Help: FAQs, tutorials, videos, page index and more
Viewing:  Sep 20, 2019

Big Data & Facility Audit Complex Reviews

By:  Shannon Cameron, MBA, MHIIM, CPC
Published:  September 29th, 2017

Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare. These areas include better patient outcomes, lowered costs, and identification of problematic processes which have resulted in improved patient flow and care. For instance, the identification of both positive and negative correlation factors has greatly enhanced research with multiple diseases, assisted with the identification of new treatments and, in some cases, cures of numerous conditions. Analyzation of large clinical data has essentially empowered researchers and healthcare providers with the constant identification of factors previously unknown to medicine, which has led to new techniques that have led to better patient care while continuing to grow at a seemingly staggering pace.

However, on the same token is the fact that large data analytics is now the driving force of many government and private payer audits. Payers now have the capability to reject thousands of facility-based claims at a time. Their utilization of big data and how they choose to use it for claim rejection and/or payment decreases has enabled payers to quickly overwhelm a hospital revenue cycle department and greatly impact the overall reimbursement.

This type of automated procedure is based on data mining methodologies which can rapidly analyze thousands of claims in a short period of time. These methods use special algorithms created to identify "incorrect" claims based on the correlation of specific diagnoses, comorbidities, and corresponding procedures related to the reported Diagnosis Related Group (DRG) code. These types of denials are growing at a staggering rate. Given that, there is no better time than the present to insure your facility is audit resistant.

The cost of denial management in these cases can be enormous. Therefore, it is essential that facilities have a strong internal quality control program in place. It is equally important that coding and billing systems are updated quarterly with information derived from Coding Clinic ICD-10-CM and ICD-10- PCS updates and audit feedback. One method of defense is a strong Clinical Documentation Improvement Department (CDI). Providers and healthcare coding and billing personnel should receive constant education and feedback while implementing a strong system of checks and balances, especially with conditions which have been under a lot of scrutiny (i.e., sepsis).

Another area of defense is to have an ongoing familiarization with the region's RAC (Recovery Audit Contractor). As with provider based issues, the RAC will post audit issues found in recent facility audits regarding specific MS-DRG (Medicare Severity Diagnosis Related Group) code sets and can be a strong reference for identification of potential problem areas.

Not only are the resulting rejections from automated algorithms problematic to the revenue stream, it's also important to remember that with multiple rejections, there is also a strong possibility of consequential audits. While the automatic denial/rejection process does not fall into the true definition of an audit since clinical documentation is not reviewed during this process, large amounts of denials can pose a red flag for payers to specific problem areas and also lead to a focused DRG audit.

For more information regarding the CMS RAC process visit:

https://www.cms.gov/Research- Statistics-Data-and-Systems/Monitoring- Programs/Medicare-FFS-Compliance- Programs/Recovery-Audit-Program/

For more information regarding Coding Clinic updates and newsletters visit:

http://www.ahacentraloffice.org/aboutus/what-is-icd- 10.shtml


References:

###

NAMAS is setting the standards in medical auditing & education    

The NAMAS team and faculty work hard to bring you membership resources, products, tools, and training that is not only timely and specific to medical auditing and compliance, but also that is      specific to the needs of medical practices today. NAMAS staff are industry recognized experts who provide audits and consulting services to active clients which gives NAMAS the cutting edge to provide relevant training.

Namas

Article Tags  (click on a tag to see related articles)


Reimbursement Guides
2020 Edition

Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.

  • Medicare
  • Procedure & Supply codes
  • Documentation
  • Compliance
  • HCC information
  • ICD-10-CM codes



Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


Our contact information

Find A Code, LLC
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Fax: 801-770-4428
Email:
Free 14 Day Trial
No Credit Card Required
Pricing
Starting at $10/month
Sign In
Welcome back!