RAC Audits Are Like Most Healthcare Issues: Prevention is Key

June 8, 2016 Streamline Health

By Steve West
Solutions Director – Financial Management, Streamline Health, Inc.

On May 9th, many observers in the revenue integrity community breathed a sigh of relief. That’s when CMS issued a scope-limiting provision in the reviews process, stating that auditors can only validate whether or not the original denial reason is valid. This certainly saves time for the legions of providers that might have been forced to justify even more charges than warranted.

Providers were understandably worried that this could have gone the other way; while some organizations have the resources to keep up with the onslaught of audits, many others are struggling to stay above water. As any clinician will tell you: the best way to address a serious health issue is to prevent it in the first place. Audits are no exception to this rule, as adding resources and adjusting your strategy to address them after the fact is not a sustainable approach.

When developing an audit management strategy that focuses on prevention, consider this approach:

  1. Assess your insurance options. While there are plenty of insurance options out there, ensure that your organization is covered beyond legal fees. There may be significant fines and potential for libel or slander, not all of which is covered. Assess your overall exposure to liabilities.
  2. Keep your finger on the pulse of CMS announcements. The best way to stay prepared is to know all of the new regulations. As with the example above, you might not need to do as much work as you think.
  3. Build out your compliance committee across the care continuum. You’d be surprised how many organizations overlook some of their care settings when establishing or reviewing compliance. RACs have been known to shift focuses rather quickly, and not having a key person from each setting involved can lead to problems down the line. Another example of assessing your overall exposure.
  4. Use your reporting tools to look retroactively for patterns in the audits. RACs are no different than any other auditor— when considering where to find new opportunities to claw back dollars, they start with previous high dollar “wins”. While this is no guarantee of future success, this will help you focus on addressing certain documentation improvement “needles” rather than taking on the challenge of improving the whole haystack.

These tips, while obvious to some, are sometimes the difference between hundreds or even thousands of man-hours. Securing your hard-earned revenue is crucial to the overall financial health of your organization, and when it comes to audit management, prevention is the key to long term health.

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