Catherine Boerner (cboerner@boernerconsultingllc.com) President of Boerner Consulting LLC New Berlin, WI.
For more than 20 years I have been saying the reason we have compliance programs in healthcare is because there was a disconnect between the clinical side and the financial side of providing healthcare. I don’t have to tell you that the financial, billing, and coding side is complicated and ever changing. The clinical folks are focused on treating their patients and providing medically necessary care in a quality manner—“Do no harm.” The clinical side needs revenue integrity, patient financial services, clinical documentation improvement, coding, health information management, finance, health information technology, and so on to help it succeed in getting reimbursed for the care it provides in a compliant manner.
I often ask compliance officers about how recovery audit contractor (RAC) and other government audits are processed, tracked, and followed up on. When I inquire about how they are followed up on, I am not just asking whether they are appealed or not. I want to know what happens after there are unfavorable findings that coding or clinical documentation improvement have confirmed and agree with. How do the clinical-side people directly involved with those denied services get notified?
I have had many clinic managers and physicians tell me no one ever told them their claims were being denied and why.
Compliance really needs to oversee this connection of the clinical side with the financial side. Compliance needs to lend their perspective and find out how the organization determines the root cause of unfavorable RAC or other government audit results to prevent the same errors from happening again.
For example, the following type of policy can be developed, and compliance should be on the work group that reviews the final outcome of the audits.
Policy title: Processing RAC and government audit requests and results
Policy: All RAC and government audit requests and results are timely tracked, processed, reviewed, and corrective action taken when denials occur.
Procedures:
Requests received (by whom – title/department of person)
Requests tracked (by whom – title/department of person)
Requests are responded to—records sent (by whom – title/department of person)
Records reviewed to anticipate results (by whom – title/department of person)
Results received and tracked
Results reviewed
Results discussed at RAC/government audit compliance workgroup
Results appealed as applicable
Results are communicated to appropriate clinic managers, physicians, etc.
Corrective action education conducted and tracked
It is so important that compliance officers are involved in this process. They can help with promoting transparency, collaboration, and education to improve processes on the clinical side and reduce compliance risk.