January 6, 2022 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Leaning into a new year, as I sit to write this audit tip, I am reflecting on questions that we have been asked throughout 2022 and wondering if any of these might help everyone launch a new year with greater perspective. Well, one such question did come to mind, and it is a question we are actually asked year after year, so I am hopeful this might help.
The Fact Needed: Industry Standards for Auditing
Rationale: There must be rationale with the answer prior to giving you a reasonable answer.
Job Type: It is obvious that auditors work in all differing types of organizations. There are consulting firms, health systems, small/mid/large practices, billing companies, insurance companies, EMR vendors… and I’m sure that I am still missing many other types! With each varying position may come a different approach in skill, technique, function, responsibility, and reporting. For example, an auditor at an EMR vendor may be auditing a series of records to evaluate the use of functionality of EMR rules throughout the system, while an insurance auditor is cross analyzing tedious LCD policy to the documentation, and a consulting firm auditor may be required to research codes from two years ago due to a take back by a carrier that needs to be audit appeal that is not current year work. The role of the auditor is NOT conventional work, while the work of the coder is direct and straightforward in approach.
Roles & Responsibilities: To further segregate auditors, not all auditors perform the same daily functions, which make giving a true production number difficult. In order to provide a “true” productivity measure, then an auditor’s role should be made up of audit only responsibilities. It would seem reasonable that these should include:
- Determining samples, pulling samples, and auditing
- Developing audit analysis (up code/down code of audit), and creation of any other reports required of the audit
- Feedback and education as part of the audit
- Necessary interactions/meetings and emails for the audit role based on the above
When the auditor’s roles deviate from these tasks, it is NOT wrong, it could just skew productivity and performance standards.
Scheduling: A moment of empathetic grace here. This is not meant to imply staffing, but rather the scheduling of provider feedback/education. Simple scheduling is easier, but when providers must be “stalked” into compliance, this can weigh down the workflow of the auditor. Our team knows this firsthand and would like to give a shout out to all of you full time stalkers! While this sounds minimal in effort, these chunks of time can quickly add up. TIP: Track the time (not just the number of attempts) per provider it takes to coordinate these providers and report this behavior to compliance.
Other Audits & Onboarding New Providers: Be sure that when calculating productivity standards of team members, to consider ALL types of audits. Compliance audits often are the focus of productivity volumes; however, our audit teams are involved in working on rebuttal/appeal audits, and onboarding audits as well.
Specialty Variances: Another variance that is taken into consideration is specialty. Each specialty does come with a unique set of rules, anatomy, abbreviations, and language all its own. While E&M is E&M regardless of specialty, AND a provider is tasked to tell provide the complexity and risk in their documentation, if the auditor is not in-tune with the specialty there may be times that lookup or fact finding is necessary for terms, procedures, or medications for self-awareness in order to educate the provider on how to better document for complexity and risk. More than E&M, specialty variances come into play in the surgical encounters, creating a reasonable gap for this convenience.
Claim Line Variances: The number of claim lines to be audited can certainly present variances as to the number of claims lines and modifier usage per single cases audited. This is slightly different than specialty specific, as it also impacts same specialty. For example, Orthopedics is a great example of how many claims can be single or 2-3 claims lines, but there can also be claims that have 6+ claims lines as well. Claim line variance can slow the productivity and performance of an auditor but should not in the aggregate impact their effectiveness.
NAMAS can provide conventional productivity standards provided that these variances are considered. These standards assume that the individual’s primary role is an auditor, and the hourly rate allocates time for audit related duties such audit analysis, reporting, and education time.
- E&M Services: 10 encounters per hour
- Surgical Services: 5-10 OP Reports per hour- depending on the specialty. Note this is NOT the full global service, but only the operative service
How do you use productivity standards?
That is a loaded question because the answer is depending on how tight you have them figured. If you use these standards and say, ok, we have 45 auditors, 2080 working hours in work year, 10 E&M encounter per hour that is 93,600 encounters per year we can audit so we can audit, so our team should be able to audit 9,360 providers but we only have 460 providers, and we can’t keep up…. WHAT IS THE PROBLEM?????
First, more than likely, the problem is in the variances we outlined above, but also there aren’t 2080 non-stop audit hours in a day- let’s be realistic.
Productivity standards in the world of auditing are used to gauge workload and balance, and to know if your team is being productive. However, because auditing is subjective, it is not necessarily a measuring stick, hence the lack of industry standards.
Let’s consider an example. An organization has 100 providers and will review 10 E&M encounters per provider. The algorithm says it should take 1000 hours to complete the audit, 6 ¼ months for one (1) auditor. At the end of the year, the auditor indicates that the workload is too much for one auditor and the organization needs to hire another auditor. The deny her request noting she has only audited 40 of the 100 providers in 12 months and in fact query what she has been doing. Curious what she was doing? She was performing onboarding audit reviews and education of the 80 new providers the organization hired over the past 12 months. Not only did the auditor meet the benchmark, but she also technically exceeded it.
Standards are a tool to be used as a guide. They help us to plan, and they shouldn’t be used as a hiring/firing resource especially when there is so much subjectivity, unless this subjectivity has been isolated in your working environment. NAMAS hopes this information is useful in your organization.
Your next steps:
- Contact NAMAS for full a auditing, documentation, and compliance consultation.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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