A drawn-out pre-payment audit with a major payer is financially devastating for a treatment center. Even if the business ultimately survives, the owner may lose control of the business they built. Erin Burke, CEO & Founder of Hansei Solutions, was kind enough to share her expertise on how to survive, and preferentially avoid entirely, such an audit on my latest Delivering Recovery podcast.
Pre-Payment and Post-Payment Audits
There’s a tremendous difference between the two types of audits. Post-payment audits are simply the cost of doing business. You should expect each of your payers to request to see charts for a small sample of your patients every five years or so.
If the payer sees coding or documentation deficiencies during a post-payment audit, they will call for a pre-payment review, which is far more serious. You’ll be requested to submit charts for all of your patients, which will be scored against a list of criteria. Typically, at least 80% of your documentation needs to receive a passing score in order for your center to be released from audit.
Multiple factors make pre-payment reviews dangerous. First, you don’t know what criteria you’re being scored against. Additionally, the payers are doing so many of these audits these days that there’s often a delay of many months before they even start looking at the documentation you’ve submitted. But what makes these audits catastrophic is that the payers cut off all payments to your center until you’ve passed the audit. And you can’t stop accepting their patients for treatment or you’ll never be cleared.
Avoiding a Pre-Payment Audit
Obviously, your center needs to make every effort to avoid finding yourself in a pre-payment review. The key is to make sure the charts you submit during a post-payment review are fully compliant with all documentation and coding requirements. Take the time to carefully study the charts to find and correct any deficiencies yourself before you submit them.
Erin identified three types of errors to watch out for:
Generic documentation: Perhaps the most common problem is documentation that doesn’t explain the unique issues a patient is struggling with and why the treatment being provided is medically necessary. The biopsychosocial assessment and progress notes need to tell the patient’s story in detail. If your clinicians are writing cookie cutter-like progress notes, you’re going to be flagged for this.
Lack of compliance with patient financial responsibility requirements: If your center is in-network, you are required to collect a reasonable cost share from the patient. If you have a hardship opportunity, make sure the patient files the necessary hardship forms and collect their W-2 info to validate that they really have a financial hardship.
Billing and coding patterns or irregularities: The payers’ analytic tools will flag if there are substantial changes in your volume, coding or billing cadence. For example, if there’s a significant increase in your census, or if you’ve always used a particular revenue code and suddenly you’re consistently using a different one, that will be flagged. If you have a lot of patients starting treatment the first of the month, all with brand new Ambetter policies, that will stand out. And if all of your patients are being given the same diagnostic code, you will be flagged for not delivering individualized treatment.
What to Do When You Receive an Audit Request
The first thing to do when you receive an audit request of any kind is to reach out to the investigator, introduce yourself, acknowledge receipt of the request, and ask for an extension. It’s very labor-intensive to produce medical records for somebody who was in treatment for an extended period, and these extensions are routinely granted.
If it’s a pre-payment review, also ask for the reasons your center is being audited so you know the focus of the payer’s investigation.
While Erin was far too self-effacing to say such a thing, the second step I would personally recommend is to make sure you have the right team in place to shepherd your review through the payer as quickly as possible. Hansei Solutions has 100 audits going at any one time, and tracks the sequence of responses that work best with each payer. If you don’t have access to this kind of expertise, Hansei Solutions would be my first call.
Erin’s final suggestion was to have a certified Revenue Integrity Analyst study the regulations in your state, the relevant CMS guidelines and your contract with the payer. If there are any issues, such as the payer not having the right to withhold payment for the type of issue they’re challenging, Hansei has found that leaning on the regulators in your state can be the most efficient way to get out of an audit quickly.
How Vista’s Outcomes Research Helps
Whenever they’re working with a Vista client, Hansei will stress this to the payer. Hansei uses the fact that the center is investing in tracking and continually improving their outcomes to convince the payer that they want this provider in their network. In fact, Hansei included the latest Vista research report and a summary of its findings in a recent appeal, and the audit was closed two weeks later. Hansei also uses Vista’s post-discharge outcomes reports to negotiate higher reimbursement rates and value-based contracts.
Missed the Forum with Erin Burke? Watch it Now.
Curious to see how Vista’s outcomes research can help your center? Set up a demo today.
