Establishing a Proactive Auditing and Monitoring Plan

Creating an effective revenue cycle auditing and monitoring plan may require help from multiple departments.

Revenue cycle leaders are paying closer attention to their auditing strategies as costs rise, denials pour in, and payers tighten their grips.

It’s not unusual for an organization’s auditing responsibilities to fall on the revenue integrity department, but when looking to expand efforts, who should be recruited to help and what would their role be?

The National Association of Healthcare Revenue Integrity recently answered this question in the Revenue Integrity Insider. Read below to see the association’s answer.

Answer: Compliance and privacy must collaborate with revenue cycle and revenue integrity professionals to establish a proactive auditing and monitoring plan each fiscal year.

This plan would be based on the following:

• Activity from previous self-audits
• Activity from previous payer audits
• Activity within the organization’s state
• Reviews conducted by the OIG
• Audits conducted by the organization’s Medicare Administrative Contractor and state Medicaid agency

It’s best practice for the organization to establish a monthly meeting between revenue cycle, compliance, and privacy professionals to share plans for auditing and monitoring as well as to go over OIG reviews. The group should review areas in which claims need to be refunded to a specific payer so they can discuss the source of the error and the mitigation plan to ensure that the error does not occur in the future.

Federal guidelines state the organization can take up to six months to quantify an error once discovered. That said, at or before the six-month mark, once quantified, the organization has up to 60 days to refund the appropriate payer.

Best practice would be for one individual in the organization to track all of those associated refunds and due dates to be reviewed by the joint revenue cycle, compliance, and privacy team so that all deadlines can be maintained and reported quarterly to the governing body of the organization.

Compliance and privacy staff will also provide guidance on privacy questions and release of medical record information as situations arise within the revenue cycle.