Wiki Auditing Dept questions

jbean911

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I am just doing some research for our Health system. We are looking at how we do Audits and how we split them within our group. Just looking for some feedback to point us in a more efficient way.

I am curious what the other Facilities are doing for Insurance Audits? How big of a facility and how big of a Reimbursement Audit team do you have.
Also, if they split the workload, what would that look like?


Any info is great and appreciated!

Thanks in advance!
 
This is a pretty broad question. It really depends on what type of facility or group and the size. It could also depend on how your facility or practice structure is set up. When you say "Insurance Audits" what do you mean? Are you talking about an incoming audit request from a payer, Medicare type ADRs, RAC, etc.? Are you talking about auditing payment posting and cash application? When you say "Reimbursement Audit", what does that mean?Do you have an internal compliance department, are these internal work plan audits? Is this regarding internal audits of coding by providers and/or coders?
 
I'm sorry for being too broad. When I say 'Insurance Audits' and ' Reimbursement Audit' I mean Payor audits. I was trying to exclude any internal audits by saying that.
By not putting in our facility size I was hoping to get a vast amount of what other facilities do.
Our Facility has inpatient and outpatient. I believe we 5 clinics, 1 hospital, 1 rehab, and 6 RHC's. Right now, we are splitting the audits by payor.
We need to look at our workload's vs employee ratio, but I wanted to see what other facilities are doing.
 
Gotcha. I think it still may depend on how you are set up. Do you have a dedicated team that only works on incoming audits? Do you have data on the incoming numbers you are dealing with? Do you have other people such as A/R or coders or others that may assist with these? I think you would have to look at your volume and the current workload against what is being completed by current staff. Are you able to work through the ones that are incoming or are they falling out of the request time limits, etc.
I am guessing MGMA or other industry groups may have benchmarks for this.
 
Hi Jbean911,🖥️👓

I believe it is great idea in your audit to divide by payers with focus on each different medical specialties. Other issues to audit of differ deficiencies can be the following......
1.Type of denials per medical specialties of IP or OP treatment. Ins denials of pre authorization not done, payer order wrong, use of unspefic. dx, wrong dx used, missing modifiers ,or attending doc's name or time on med record, Etc)
2.Unspecified dx code used when a definitive dx or narrative telling you what should be correctly listed in documentation
3.Are chronic conditions and comorbidities coded since listed in the documentation? Are combination dx codes used properly?
4. Is there conflicting assessment or dx. with the ROS and HPI
5.Is the chief complaint missing? Is the provider describing the care and plan of treatment properly?
6.If use follow up visit should tell what illness being followed up on returned visit
7.Are any TOAD(Transplants, Ostomies, Amputations, Dialysis) mentioned patient suffering with added to coding dx list if applicable
8.Noticed any upcoding or downcoding or unbundling?
10 Proper use of Z codes which does affect sequencing if wrong
11.Notice any cloning of med records?
12. Lab or x-rays ordered but not documented of their medical necessity
13. Is the proper gender of patient used in documentation , verifying if telehealth & minutes used in relation to phone or video treatments ? Hopefully no slang acronyms added either
Well I hope this data helps you!
Lady T:)(y)
 
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