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Dodging them means your practice will better serve patients, decrease risks, and improve cash flow.

In today’s environment of increasing regulatory oversight and ever-changing reimbursement policies, compliance requires concerted effort and plan. Although healthcare organizations are not federally mandated to implement a compliance and auditing program, it’s foolish not to.

Done right, a compliance and auditing program helps an organization to better serve patients, mitigate risk and exposure, and improve reimbursement and revenue. But what constitutes “doing it right?”

As senior vice president of coding and documentation at Panacea, I have a front row seat to auditing and compliance at healthcare organizations across the nation. Here are the three most common mistakes we see organizations making in their compliance and auditing efforts.

Mistake No. 1: Jumping Right In

You’ve lined up your auditing team, you’ve pulled the records, and you’re ready to get this done. But if you haven’t done the pre-work of identifying where to focus your auditing efforts, it may be all for naught.

This is probably the biggest mistake organizations make. It’s a major problem because it can negate all the time, money, and effort you put into your audit.

To avoid jumping in too fast, identify your areas of risk before starting. A random audit offers no benefit because you may not identify the problem(s), which means you come away with a false sense of security.

Auditing only 10 records per provider, per year, does not provide a broad enough picture to identify where your audit efforts should be focused. Instead, start with a comparative analysis of a year’s worth of data. This will help you to identify outliers, direct your auditing efforts, and enable you to determine whether there are viable reasons for discrepancies or problems that need to be corrected.

Mistake No. 2: Not Knowing the Auditors

Coding is a field that requires a very high level of accuracy; and when you’re auditing, you must up that game even further. Unfortunately, we’ve seen too many organizations compromise or turn a blind eye to exactly who is doing the auditing.

To ensure a quality, useful audit, make sure the auditors have the expertise your specific organization requires. If you settle for the lowest auditing bid, the coders performing the audit may barely be able to code correctly, let alone audit the work of your coders. That’s why you should check credentials of those doing the auditing work before assigning someone to the task. On the other hand, the most expensive audit bid may not be the best fit if, for example, their auditors are certified coders but aren’t experienced in your areas of specialty.

When selecting a vendor to conduct your outside audit, do your homework and understand exactly who will be doing the work. This will make sure you get the best value for your investment.

Mistake No. 3: Skipping Implementation

Choosing the right auditors ensures you receive quality feedback throughout the process. They should be able to tell you what was right, what was wrong, and why — along with recommendations on how you can improve. Unfortunately, too many organizations skip the last step of implementing those recommendations.

Compliance and auditing are an opportunity for improvement, but you must act on that opportunity. If you get the audit results and just stick them in the back of a drawer, they do no good for anyone. You must implement the recommendations; and that often means educating your staff on how they can improve.

Staff education takes different forms: With your coders, focus on correct coding, following guidelines, etc. With your providers, education efforts will center on ways to improve documentation. Either way, make sure you take that final step and implement the recommendations: It is a critical part of the compliance and auditing process.

The modern healthcare environment and its goals for compliance are simply too complex for a random, haphazard approach to auditing. To move past the checkbox mentality and reap the benefits of continuous improvement, healthcare organizations must make their audits count. Only then will they move forward, and not just spin their wheels.

Auditing and Compliance Solutions

If you want to prove your expertise as an auditor, seek the Certified Professional Medical Auditor (CPMA®) credential.

To demonstrate an understanding of the key requirements necessary to effectively develop, implement, and monitor a healthcare compliance program, look to obtaining the Certified Professional Compliance Officer (CPCO™) credential.

For auditing and compliance software and training and auditing management solutions go to the Healthicity™ website.

Moving Past the Checkbox

The benefits of a strong auditing and compliance program are many. Favorable results include:

  • Optimized reimbursement
  • Reduced delays in coding and billing
  • Positive impact on case mix index*
  • Improvements for key processes
  • Identified reasons for denials and risk areas
  • Medical necessity of services linked to coding accuracy
  • Queries meeting compliance guidelines
  • More concise and clear queries
  • 95 percent, or greater, coding accuracy for individual coders

*Case mix index (CMI) is a relative value assigned to a diagnosis-related group of patients in a medical care environment. The CMI value is used in determining the allocation of resources to care for and/or treat the patients in the group.

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