5 Steps to Audit-Proof Every Claim

Audits are an ever-present challenge for HME providers. In fact, in 2013, $4.3 billion was recouped by Medicare, with “improper claims” cited in most of the audits. With a backlog of 357,000 claims appeals cases and appeals acceptances suspended until 2017, it is more important than ever for HME providers to prioritize implementation of processes and technology solutions to improve the likelihood of a positive audit outcome with no need for appeal. While there are many billing solutions available for your HME business, buyers beware. A technology solution may claim to automate order and billing functions, but all systems are not created equally. More importantly, technology alone cannot make your organization audit proof. With this in mind, these five essential steps can help you proactively prepare for audits while minimizing negative impact on staff time and enhancing the organization’s cash flow.

1. Get the Intake Right

Knowledgeable customer service representatives (CSRs) at intake can ensure the right information is collected in the correct format at the start of service. While staff turnover and constantly changing regulatory requirements make it difficult for providers to keep up, shifting responsibility for documentation to the billing staff is less efficient and leaves room for error. As such, HME providers should implement intelligent technology that prompts CSRs to collect documentation that meets a specific payer’s requirements and ensures inclusion of all information needed to support the claim.

2. Set Up Validation Rules

One way to support the CSR’s efforts to collect the right information is to establish validation rules reflecting the requirements of different payers. While Medicare rules may call for a document to support specific Healthcare Common Procedure Coding System (HCPCS) codes, other payers may have a looser set of rules for that procedural code. Setting rules that prompt collection of payer-specific information improves efficiency while still ensuring an audit-proof claim. Because most HME organizations have four or five payers that represent 80 percent of revenue and four or five products that represent 80 percent of sales, they should develop comprehensive validation rules for these key payers and procedures. Additionally, HME providers should also establish rules that stop order delivery or confirmation if data is missing, delaying claim submission until all accurate documentation is available.

3. Match the Documentation with Billing

Unfortunately, it is not enough just to collect the necessary documentation. Staff should be able to easily and quickly access documentation when responding to an audit letter, which can be difficult in the case of a long-term service, such as a CPAP setup. Because documentation is housed with the initial sales order, a link between billing records and the sales order documentation is critical. Relying on a staff member to pull the correct paperwork or digital records that are filed separately from the sales order—especially in the case of a long-term service with monthly invoices—results in a higher potential or errors or inability to find the requested information. If all invoices are digitally linked to the original sales order, supporting documentation and other necessary information can be gathered efficiently and accurately in advance of an audit.

4. Align Document Management to Workflow

Many times, an HME provider decides to deliver products to a patient in critical need before documentation is complete. Even if the progress note is attached, a system or a documentation specialist needs to review it carefully to ensure the correct wording is included to support medical need for the product. Unfortunately, this review usually occurs after an audit letter is received, and months after the physician saw the patient, making the HME provider’s defense of the claim more difficult. Automating the review process throughout the workflow, implementing document management technology and installing checkpoints that alert staff to missing or inaccurate information enables the provider to delay confirmation of a claim until the file is complete. The alignment of document management to workflow will result in submission of a cleaner claim, which is preferable to taking a chance that an unsubstantiated claim will escape audit.

5. Track Your Actions

As in all areas of health care, if it isn’t documented, it didn’t happen. As such, HME providers must set up a process to capture all telephone calls to patients, verbal orders from physicians or communication with other providers. This is difficult when multiple people handle each case, so having technology that documents actions by time, date and personnel involved strengthens an HME provider’s ability to demonstrate compliance with billing requirements. Although well-defined processes and workflow with checkpoints for documentation review are critical, technology solutions can enhance the efficiency and accuracy of staff efforts to produce claims that are audit proof. Moreover, seeking strategic guidance from a revenue-cycle management partner with robust knowledge of regulations and audit processes can also ensure HME providers aren’t caught off guard when an audit does pop up. When a provider responds with complete documentation and proof of compliance within days of receiving an audit letter, as opposed to scrambling to find documentation as the deadline for response approaches, the result is more likely to be positive. Not only does this save the provider money, but also staff time required to respond to the audit is minimized. Good HME business technology is like good auto insurance—there’s no guarantee that you won’t be involved in a car accident or an audit—but if you are, the resources you need to successfully navigate the process and avoid financial losses are at your fingertips.