to feel supported and heard by leadership — and be fully equipped with the latest care protocols and documentation directives.  

Where do we go from here?

If your organization is grappling with the impact that changes in audit practices may have, our experts at MedeAnalytics would be glad to sit down with you. As we discuss your strengths and pain points, we can develop a collaborative plan to ensure your organization’s high performance and success.  

Donna Kennedy, RN, JD

Donna Kennedy is a senior director of product management at MedeAnalytics. She is a registered nurse and is a Doctor in Law. Donna is a skilled leader with extensive experience in all aspects of the healthcare revenue cycle. By taking a strategic and pragmatic approach to leveraging people, processes, and technology, Donna is able to enhance existing and new product development with a goal of delighting customers.