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From Audit Chaos to Control

By Jeff Burbank

As audit volumes continue to explode, providers are seeking solutions to simplify workflows and automate data retrieval to maintain stronger payer relationships for improved patient care.

Managed care audits, particularly Medicare risk adjustment (MRA) audits, are a huge burden on care providers—one that has only grown heavier in recent years. Going back at most a decade, request volumes from third parties for managed care audits made up about 10% of a provider’s release of information (ROI) requests. Today, these audits comprise upward of 50% of the volume received. And as both payers and providers are aware, these requests do not present in a steady stream, but rather in massive waves due to their seasonal nature. Managing the onslaught can be overwhelming—or even untenable—for providers, particularly in the current staffing environment.

The use of application programming interfaces (APIs) is helping care providers—and HIM departments, specifically—to streamline efforts and simplify workflows surrounding ROI. The process for responding to these audit requests, while complex, is manageable when providers can leverage data control and automate workflows with complementary EHR tools. Efficient management of managed care audits improves relationships with payers and allows care providers to better meet patient needs.

Administrative Headaches
Not only is the volume of information requests growing but complexities stemming from requestor specifics also have expanded. A provider may deal with 20 different payers that require the information to be sent in 20 different ways. Accessing the right information from various locations in a timely manner to meet requests via portals, faxes, mailings, or direct EHR access all present management challenges to overworked HIM departments. Providers respond with piecemeal strategies resulting in numerous workflows and, frankly, total audit chaos. Once behind on audits, it becomes difficult for the department to catch up, let alone keep up.

A Standardized Solution
Considering that MRA audits consistently look for the same data points in a consistent date range, the requests themselves have become more standardized. Such standardized request elements allow for the creation of an API for a set number of exact data points to be mapped directly to the EMR. This “hands-free” solution is effective due to existing industry FHIR standards that provide a means of achieving consistency, reliability, and control among various data sharers.

A decade or two ago, every MRA request was like a snowflake: unique and individualized, requiring human interpretation. By asking the right questions of requesters to understand what information is really needed to make decisions, APIs can be further refined to request the right information from the EMR. Through a better definition of the requests, it’s simply easier to retrieve the information.

As an additional benefit of interoperability improvements in recent years, installing the API capabilities for automation of retrieval tasks takes mere hours compared with the days, weeks, or months typically required for these types of projects. Since API implementation is simple and standardized, the basic blueprint requires minimal IT lift for a huge return.

Savings Analysis
Automation in the auditing process frees up a tremendous amount of resources in HIM departments, particularly when labor is at a premium. The administrative process of designating human workers to track down and gather information to send it back to requestors in a variety of ways is extremely time-intensive. The array of workflows to accommodate disparate, yet timely data requests also generates the potential for errors. Automation solves these problems.

Furthermore, through automation, HIM departments are able to efficiently respond to more audits, generating increased reimbursement opportunities. They are also able to increase compliance with a digital audit trail and increase the security of patient data via electronic, encrypted transference. With API use, providers no longer have to request or manage the temporary credentials of various requestors needed for direct access to the EHR. Overall, the benefits of pain-free APIs paired with the elimination of clunky workflows is a huge leap forward for management of the audit process.

Case in Point
A prominent upstate New York health system recently experienced the benefits of this substantial leap. The organization struggled to manage the increase of audits, with various manual processes and workflows in place yielding eight to 10 charts per hour per person, or about 80 per day. The environment was chaotic, and staff tried to manage numerous calls from requestors following up on audits and their approaching deadlines.

Via an API—connected through an application and tied to their EMR— a team was able to receive and log the audit requests, automatically gathering information and returning the appropriate records to each requestor.

Within one month, the API was processing 900 MRA requests per day, with the capability to handle 2,300 requests daily. In all, 25,000 requests were processed in a month with little to no human involvement, yielding a high return on investment for the health system.

Reaping the Benefits
Leveraging API technology, providers and payers can connect seamlessly and identify optimal programs based on patients’ health care needs. By providing the necessary information to requestors, HIM departments are helping to paint a more holistic picture of patient health—as opposed to a partial snapshot—enabling patients to take full advantage of available programs. All parties benefit from the leveraging of these technologies that improve the auditing process and ROI communications among key stakeholders.

— Jeff Burbank is executive vice president, provider commercial leader at Ciox Health.