After more than a year of quarantine orders, social distancing, and mask mandating laws, we’ve seen the national sentiment toward telehealth shift and grow. Virtual care opportunities have provided greater – and easier – access to healthcare services across the country while allowing providers to continue quality care in safe environments. The Centers for Disease Control and Prevention noted a 154% increase in telehealth visits during the last week of March 2020, compared with the same period in 2019 and related it to telehealth policy changes and public health guidance associated with the pandemic.
But this expansion has also led to the concern for potential abuse within the healthcare community. These concerns were addressed by the U.S. Department of Health and Human Services Office of Inspector General (OIG) to announce that 7 different audits that look more deeply into virtual care services under the Medicare and Medicaid programs.
Auditors are crucial to healthcare organizations, as they help maintain compliance and billing integrity. In fact, given all the uncertainty and challenges during the pandemic, they’re arguably more important than ever. Let’s explore how to keep healthcare audits on track amidst the ongoing changes and beyond.
Auditing and validation 101
The importance of auditing can really be boiled down into one key phrase: it minimizes errors and maximizes revenue opportunities.
The pandemic upended so much in the healthcare world, but it’s not as if things were simple before. With the resumption of scrutiny into these areas, it’s crucial that healthcare organizations adhere to strict coding and billing processes. The stakes are high and include the financial viability of healthcare systems as well as the accuracy of medical billing codes, data integrity, reimbursement, and overall quality of services.
A look at the multi-layered benefits of auditing
Patient care
Quality care depends on accurate and complete documentation in medical records. Audit findings empower providers to enrich the quality of patient care through facilitating clinical documentation accuracy, improving security, and identifying potential revenue gaps.
Strengths and weaknesses
Those findings also highlight the quality of coding and identify areas of both strengths and weaknesses to help organizations establish and maintain a robust quality assurance process.
Compliance
Audit findings are the ultimate step in ensuring that providers are maintaining compliance. This can help to mitigate fraud and abuse penalties through identification of incorrect coding. Given the current healthcare environment, this is why auditing tools and solutions are more essential than ever for all types of healthcare organizations.
The auditing process and its goals
Most audits revolve around a series of similar goals. In designing an audit, strategic initiatives are identified, which may include the validation of coded claims, performance measures, the accuracy of information, proper data cybersecurity policies, and adherence to policies and procedures.
While providers can perform audits internally, having an outsourced auditing solution can offer a range of benefits. In addition to having the latest industry training, an outsourced team can offer a fresh perspective while helping organizations optimize reimbursements and uncover risks.
Common audit goals include:
- reveal errors in provider documentation
- identify mistakes or inefficiencies in payer reimbursement
- determine whether incorrect medical codes have been used
- reveal internal and external risk assessment and risk management strategies
- verify electronic health records are up to required standards
- identify intentional or unintentional fraudulent billing practices
- explore areas of risks to prevent visits from a Recovery Audit Contractor
- identify software errors that may have led to erroneous claims
- discover areas of payer rules where medical practices billed incorrectly
Specific objectives differ with each audit. By keeping health audits on track, organizations can explore a wide variety of new avenues for improvements.
What to expect from the OIG telehealth audits
It’s clear that with the growing demand for telehealth opportunities, there must be a focus on audits and oversight as to not compromised benefits by fraud, abuse, or misuse. Here are the 7 audits OIG announced involving virtual care services:
1. Home health services
This audit will assess home health services provided virtually by home health agencies during the public health emergency. Auditors will evaluate the types of “skilled services furnished and determine whether the services were properly administered and billed in accordance with the Medicare requirements.”
2. Medicare Part B telehealth services
This 2-phase audit will first assess whether specific services meet Medicare requirements. It will then move to additional audits and evaluates Medicaid Part B telehealth services related to “distant/originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.”
3. Home health agencies responses to the pandemic
This audit will explore how home health agencies responded using virtual care. This will include looking into staffing challenges and solutions and emergency preparedness plans.
4. Medicare telehealth services
This audit will take a look at integrity concerns related to Medicare telehealth services provided during the pandemic. Auditors will take a deep dive into billing for those services to uncover patterns and characteristics of providers that may pose risks.
5. Use of Medicare telehealth services
This audit will inspect the use of telehealth services in Medicare Parts B and C during the public health emergency. Auditors will explore which specific virtual services were used and how that use compares to beneficiaries’ use of in-person services.
6. Medicaid telehealth expansion
This audit will investigate compliance with federal and state guidelines by Medicaid agencies and providers. Auditors will also focus on if states providers proper guidance.
7. Use of telehealth to provide behavioral health services in Medicaid managed care
This audit will survey how selected state Medicaid programs and managed care organizations use telehealth to provide behavioral health care.
Looking ahead
Ultimately, the purpose of healthcare audits is to provide organizations and associations with data they need to improve the quality of patient care and to ensure long-term stability through regulatory compliance.
Protecting data integrity, adhering to ever-evolving compliance guidelines, ensuring reimbursement accuracy, and protecting patient care standards hinge on auditing experts. Kick-start a higher level of integrity for your organization with our experts today.
