In today’s environment of increasing regulatory oversight and ever-changing reimbursement policies, compliance must be more than a checkbox. Though an annual compliance and audit plan is not legally mandated, there are few healthcare organizations that don’t have compliance on their radars. However, if your compliance focus is simply to check a box, you’re missing out.

Compliance and auditing offer an opportunity for continuous improvement. Done right they help organizations better serve patients, mitigate risk and exposure, and improve reimbursement and revenue. But what constitutes doing it right?

In my role as Senior VP of Coding and Documentation at Panacea I have a front row seat to auditing and compliance at healthcare organizations across the nation, and we’ve learned a few things over the years. Here are the three most common mistakes we see organizations making in their compliance and auditing efforts. Make sure you’re not guilty of them too.

Mistake #1: Jumping Right In

You’ve lined up your auditing team, you’ve pulled the records, and you’re ready to get this done. However, if you haven’t done the pre-work of identifying where to focus your auditing efforts then it may all be for naught.

This is probably the biggest mistake we see organizations making, and it’s a major problem because it can negate all the time, money, and effort you put into your audit.

To make sure you’re avoiding it, you must identify your areas of risk before starting. Simply doing a random audit offers no benefit because you may or may not identify the problem(s), which means you walk away with a false sense of security.

Auditing only 10 records per provider a year does not provide a broad enough picture to identify where your audit efforts should be focused. Instead, start with a comparative analysis of a year’s worth of data. This will help you identify outliers, directing your auditing efforts and enabling you to determine whether there are viable reasons for discrepancies or problems that need to be corrected.

Mistake #2: Not Knowing the Auditors

Coding is a field that requires a very high level of accuracy; and when you’re auditing you have to up that game even further. Unfortunately, we’ve seen too many organizations compromise or turn a blind eye to exactly who is doing the auditing.

To ensure a quality, useful audit you must make sure the auditors doing the work have the type and level of expertise your specific organization requires. If you settle for the lowest auditing bid, the coders doing the work may barely be able to code correctly, let alone audit the work of your coders. On the flip side, the most expensive audit bid may not be the best fit either if their auditors aren’t experienced in your areas of specialty.

When selecting a vendor to conduct your outside audit, it is critical that you do your homework and understand exactly who will be doing the work. This will make sure you get the best value for your investment.

Mistake #3: Skipping Implementation

Choosing the right auditors ensures you receive quality feedback through the process. You should know what was right, what was wrong, and why, along with recommendations on how you can improve. Unfortunately, we’ve seen too many organizations skip the last step of implementing those recommendations.

As we said earlier, compliance and auditing are an opportunity for improvement—but you have to act on that opportunity. If you get the audit results and just stick them in the back of a drawer, they do no one any good. You must implement the recommendations; and that often means educating your staff on how they can improve.

Staff education takes different forms: With your coders you’ll focus on correct coding, following guidelines, etc. With providers your education efforts will center on ways to improve documentation. Either way, make sure you take that final step and implement the recommendations—it is a critical part of the compliance and auditing process.

Moving Past the Checkbox

The benefits of a strong auditing and compliance program are many. Among our clients we’ve seen results that include

  • Optimized reimbursement
  • Reduced delays in coding and billing
  • Positively impacted case mix index
  • Improvements for key processes
  • Identified reasons for denials and risk areas
  • Medical necessity of services linked to coding accuracy
  • Queries meeting compliance guidelines
  • Greater query concision and clarity
  • 95% or greater coding accuracy for individual coders

The modern healthcare environment and its goals for compliance are simply too complex for a random, haphazard approach to auditing to work. To move past the checkbox mentality to compliance and reap the benefits of continuous improvement, organizations must make their audits count. Only then will they be able to make sure they’re moving forward and not just spinning their wheels.

Author: Kathy Pride, Senior Vice President, Coding and Documentation, RHIT, CPC, CCS-P, CPMA