updated just as frequently. If organizations wait until six months
or a year has elapsed before conducting an audit, there could be
months of potential errors that go unnoticed, says Eileen Dano
Tkacik, vice president of operations and information technology at Pena4.
Organizations should also supplement these audits with ongoing coder evaluations, ideally using software that provides coding professionals with immediate feedback and allows managers
to drill down into knowledge gaps, Tkacik says. Doing so helps
target coder education and allows organizations to develop internal edits and flags to check for errors before a bill is dropped.
It’s also important to ensure that denials and education go
hand-in-hand, Miller says. At Carolinas HealthCare, patient financial services used to handle all inpatient denials. Now, Miller
oversees these denials and plans coder education accordingly. “I
can see what denials are coming in first-hand and turn that into
education fairly quickly and get it back to our coders,” she says.
Internal audits help identify compliance problems before
auditors do, thereby circumventing costly recoupments, Head
says. “I believe we should be performing our own continuous
assessments to look for compliance prior to being externally au-
dited,” Head says. “Coders should participate in ongoing educa-
tion to stay on top of guidelines and changes, and internal au-
dits should be performed regularly to ensure compliance.”
There are plenty of resources that can help HIM professionals
get the most “bang for their buck” in terms of internal audits. On
the coding/billing side, resources such as payer denials, the an-
nual OIG Work Plan, RAC targets, and a hospital’s own Program
for Evaluating Payment Patterns Electronic Report (PEPPER) are
all goldmines of information that can help structure audits inter-
nally. PEPPER summarizes provider-specific Medicare data sta-
tistics for target areas often associated with Medicare improper
payments due to billing, DRG coding, and/or admission necessi-
ty issues. TMF Health Quality Institute, under contract with CMS,
began providing PEPPER to providers in January 2010.
On the HIPAA side, OCR’s audit protocol can essentially serve
as a blueprint and checklist for internal HIPAA compliance audits, Holtzman says. “The real value in the OCR audit program
was the development of the audit protocol that, for the first time,
provides organizations with insight into what OCR believes are
measures for performance of the rules,” he says.
Leveraging Data Analytics
It’s not just about the frequency of audits, however—it’s about
performing audits that are most significant for your facility, says
Miller, who works with an internal data analyst to plan focused
audits in advance for the entire year. “If I think there’s a topic
that we need to look at, the analyst is easily able to get the data
to help me decide whether we need to audit,” Miller says. “It was
better than 15 years ago when you didn’t have the data and were
just spinning your wheels. I’d rather have the data than random-
ly picking topics that weren’t appropriate for our facility.”
Carovillano agrees that analytics make audits more meaning-
ful. “In the absence of a robust data analytics program, an HIM
director may end up spending a great deal of time trying to make
sense of the issues that may exist within the data,” Carovillano
says. “Using robust analytics to understand where opportunities
for improvement exist is critical in ensuring your documenta-
tion and coding can stand up to any external auditor.”
In the future, organizations may even start to team up and
share data to address payer denials and audits, Tkacik says.
“There’s so much leveraging that can occur,” she adds.
Head uses analytics to mitigate risk with “meaningful use” audits. “We validate all of the abstracted and coded data prior to
submission to CMS,” she says. “We do a sweep of accounts using
data analytics to make sure everything is coded and validated
prior to uploading our data to CMS so that we can mitigate any
potential fallouts and mistakes.”
When Auditors Give You Lemons…
…Make lemonade, says Carovillano. For example, coding audits
can reveal costly coding errors, documentation problems, or
chargemaster omissions. “For sure audits are frustrating; however, it is very true that they are sometimes the single driving
force behind effecting any change towards documentation or
process improvement in an organization,” she says.
Carlson agrees that audits come with a silver lining. “We com-
pletely revised our Notice of Privacy Practices as a result of the
audit,” she says. “I do feel strongly that it is going to be better for
our patients. It’s easier to read and understand. That’s one very
positive thing that came out of this. It made us revisit the docu-
ments we felt complied with the rules, but weren’t necessarily
user-friendly for our patients.”
The OCR audit also revealed an underlying systemic compli-
ance issue with Mayo Clinic’s ROI vendor. As Carlson and her
team pulled records for the audit, they discovered that the ROI
vendor wasn’t sending a 30-day extension letter when necessary.
“Once we identified the issue we had it fixed within a day,”
Carlson says. “It was an important reminder that we needed to
have better vendor oversight. It allowed us to find an issue that
we probably still wouldn’t have known about had we not been
audited.” Mayo Clinic now has a more defined quality oversight
process in place with its ROI vendor to ensure they’re sending the
30-day extension letter, charging the correct fees, and more.
“Really, it’s about the patient,” Carlson says. “We want our patients to be protected, and we want them to have the rights that
they’re entitled to. If we all do a better job, that’s what’s going to
benefit patients in the end.” ¢
Lisa Eramo ( firstname.lastname@example.org) is a freelance writer and editor in Cranston,
RI, who specializes in healthcare regulatory topics, HIM, and medical coding.
Quiz ID: Q1818903 | EXPIRATION DATE: MARCH 1, 2019
HIM Domain Area: External Forces
Article—“Attack of the Audits”
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