For FY2024, the Centers for Medicare & Medicaid Services (CMS) has requested $937 million for Health Care Fraud and Abuse Control (HCFAC) funding across its agencies. Of those requested funds, $238 million is earmarked for Recovery Audit Contractor (RAC) audits, a 14% increase from the FY 2023 approved budget.
The burden on hospitals and health systems is growing in tandem with CMS’s escalating audit efforts. This burden partly lands on the shoulders of health information management (HIM) professionals.
Today’s HIM departments play an integral role in the audit process. They have moved beyond traditional tasks related to medical coding and data analysis to become the point people for compiling documentation in response to external audit requests. Given the increased CMS funding request, it should be all-hands-on-deck for the next fiscal year to respond to documentation demands.
Here are five ways that HIM staff can help hospitals and health systems respond effectively to audits.
1. Understand the role HIM plays in auditing functions.
As the number and complexity of audits grows, HIM staff have moved to the forefront of the process, bearing much of the responsibility for compiling claims and supporting documentation for audits. The clock starts ticking when a records request is received, which places HIM teams under intense pressure. Executives must understand the importance of HIM to external audits, making sure that sufficient and sufficiently trained staff are available to compile the relevant documentation.
2. Create uniform processes for external audit requests.
Ad hoc or haphazard responses to documentation requests won’t provide hospitals and health systems with the breadth and depth of materials they need to defend themselves against an audit. Many cases get appealed after the initial decision, so funds could be tied up for years awaiting a final decision – money many hospitals can’t spare with operating margins in the low single digits. Getting a handle on external audit requests starts with creating uniform response processes. What agency or payer is requesting the audit? How many days remain to respond? Where do health information management staff need to look to find the relevant records? Who else should review these records?
3. Adopt a central repository for auditing functions.
Regardless of whether an audit is in response to an external request or is being conducted to monitor internal processes, a central audit management tool can bring consistency to the processes. An audit file likely contains a demand letter, determination letters, patient records, claims information, appeals documentation, and more. Imagine electronic (or physical) file folders residing on multiple computers that may or may not be connected versus on a single platform specifically designed for compiling audit materials, tracking audit progress, and submitting results to the requesting department or agency. Which makes the most sense?
4. Develop consistent workflows to boost staff efficiency.
HIM teams already handle most release of information (ROI) requests, so it’s logical that they should be central to the data compilation for audit requests. Developing efficient processes can reduce the amount of time needed to compile records, leaving more time for the actual audit. The ability to preconfigure audit-related tasks takes much of the guesswork out of such issues as who should be involved, which documents should be compiled, who the point person is, deadlines, and more. Audit staff must also be able to track work-in-progress and past-due items to give each task within each audit request the attention it deserves.
5. Gain transparency into requests using AI (Artificial Intelligence) tools.
CMS and private payers are leveraging more artificial intelligence (AI) and machine learning (ML) tools to uncover anomalous trends that can trigger an audit request. Hospitals and health systems can use similar tools to gain insight into the exact nature of each request. Using AI/ML-enabled tools, audit staff can convert request letters into electronic formats that can then be parsed to extract relevant keywords and attributes needed to streamline record searches, thereby reducing much of the manual work needed to compile records while also reducing the potential for error.
No letup seen in number of audit requests
In FY 2020, RAC audits identified nearly $266 million in overpayments and successfully recovered 83% of those funds. Based on that success, CMS has been increasing its efforts to audit providers; detect and prevent fraud, waste, and abuse; modernize auditing tools through increased use of AI/ML; and improve detection of emerging fraud.
Health information management employees are on the front line of these requests, and they need the appropriate tools and workflows to adequately process them. Hospital and health system executives must ensure that these tools are in place to create robust processes around external audit requests to adequately respond to and safeguard legitimate revenue.
