January 14, 2022 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
In 2022, when we sit down to configure an audit plan, we often consider whether we will perform an audit retrospectively or prospectively and whether the sample will include evaluation and management (E&M) services, procedures or some combination of them both. What we find ourselves not always considering these days is whether the claim has been paid or not. I hadn’t thought about this consideration of the audit process in a long time until recently when a NAMAS member emailed me a question. She asked if her organization should insist on using paid claims as their audit sample or if it didn’t matter.
It brought me back 18 years when I first came into DoctorsManagement. What we requested as part of an “old school” audit and what has become the industry norm has shifted. It goes without saying that we would ask for the documentation and any supporting reference documentation from the date of service along with the billing information, but there were extra steps.
We standardly requested the Explanation of Benefits (EOB) as well as the encounter form (pre-EMR and integrated PM systems). Incorporating this into the review allowed us to look at the service from inception all the way through to collection – and it is a very telling process. For example, reviewing the EOB and comparing it to the encounter form allows the auditor to identify variances between the provider’s intended billed services and those actually billed to the insurance company, in case there are changes made by the staff. Additionally, reviewing the EOB allows us to identify how the insurance company reimbursed the claim and any denials that may have occurred on that claim.
By auditing the claim from inception to collection as an entire process, there was also this concept that a portion of revenue cycle was also being a valuated within the scope of the audit. OK, I am the first to admit it wasn’t a whole revenue cycle analysis, but it was some form of revenue cycle review. Unfortunately, over the years we have seen this additional review within audits taper off not only within our organization, but within organizations across the country. This isn’t merely a biproduct of the push toward productivity in auditing- although there is that, but it also comes from the staunch separation of audit services and revenue cycle.
Most health systems have segmented the functions by the front of the claim and the back of the claim and compliance of the encounter from the billing of the claim. Things are so disjointed within most health systems that auditors within the health system cannot even access the payment information internally to cross populate such an audit plan anymore. Audits are sanctioned based on whether it is a revenue cycle audit or whether it is a coding and documentation audit, a probe audit, a peer-to-peer review audit or a medical necessity audit.
Audits that evaluate the integrity of the service from inception to collection have immense value and more than ever should have their place on an audit plan organizational chart. They don’t need to be the “go-to” approach, but they shouldn’t be dinosaur of field either.