The applications for Recovery Audit Contractors (RACs) are increasing. According to the RACTrac survey conducted by the American Hospital Association (AHA), the number of requests for medical data made by RACs, the number of denials issued, and the financial worth of those rejections all rose by 21 to 26 percent in the third quarter of 2012. Nearly 90% of hospitals say they have experienced RAC activity, the survey adds, and hospital staff is spending more time responding to RAC inquiries, and 56% say they have experienced additional administrative expenditures.

Moreover, the scope of recovery audits has grown much beyond Medicare’s RAC initiative. Following the RAC tracker lead, many payers have instituted revenue recovery initiatives of their own in an effort to recoup what they believe to be improper or fraudulent provider reimbursements. Providers can deal with the RAC audit process by using RAC audit management software.

A robust program with many useful features can aid hospitals in meeting increased audit requirements and safeguarding income. But where do you even begin when faced with over 20 different package providers?

This write-up examines RAC audit management software, discussing its essential features, deployment, and potential benefits for healthcare provider organizations.

Four main aspects to consider while assessing RAC audit management software

As the number of revenue recovery audits continues to rise, RAC audit management software will become increasingly important. Experts in the healthcare sector estimate that between 30 and 50 percent of institutions have already adopted a RAC solution. According to the same AHA RACTrac survey, 44% of respondents actually utilize RAC software. A hospital that has not yet implemented RAC software should take into account the following four factors.

1. Compatibility with AHA RACTrac

According to the American Hospital Association, a hospital is RACTrac-compatible if it has created a mechanism in its claim-level RAC audit tool that would aggregate RAC experience data at the health facility level that is consistent with the AHA RACTrac object of research. As a result of this interoperability, the RAC is able to speed up its quarterly reporting to the AHA, and the AHA is able to get complete and precise information from across the country.

The majority of vendors have qualified for RACTrac certification, and the full list may be seen on the AHA’s RACTrac website. The American Heart Association also conducts webinars every quarter to analyze survey results. Providers can stay up-to-date with RAC developments, priorities, and program worries by attending these webinars.

2. Strong centralization and expansion support

Provider companies should think about consolidating their audit management and appeals process due to the proliferation of audit types and recovery contractors. Having everything consolidated allows you to get the most out of your auditing personnel, save on expenses, and limit revenue losses.

Organizations can promote departmental responsibility and streamline the process of identifying duplicate audit requests by automating the management and appeals process across all departments. Documents that have already been subject to an audit by another government agency are ineligible for a RAC review. These conflicting or redundant audit requests should be easily spotted by audit software.

Furthermore, the audit management software should be scalable to handle numerous locations, additional users, and new patient service types when firms expand through mergers, acquisitions, and consolidation.

Centralized audit management can be achieved by following these five simple procedures. Important features for audit management software systems include:

●      A dedicated audit management group should be set up to handle the inflow, processing, and management of audits from all around the company.

●      Give everyone a crash course in audit request letters, covering everything from the format to what should be included to how they should be sent off to central audit.

●      Create a central audit monitoring system to record all audit request letters, responses, appeal findings, and outcome letters.

●      Scanning or uploading scanned copies of audited papers, communications, and medical record documents to a central repository makes them easily accessible.

●      Create standardized reports for sharing information with the “C-suite” and other interested parties.

3. Ability to adjust to any kind of audit

First, since the number of audits that aren’t conducted by RACs continues to rise, the program needs to be able to handle these as well. Comparing 2011 and 2012, we see that HealthPort users recorded 39,000 non-RAC audits in 2012, up significantly from the average of 13,000. One of the essential features is the capacity to adapt to any kind of audit, including internal ones. In addition, the key federal audits are already defined within the system, which reduces implementation and configuration time. In general, you should be able to find prebuilt audits and system rules from your chosen audit software vendor.

It is important for businesses to clearly distinguish between the various review kinds and service offerings within the selected software. There are many different kinds of reviews, such as prepayment reviews, sophisticated reviews, and automatic reviews. The system should also keep track of the sort of service provided to each patient (e.g., inpatient, outpatient, home health, etc.). As more and more businesses centralize their audit administration and processing, it is crucial that their systems can accept a wide variety of audits and services.

4. Reporting-relevant specifics

Every sort of audit or set of audits must report back to management. This is of paramount significance in settings where audit management is handled centrally. Important data, such as the number of audits in progress, revenue at risk, and the status of appeals, must be regularly communicated to the team in charge of the process. Moreover, custom reporting by audit or across all audits should be available without the need for vendor support or extensive programming.

The following best practice implementation considerations will help firms get the most out of their audit software investment beyond these core criteria.

Key practical considerations

There are often two main areas of trouble in audit software systems that need to be looked at and fixed: system workflow and user education.

The most obvious issues in audit management can be fixed by identifying and eliminating the bottlenecks in the underlying processes. Users (either individuals or groups) can be notified through email when they have been assigned tasks or responsibilities inside the system’s audit process. When there is a problem with the software, it is best to look into the system workflows and fix any incorrect assignments from within the program itself.

Most companies that make audit management software also stress the importance of user training. When entering information into the system, businesses should adopt a standardized vocabulary. Users should consistently record review and denial reasons in the same format and with the same terminology. Organization-wide uniformity in documentation ensures correct reporting, reliable data, and quick, easy case identification.

Lastly, the entire audit management team needs to be aware of any and all new review problems released by the RAC and, in certain situations, the Medicare administrative contractors (MACs). Their separate sites are where you may find the latest information. Personnel responsible for audit oversight can also subscribe to relevant CMS publications and industry list services to be abreast of emerging hazards and audit risks.

Optimization of auditing program functions

Successful appeals and the administrative complexity of completing audits are both greatly improved by two capabilities provided in audit management software packages. Electronic transmission of documents straight from the audit management program and the opportunity to examine and approve submissions before they are delivered to the authorized entity are two examples.

Organizations can see and approve or reject all records before they are sent to the relevant audit contractor by using a review and approval queue. Organizations can improve their chances of a favorable response from the RAC by ensuring that all papers included in the audit package are accurate, full, and relevant to the care provided. Denials of medical necessity are the most expensive audit cases for providers to process, so this function is extremely useful for them.

One useful addition is the ability to send files directly to auditors via electronic means. There are now two types of technology available: the CMS esMD project and a portal link to the payer. A direct gateway serves as a centralized point of contact for an auditing group to reach out to any and all relevant parties. It can be used by the HIM business office and any other division that must provide documentation to auditors. By eliminating the immediate need for so much paper during the auditing process, electronic delivery methods can cut expenditures by as much as half. You can learn more about both of these choices by visiting the CMS site or the sites of specific HIPAA-compliant health data processors (HIHs).

Final Thoughts

Audits are a drain on a company’s resources and can drive up overhead costs. They might cause an income drop if not handled properly. Moreover, technology has helped to streamline the auditing process and cut down on labor costs. The solutions have been demonstrated. Newer, improved technology is now at your disposal. Now is the moment to adopt an audit management solution if your company hasn’t already done so.

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