Auditing is an integral aspect of governance and quality management for organizations across industries. Many healthcare organizations adopted new electronic health record (EHR) technology with the implementation of ICD-10 (International Classification of Disease, 10th version). It outlined unprecedented detail in record-keeping, with over 71,000 procedure codes from just over 3,800 in the previous ICD-9. In order to make the most of a system as intricate as this, healthcare providers would do well to adopt solutions driven by technologies powered by natural language processing (NLP) and artificial intelligence (AI). This would lead to fewer errors in data and billing, and thereby fewer payment lapses.
The Growing Need for Audits
Medical coding audits seek findings that support the implementation and enhancement of clinical documentation improvement (CDI). Auditing CDI teams can optimize diagnosis-related groups (DRGs) as well as retain and hire the right staff that can maximize revenue. Initiatives such as the Recovery Audit Contractor (RAC) program by the Centers for Medicare and Medicaid Services (CMS) have proven the need for effective CDI by recovering millions in improper payments in Medicare and other insurance schemes.
Here are five reasons why audits are more important than ever:
Enhanced Data Quality: Reliable data is a cornerstone of healthcare. The right compliance auditing program, along with informed stakeholders, a rigorous feedback loop, and consistent follow ups, significantly increases the quality of data. This leads to better reporting and research, making it easier for healthcare organizations to win funds or grants.
Higher Operational Efficiency: Manual medical coding and billing is a big challenge for providers everywhere. Each manual transaction costs $4.40 more than each automated transaction, according to the 2018 CAQH Index Report. The same report states that automating claims-related dealings can save healthcare providers around $11.1 billion yearly, yet the industry has made modest progress in transitioning from manual to fully automated transactions. Automated auditing can detect various errors and also shine a light on the root causes of coding and documentation discrepancies. This can even improve employee morale and productivity if seen as complementing their work instead of supplanting it.
Improved Patient Safety: According to an article in the International Journal for Quality in Health Care, internal auditing decreased patient-related adverse events by 4.8%. With timely detection of errors and instant feedback to medical personnel, real-time auditing can enhance patient safety. Changes in clinical policy and practice can be ushered in with confidence, since auditing will pinpoint the areas where lapses exist.
Improved HIM-Physician Relations: Properly executed audits by health information management (HIM) staff will root out documentation errors induced by all involved parties, including physicians. With correct practices in place, these two primary stakeholders in patient care gain a better understanding of how their own work processes affect the other. Physicians who frequently make errors in documentation can work with HIM personnel to learn more about the right practices. Regular feedback and increased transparency will ensure better quality work.
Enhanced Accuracy of Reimbursements: Underpayments and overpayments have plagued hospitals and care centers for a long time. According to a CMS report submitted to the U.S. Congress, RACs recovered $214.09 million during the 2016 fiscal year. Correct auditing practices will ensure proper documentation of complications and comorbidities (CCs) and their major variants (MCCs). The seriousness of any illness is, of course, decided by the presence or absence of CCs and MCCs, which determines payment for hospital services. In short, correct auditing can recognize these lapses in billing processes and ensure that both organizations and patients get the reimbursements due to them.
Case in Point: a Syracuse Hospital Halves DNFC and Saves $1 Million
In 2016, Auburn Community Hospital (ACH), a not-for-profit acute care facility in Syracuse, New York, experienced difficulties with their encoder software while completing their coding and CDI-related work. Their discharge not final coded (DNFC) was seven days and they had a case mix index (CMI) of 1.2024.
ACH needed to eliminate coding backlogs, assign accurate ICD-10 procedure codes, and improve coder efficiency. The facility needed customized worklists and an intelligent platform that could track missing documents and recognize opportunities for CDI. Their DNFC and CMI needed immediate improvement as well.
At ezDI, we believe healthcare organizations need to adopt the right NLP-based auditing application. Such an application can automate manual processes, enforce smart wordlist prioritization, auto-generate evidence-based queries, and more, all on a collaborative single platform.
These were the benefits we were able to provide ACH when the hospital decided to leverage ezDI’s NLP-based technologies. This included the computer-assisted coding (CAC) application, ezCAC, a fully integrated encoder, ezEncoder, and ezAssess, ezDI’s coding compliance software.
Our applications went live at ACH and, in the course of a year, the organization experienced:
- 4.59% increase in CMI by improvement of the complication/major complication (CC/MCC) capture rate, resulting in optimized DRGs
- 50% decrease in DNFC days from the initial 7 days to 3.5 days, leading to greater cash-on-hand
- Over 40% improvement in coder efficiency by the provision of automated code suggestions to coders
- Elimination of all IT support through our cloud-based technology
ezDI helped ACH better their revenue cycle process, where the bottom-line impact after a year was $1 million.
Achieving New Heights with AI and NLP
It is imperative for healthcare organizations to adopt rigorous auditing practices that promote employee performance and organizational transparency. While AI-based NLP auditing tools have become more popular, only organizations that choose the right vendor-cum-partner will witness a robust return on investment (ROI). ezDI can assist your organization to improve patient outcomes and revamp your healthcare processes for the future.