Keep Medicare At Bay With Audit Technology

By Scott Westcott, Contributing Editor

Appalachian Regional Healthcare System increased its Medicare Recovery Audit appeal success rate by 35% with the help of a Web-based audit tracking solution.

Tasha Yoder cuts right to the chase when describing her team’s goal for efficiently processing audit requests at Appalachian Regional Healthcare System (ARHS). “We’re trying to keep our money when it comes to optimizing reimbursements,” says Yoder, the revenue integrity manager at the Boone, NC, healthcare system that includes two hospitals, a physician practice management group, and rehabilitation/ extended care center.

Yoder’s mission was proving to be painstakingly difficult back in 2011. The problem: The audit software being used was significantly deficient in functionality at a time when audit requests were soaring. ARHS’s audit response process was notably old-school, with employees needing to hand-key 835 and 837 transactions for RAC requests. An 835 provides payment information that allows customers to monitor their original payments, as well as what they actually won back on appeal. An 837 includes claim detail information that is automatically collected, such as service dates and the amount billed.

Manual data entry was clogging the audit response process while also devouring the time of the employees charged with keying in the information. Equally troubling was the system’s limited audit tracking and visibility capabilities, posing increased potential compliance risk, while also making the generation of reports for senior executives decidedly difficult. “Leadership was not able to get the reports it needed in a timely manner,” Yoder says. “We had to do a lot of ‘slicing and dicing’ of the data just to pull out the data elements we needed to make decisions on how to proceed with various audits.”

The system’s poor tracking capabilities also meant that, despite their best efforts, an audit would inevitably come up against a hard deadline, creating a Friday fire drill that would often stretch into the weekend. “We got right down to the wire on quite a few,” Yoder says.

Web-Based Audit Tracking Streamlines Response Process
Yoder and the team at ARHS knew an upgrade was badly needed. With the expiration date for its existing audit package nearing in 2011, ARHS took a hard look at a solution called InSight Audit offered by Craneware. ARHS already had a range of Craneware software solutions deployed throughout the hospital, offering the advantages of built-in familiarity and a track record of success. After assessing its needs against Craneware’s capabilities, ARHS moved ahead with replacing its existing system with InSight Audit, a Web-based tool that manages all of a hospital system’s claim audits and workflows from one central location.

It didn’t take long for ARHS to put InSight through a rigorous test drive. In the midst of the software implementation, ARHS’s primary hospital received a request for 130 charts. Yoder immediately engaged InSight Audit to automate the reply to the request, as opposed to hand-keying the data. “We had 45 days to respond to those requests, and we were right in the middle of our transition to the new system,” Yoder recalls. “We had to load all the historic data going back three years. Working closely with finance, IT, and Craneware’s implementation team, we were able to get all the data pulled in and met our deadlines.

Yoder was impressed with the rollout of the new solution. “Software implementations of this scale can go on for months and months because of server issues and miscommunication. Here, we were able to get everything transitioned in about three weeks from start to finish. I think the key was having the right people there at the right time both from Craneware and our organization.”

Indeed, the new RAC solution successfully addressed the most pressing issue for ARHS — eliminating the manual date entry of 835 and 837 transactions into the audit software. The software provides real-time patient look-up and account billing information retrieval for the 837 claims by creating the electronic Additional Documentation Request (ADR), as well as automated EOB retrieval for the 835 transaction for monitoring and tracking of payments, recoupments, denials, and refunds.

The transactions are imported directly into InSight Audit over daily secure file transfers, and any transaction can immediately be retrieved as needed when an authorized user searches by patient identification number. ARHS can also submit electronic records through the system, and Craneware is a CMS-certified vendor authorized to offer esMD (Electronic Submission of Medical Documentation) gateway services to provider organizations that submit electronic medical records to review contractors. Yoder says the esMD portal is used to transfer 85 to 100 records monthly, eliminating the printing of an estimated 13,500 pieces of paper per month.

Audit Technology Increases Compliance, Appeal Success
In addition to effectively streamlining the audit response process, the new RAC solution has helped to increase the overall efficiency of the audit department, which has minimized compliance risk and optimized reimbursements. “InSight gives us the tools we need to analyze and trend our audit findings to identify weaknesses and eliminate them,” said Yoder. “As a result, we’ve improved our compliance, not only for RAC, but for other audits as well. The solution also helps us optimize reimbursement by tracking and quantifying cases where we should have received full payment versus partial payment. When we file an appeal, the case studies and review templates in the product’s knowledge base help us determine the best approach to take.”

Once an appeal is under way, InSight Audit tracks every step of the process. As a result, ARHS has been able to track and rebill denied claims, netting an additional $75,000 in previously lost revenue. Meanwhile, ARHS’ appeal success rate has grown from 5 to nearly 40 percent.

In addition, InSight has proved useful well beyond its original scope — now serving as the audit platform for ARHS home healthcare services as well as its physician group.

“The system has been able to grow along with us,” Yoder says. “It’s been a pleasant surprise that the system’s capabilities now are able to meet the audit needs throughout the hospital system.”

The new efficiency and capabilities also have allowed Yoder and her colleagues to play a more strategic role in the organization. The tracking and reporting systems help inform decision makers as to which audits should be challenged. Real-time reports also can be generated that focus on the number of RAC requests, dollars at risk, the number of favorable and unfavorable findings, and more. The bottom line: With the new solution there is less risk, more efficiency, and optimized reimbursements.

“I think our new RAC solution allows us to be more productive with our time,” Yoder says. “We can be more strategic and more offensive than defense. Before it was discouraging when we were trying to do everything right and stay current with the audits, and then we’d get a call on a Friday that something was missed and was due on a Monday. We’re in a much better place now in a lot of ways.”