Compliance Audits shed light on performance improvement in medical coding
Is my team’s coding accuracy up to industry standards? This is a question many HIM and Coding decision makers find themselves asking. Coding compliance audits can provide an organization the ability to follow regulatory guidelines in regards to their coding practices. These can be performed at both the hospital level as the physician-practice level.
Audits can be external, internal or a mixture of both. “Consultants and auditors are ideal subject experts in helping providers address areas of concern that OIG or insurers will find in an audit”, Karen Youmans, President and CEO of YES HIM Consulting, (2018, September 18). How coding complacency can cause problems when regulators come. Organizations should have one of these in place, in order to follow guidelines set by the Office of Inspector General (OIG).
“Although many monitoring techniques are available, one effective tool to promote and ensure compliance is the performance of regular, periodic compliance audits by internal or external auditors who have expertise in Federal and State health care statutes, regulations and Federal health care program requirements.” – Office of Inspector General (OIG).
A key benefit of performing compliance audits regularly, is the ability to reduce payer denials. Approximately one of every five claims is either delayed, or denied. Our data analytics team at YES know the importance of good data; gathering data about claim denials helps an organization to identify trends, patterns and opportunities. Identifying key elements as to why specific medical claims get denied enables a proactive approach to take place. By communicating with front office staff and clinicians, claim denials can be prevented, and ultimately revenue will be improved.
Do you know who your top and low performers are? More importantly, do you have statistical evidence to support these conclusions? An effective audit provides leadership not only with an overview on overall performance, it also offers insights on how well individual coders are doing. If data analysis shows a coder is struggling, a corrective action plan (i.e. personalized education, secondary reviews, etc.) can have effective results. When a coder is excelling, best practices should be gathered in time, standardized and implemented accordingly.
In the HIM industry, coding guidelines change frequently. “Good trends show decision makers their team’s current success, great trends enable decision makers foresee continuous improvement opportunities”, Mari Cely, Director of Strategy and Marketing. Its imperative coders are accurately informed of all updates, as well as when these will go into effect. A great benefit our teams encounter when performing compliance audits, is the ability to identify if a guideline is being applied correctly, or if there’s room for improvement with considerable impact on future revenue.