blog seasonal audits

In my past position as a network Director of HIM, watching the number of requests grow exponentially each year was stressful for my staff and me. During certain times of the year, the sudden influx of requests was a terrible burden, in both workload and budget, for the hospital and physician offices. IF you are managing these on your own, it can have a negative effect on your service levels.

At my previous organization, we took the proactive step of outsourcing the Release of Information services to lower the risk of inappropriate releases as well as to reduce costs. Additionally, I was grateful to have the help with the unexpected high number of requests coupled with limited time to respond associated with seasonal audits. Without their help, I would have had to pay significant overtime to ensure patient care requests were still the top priority.

With Halloween fast approaching and as a longtime healthcare professional, I understand how scary a sudden influx of audits can be. Below is a summary from a recent webinar that I conducted. I am sure you will find it helpful to take the bite out of the process.

1. Track requests and disclosures by payer – Don’t be tricked into sending the same request multiple times.
  1. Let the subsequent subcontractors know it was already submitted for that payer.
2. Request ONE List and ask for ONE Representative to avoid duplicates, calls, and allow for easier tracking.
3. Release in electronic format whenever possible (EHR vs. paper record).
4. Call if more time needed – usually not an issue and stops calls.
5. Save envelope to show mailed vs. letter date.
6. Ask for payment – it is an administrative burden.
  1. A flat fee is usually easiest for all involved.
  2. Get pre-payment whenever possible. I would charge a flat fee for about 95% of charts on big lists since we often would not find all of the records requested. That way I would not have to do a payback, and I would not want to do the work if they were not going to pay.
  3. If you do not have a contract with the payer, many sites refuse to send them at all, avoiding the burden on their staff.
7. Compare payment denials against records requested. Define what a ‘denial’ is for your organization. My team looked at both under- and non-payment. Consider some of the following questions once you have determined the overlap:
  1. Are they just being used for Risk Assessment or other audit reasons?
  2. Are they being reviewed for payment without a separate request for records?
  3. How many payment reviews are they conducting? Get an accounting of disclosures to see how many different review departments (payer and subcontractors) received a copy of your records if you see anything unusual. Usually, payer contracts have a limit of payment reviews, but nevertheless, you should be aware of payment reviews so you can keep an eye on upward as well as downward trends.
  4. Are subcontractors getting payment for Risk Review and a percent of any payment denials? You may need to track and trend between departments.

8. Long term, work with your payer contracting team to reduce administrative burden and costs within the payer contracts. Ask to review contracts, ideally before signing.
9. Teach data literacy to your team. Ask for analytical collaboration to best turn data you have into accurate and useful information to help make appropriate decisions.
10. Consider working with a reputable Secure PHI Transfer company, like RRS Medical, that can manage the process for you.

For more information, watch the webinar for more details about some of the lessons I have learned and techniques I have used to deal with these audits: