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Beckers Healthcare states “The house always wins” as Insurers’ record profits clash with hospitals’ hardship. As a matter of fact, with most healthcare organizations having now released their third-quarter earnings, the gap between provider and payer profits continues to widen. It is startling that over half of the hospitals will have negative margins through 2022. Becker is not alone in their sentiment. A new American Hospital Association (AHA) report shows that hospitals are facing the most difficult year financially since the start of the pandemic as expenses and margins fail to hit pre-pandemic levels. The cat is out of the bag. Payers are looking at record profits while providers are looking at record losses.
How can this be as our health systems went through (and continue to go through) a health pandemic? It is because denials, specifically complex audits are on the rise.
One type of complex audit is a post-payment audit (often referred to as a RAC audit). Various experts from the RAC Monitor (which for many years has been the industry gold standard for audits) have stated over the last five years post-payment audits have risen by over 900%. The Biden Administration has provided funding for CMS to conduct more RAC audits, so this trend, while shutting down momentarily during the height of the pandemic is back on with a vengeance.
The Emergency Department Practice Management Association (EDPMA) has reported a large increase in medical necessity audits (another type of complex audit) among their members. Notable expert and Board of Director Member Andrea Halpern Bryant of EDPMA have confirmed their members (many of whom are intimately involved in emergency department matters) are seeking guidance for assistance in dealing with the growing number of medical necessity audits.
Unfortunately dealing with complex audits has become more difficult as providers have experienced major decreases in staffing. I-Med Claims blog stated “Efforts to reduce hospital workforces during the pandemic have forced revenue cycle teams to redeploy existing staff to new areas. One consequence of this shift is that there is no suitable expertise to master complex and ever-changing payment standards”. More than half of RCM department leaders state that their departments are down by 20 or more people.
This session will instruct the listeners on how to respond and win more complex audits with fewer people. Listeners will be taken through the up to five-step process of a RAC audit including receipt of the letter from the auditor and learning of strategies and processes that will help them respond to them (in less time and with greater success). In addition to CMS audits, the listeners will be given strategies and processes to help respond to private payer post-payment audits as well. The listeners will also learn helpful, winning strategies for medical necessity pre-payment audits. They will learn of the five most common audits and be given ideas and processes to have greater success in response with fewer assets at their disposal. Lastly, strategy and processes will be shared to lessen a load of incoming audits for the future by using data to the provider’s benefit.
If you want to learn how to do more with less and have greater success, please join us as we help you combat bad payer behavior as it pertains to complex audits!