Throughout the revenue cycle management process, there is room for human error as hospitals and health systems work to capture charges and submit accurate claims to payers. However, a proper audit of charges and claims can go a long way in helping healthcare organizations maximize reimbursement.
"The billing process is very complex in every organization, even in small organizations," says Karen Bowden, executive vice president of revenue integrity operations at Craneware, a value cycle company. She says larger organizations likely have "additional levels of complexity in terms of what happens to a piece of data from the point of service being provided in the clinical area until the right coded and charge data ends up on a claim that goes out to a payer."
"And auditing allows an organization to make sure they're properly paid for the services they provide," Ms. Bowden adds. "So there's a compliance risk or [the auditor's] validation that you're billing correctly."
Here are four thoughts from Ms. Bowden on conducting a successful RCM audit.
1. Use technology to identify missed billing opportunities
When embarking on an RCM audit, there are various things to consider. One of those is using an automated tool programmed to identify potentially missed charges and/or overcharges using predictive analytics, according to Ms. Bowden. This allows healthcare organizations to evaluate their full scope of services. With an automated tool, "you're allowing your full set of claims to be evaluated rather than going in and just looking at one department and looking at 50 claims and hopefully finding something that might be wrong," she says. "A tool can do it quickly, can identify where charges may be missing or where something may be overcharged."
2. Hire the right person with the right skill sets
Ms. Bowden also recommends hospitals and health systems have "the right person with the right skills" conduct the audit, whether that's someone from an outside company or somebody within the organization. She says the auditor should understand how the organization's billing process works, as well as the organization's charge flow and payer guidelines. Also, the auditor should be able to read a medical record and itemized bill, and should have good analytical skills. Ms. Bowden says it's important to have someone who is qualified to understand where an organization might see potential issues and if there are concerns the organization needs to address.
3. Correct the issue at the source
Once an issue is validated, hospitals should correct that issue where it originated, according to Ms. Bowden. The issue could have originated as a data issue between the organization's charging system and the chargemaster, or someone in the billing office may have unintentionally removed a charge from the claim to clear an edit, she says.
If a hospital or health system missed receiving payment, Ms. Bowden recommends they ensure it was corrected where it happened initially so the charge is captured the next time the service is rendered. Also, she says hospitals and health systems can look at a claim and see if it's in the payer's billing window still, where the payer can add the charge and the claim can be rebilled. In a different instance, where the auditor finds the organization overcharged for something, the hospital or health system should check with its compliance department for reporting guidelines, according to Ms. Bowden.
"It's important that hospitals understand finding something is probably only 50 percent of the work" and the other half requires hospitals to "go back and understand where it needs to be fixed in the billing and claim flow," she says. "It's almost like playing a CSI detective to understand where an issue needs to be fixed and once it's fixed continue to monitor to make sure it really is fixed."
4. Initiate frequent audits
Overall, Ms. Bowden sees the RCM audit process as extremely significant for most organizations. Therefore, due to the complexity of billing, she recommends auditing on a continual basis and ensuring accuracy of claims following submission to payers. "The rules change, staff changes, [RCM] system changes — they all can impact quality of claims that go out. So making sure you're sending out compliant bills is everyone's mission, but it's complicated and can go wrong without any visibility from people managing those departments," she says. "If you don't look, you just don't know."