December 06, 2024 | By Pam Warren, MHA, COC, CPC, Fellow
It is very important to healthcare providers and leaders that the work auditors perform, the results auditors report and the recommendations auditors make are valid. An auditor’s reputation is dependent upon audits that are legitimately performed and accurately reported. If audits are perceived to be invalid, not only will it be difficult to get buy-in from physician leadership, but also the auditor’s time is spent on work that has little value to the organization.
The purpose of any audit is to provide an impartial review of a record, process, service or workflow to ensure that accuracy and compliance exist. An auditor must provide an unbiased determination as to whether the review is free from error or fraudulent practices. Finally, an auditor must perform audits using a systematic, independent and documented process in order that the evidence obtained addresses the criteria set forth by the audit scope. In other words, audits must be clearly defined, consistently structured and performed without prejudice.
Compliance is a hot topic in healthcare these days. While auditors generally provide reviews of services and codes to ensure that providers are performing in a compliant manner, there is also an expectation that auditors employ the same level of compliance. This means that an auditor must avoid any opportunity for conflict of interest or lack of objectivity. If an auditor is unable to review the work of a provider who happens to be a friend without having any partiality, then the auditor should be assigned other providers to review. If an auditor already has a preconceived notion that an audit is going to show poor results, they could inadvertently audit within a prejudiced mindset. Auditors must approach their auditing without expectation.
Proficiency means having a high degree of competence, skill or expertise. A valid audit relies on the competency of the auditor. The expectation would be that the auditor has the appropriate skill set necessary to evaluate the audit subject, to ensure that findings and recommendations are correct, reasonable and reliable. To confirm that level of skill or expertise, auditing the auditors shows that they are proficient and reliable and can offer their audit findings as valid information.
The audit process must be systematic. Although there are multiple types of healthcare audit topics, the structure of the audit planning should be consistent. Auditors should identify audit topics based on a measurement of practice or organizational risk, and determine a standard. For example, an audit team may choose to review Dr. Smith’s E&M services because his work RVUs are lower than the determined average of 0.95 per visit, but they shouldn’t avoid auditing other providers with similar lower averages, which might be seen as showing impartiality. Along the same lines, auditors working on a team must employ the same standards and interpretations so that none of the team is assumed more or less accurate.
The research and guidelines used for the audit process should come only from regulatory sources. Nothing will derail an audit quicker than when an auditor gives a personal opinion (or varying opinions) for an audit finding that has regulatory implications. All audit fieldwork should be systematically performed with the same information reviewed for each case. For example, if the audit includes a review of certain clinical indicators, each chart should be equally reviewed for those indicators. It will be impossible to provide reliable results if charts are not reviewed consistently.
Findings and recommendations must be accurate, measurable and based on appropriate guidance. If not linked to regulatory guidance, auditors should convey that they are offering an opinion. Accuracy should be correctly calculated and based on a comparison of same or similar findings so that there is a clear picture of where the errors lie and what needs to be done to fix them. Provide recommendations for action plans that truly can be attained, since an unreasonable recommendation could be viewed as uninformed or retaliatory.
Many auditors struggle with communicating the executive summary, but it does not have to be difficult. Consider the audience, and provide only that which is necessary to convey the results. If reporting to executive leadership, bulleted findings with accuracy statistics and brief suggestions are sufficient. Operational leaders may need more detail. Identify each finding, cite the guidance and provide a recommendation for a corrective action plan. Charts and graphs are helpful and convey trends in a far better way than words alone. Written reports should be clear and concise, and without grammatical or spelling errors.
By following a structured and standardized audit process, by ensuring auditor reliability and impartiality and by holding auditors to high expectations, practices and organizations can trust that the completed audits are valid and valuable tools for performance and process improvement.
About Pam
Pam has over 34 years of experience in healthcare, having worked in billing, coding, practice management, compliance, and auditing. She has led coding, auditing and clinical documentation improvement teams, and currently works as the manager for Regulatory Billing Audit and MaineHealth, Northern New England’s largest healthcare system. She earned a BS in Adult Education and Workplace Training from Granite State College and her Masters in Health Administration from St. Joseph’s College of Maine. She has served multiple times as an officer for the Seacoast Dover NH Chapter, and is currently a member of the Portland, Maine Chapter. She is a well-known local, regional and national speaker for AAPC on a variety of healthcare business and career development topics. She served from 2013-2016 as the Region 1 Representative for AAPC’s Local Chapter Board of Directors and served from 2018-2021 on AAPC’s National Advisory Board. She earned her AAPC Fellowship in 2016, sits on the Education Committee for HealthCon, and is a frequent contributor to Healthcare Business Monthly. She lives in Maine.
