Technology Key To Successfully Navigating Medicare Audits

Edited by Health IT Outcomes staff

Implementation of audit management technology has helped INTEGRIS Health streamline revenue workflows to achieve a high success rate for audit appeals.

Not-for-profit INTEGRIS Health is Oklahoma’s largest health system, with hospitals, physician clinics, rehabilitation centers, mental health facilities, independent living centers, and home health agencies located throughout the state. It maintains more than 1,900 beds, manages a staff of more than 2,500 physicians, and is one of the largest private employers in the state. Jenny Jones, director of revenue recovery at INTEGRIS, explains how the implementation of audit management technology has helped the health system streamline workflows to better prepare for and handle Medicare audits while also successfully navigating its appeals processes.

Q: What challenges facing INTEGRIS prompted you to seek out new Medicare audit management technology?

Jones: We had become very overwhelmed with tracking all of the different requests from the Medicare Audit Contractor (MAC) program and Recovery Audit Contractor (RAC) program and making sure we met all of these deadlines. We had started our RAC preparations in 2008, and it wasn’t long after that we started getting audits from TrailBlazer Health, our Medicare contractor.

At this point, we weren’t even seeing RAC audits. They hadn’t even begun yet, but we were drowning in the Medicare contractor audits and knew we needed help. We saw a lot of vendors that wanted to provide a solution, but they weren’t really familiar with the government audits or what they needed to develop, and they didn’t invest in enough resources to fully develop and support the software.

For instance, early on we connected with a company that allowed us to beta test a RAC-only audit management tool, but they simply did not have the resources to support it. That tool didn’t offer deadline alerts or triggers, which is so important when you’re potentially dealing with hundreds of audit requests at one time, trying to manage deadlines around each one, all the while knowing that hundreds of thousands of dollars could hang in the balance. It was very manual — we had to input a lot of data, and the application didn’t offer a way to reconcile financials. We weren’t able to record what was denied, when that dollar amount was retracted, or when we had to refund.

We began to look for another audit management solution and, after checking out a lot of vendors, ultimately decided on HealthPort’s AudaPro solution. A large part of that was due to the fact that many of our health information departments were already using HealthPort’s Release of Information (ROI) services.

Q: How did the new audit management technology benefit your organization?

Jones: One of the things that appealed to us with HealthPort’s tool was that we were able to integrate it with our release of information, so we could house our correspondence. We could actually house the medical record within the tracking tool. You don’t have to go back to the health information department and request that same record. It saves multiple steps within the process. Our previous tool didn’t have that, so that was another big thing that appealed to us with HealthPort. We’re still struggling with the reporting capability, and HealthPort knows this because I talk to them a lot about it, but their solution is light-years ahead of the tool we had and many of the tools we demonstrated.

Because we’re now able to keep our record-tracking system up to date, we can run reports and share that data with departments that have cases highly targeted by the audits. We can start to provide feedback on the rationale behind the denials we’re seeing and better determine how to improve documentation to avoid future denials.

Q: What measurable results around productivity and revenue have you seen since implementation of the new tool?

Jones: The great thing about the tool is that it allows us to set up different audit types for MACs and RACs and to report each audit type separately. That saves us a tremendous amount of time. Previously, we had to keep other spreadsheets and communicate with the business office and with the health information systems department. It makes the process more efficient because we don’t have to email back and forth as often regarding different cases.

Also, we always save copies of the request for the record and any correspondence we get on the appeals, if the case is denied. All of that is housed at the patientlevel detail within the HealthPort system. That has saved a lot of time as well because we don’t have to store the images in a different system.

The system also helps with communication. We’re able to track FedEx shipping information to prove that things are received in a timely manner. We’ve gotten calls on numerous occasions, both with appeals and with records, alerting us to the fact that our appeal is going to be denied on a technicality for no receipt. However, we’re able to produce proof of the FedEx tracking slip, which prevents that denial of appeal from occurring.

We’re able to monitor appeal deadlines very closely, which is a must when working through the audit process. There’s really not any recourse if you miss an appeal deadline. We have a very high success rate in our appeals process. As a health system, we currently have 1,200 cases pending appeal. That speaks to the volume of what we’re dealing with. We are currently overturning about 93% of our cases on appeals. If we were still doing it all manually, as we were before implementing our audit management solution, we would have missed deadlines, and that would have just been revenue down the drain.

Q: Does the audit management technology integrate with any other INTEGRIS systems?

Jones: It doesn’t integrate at all with our Cerner Millenium EHR. At this point, I don’t really see the need. AudaPro interacts, to a certain extent, with our Siemens software and of course our HealthPort ROI system.

We work with another company, which HealthPort has integrated with, to exchange information securely for our appeals. That company will need a copy of the complete medical record and all of our correspondence. Whereas before we were sending that information on paper, we’re now able to upload and send it through HealthPort to the appeals vendor — that’s a huge time saver.

Q: What implementation best practices and lessons learned would you share with other health systems?

Jones: It’s important to have all your correspondence centralized. You could miss deadlines simply because a letter is floating around the hospital that you’ve never received. Also, make sure you’ve got proof that medical records were submitted in a timely manner.

The other huge thing is reporting and analyzing so that you can offer feedback to hospitals and physicians. Physicians are starting to see audits now as well. It’s nice to leverage this opportunity and compare audit experiences with them. It has helped us get their buy-in on helping improve documentation so we can avoid denials down the road.