The Impact of Audits on a Health Information Department

When you receive a large medical record pull list from a Health Plan for a HEDIS or Risk Adjustment review/audit, is your first instinct to panic? You’re not alone. HEDIS, Medicare, Medicaid, and commercial risk adjustment audit requests can translate to thousands of transactions and hours upon hours of additional work, often with an intimidating deadline.

Health plans like United HealthCare, Aetna, Cigna, and Humana all require medical records on an annual basis for their HEDIS and Risk Adjustment Reviews. These organizations use medical records to verify or “audit” the care provided by a hospital, health system, or clinic. These HEDIS and Risk Adjustment Reviews or “audits” by health plans generate millions of medical record requests each year and place additional work on the shoulders of health care providers.

These requests come on top of normal operational expectations to complete medical record requests for other requestors and patients – but your world can’t stop for these chart review/audit requests. If your world does stop as a result of these requests, it can lead to teams working overtime, burning out, and an overall operational and cost headache for the health information management team.

With so many healthcare organizations facing staffing challenges, it comes as no surprise that the phrase “we received a large pull list from a health plan” creates panic.

HEDIS & Medicare Risk Adjustment Audits

Health Effectiveness Data and Information Set (HEDIS) and Medicare Risk Adjustment (MRA) audits provide valuable insight to health plans. In many cases, health plans use an intermediary company like Ciox or Change Healthcare to facilitate retrieving the records and performing the coding for the audit. Health care providers typically receive a letter from the intermediary company on behalf of the health plan, which outlines the records being requested along with a deadline to complete the audit. These letters can request thousands of medical records.

Payment Integrity Audits

Payment integrity audits, on the other hand, are critical to complete due to the financial implications. If a hospital does not respond to payment integrity requests, they potentially face a technical denial of the related claim or payment. A technical denial will result in recoupment of the payment the healthcare organization received from the health plan – significantly affecting the health care facility’s bottom line. Some of the most common types of payment integrity requests/audits include Medicare, Medicaid, and Recovery Audit Contractor (RAC).

Don’t Panic – ScanSTAT Can Help

Healthcare providers can manage these requests in-house but utilizing an expert third-party vendor can alleviate the stress of audits without compromising day-to-day patient needs. While an audit request might feel overwhelming, you don’t have to struggle alone. ScanSTAT is a scalable resource of experienced release of information staff, ready to tackle any audit request quickly – without interrupting any regular, ongoing operations. ScanSTAT uses technology to integrate with your EHR, provides intensive quality assurance on each and every record, and delivers records in the format requested. You can check ScanSTAT’s progress using their web-based reporting system for real-time updates.

Depending on your EHR, ScanSTAT offers an automated solution which seamlessly integrates to your system and EHR to complete audit requests. In some cases, this automation completes each request in as little as one minute. This solution enables your staff to continue to focus on their day-to-day priorities without being interrupted by these audit requests.

In addition, ScanSTAT frequently works with record retrieval organizations like Ciox and Change Healthcare who request records on the behalf of health plans. We will develop specific delivery methods with them and negotiate more practical deadlines for those audit requests.

To the 10,000 Record Request, We Say Bring It On!

If you’re ready to completely offload the burden of handling audit requests, contact ScanSTAT.

Let’s make this easier for everyone.

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