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In this way, an ounce of prevention is certainly more cost effective than appealing auditor denials down the road.

These audits produce a similar, dual effect for hospitals and health systemsfinancial blows and potential lessons to learn.

For example, in 2015, the Centers for Medicare amp; Medicaid Services (CMS) Medicare fee-for-service recovery audit contractor (RAC) program found 171.38 million in reimbursement corrections from hospitals, health systems, and other providers, according to the American Hospital Associations (AHAs) RACTrac survey 4th Quarter 2015 results.

Reimbursement tempests provide valuable insight for quality improvement initiatives.

For example, a large, Level 1 trauma center in Atlanta, Ga., recently used Medicare administrative contractor (MAC) audit findings (formerly probe and educate audits) to guide clinical documentation improvement (CDI) and electronic health record (EHR) upgrades.

Another organization used RAC audits as lampposts to guide new process improvements in rehabilitation services.

Providers have found three principle ways to use audit storms to strengthen operational processes and mitigate reimbursement losses.

Audits are growing more common and increasing their scrutiny of health information from medical records, clinical documentation, and EHR data.

The most common audits in 2016 will include recovery, commercial plan, and government audits, such as MAC, RAC, comprehensive error rate testing (CERT), Office of Inspector General (OIG), and quality improvement organization (QIO).

Recent regional RAC trends include focusing on claims involving the following factors.

While health plan audits impart no direct financial impact on insurers, the number of medical records requested is typically higher than with recovery, government, or commercial auditscreating a heavy staffing burden for audit and health information management departments.

The following are examples of providers learning such lessons.

By taking a deeper look at audit findings, facilities can identify root issues and implement corrective actions.

Such was the case at a Level 1 trauma center where the audit management team reports directly to the organizations director of compliance.

In the early stages of probe and educate audits, very few problems were identified.

However, over time this facility experienced a 67 percent increase in denials.

Drilling down to root issues and taking corrective actions is the most important silver lining for providers to recognize and leveragethe sooner, the better.

Some organizations have replaced three-year-old case findings with efforts to identify root causes in real time, reaping faster rewards in coding, quality, and compliance.

In this way, internal reviews shed light on organizations top reimbursement risks for the year ahead and allow for successful rebilling of accounts.

In conjunction with their local department of community health, compliance department, and quality improvement team, audit managers create a quarterly and annual agenda based on the OIGs annual work plan.

Each service line also provides input into the internal audit plan.

Specific 2016 targets for documentation and process improvement at this health system include the following areas.

Findings are immediately shared with the organizations CDI team and medical staff for education and corrective action.

Healthcare Compliance Audit Tools