You must do one thing to make audits go away…pass them. Passing audits opens the door to fewer audits and the ultimate prize: EXEMPTION. But, appeals can’t get you there – it doesn’t matter how many get overturned. Without realizing it, we have become an industry plagued with “second chance disease”. Reliance on appeals to get a favorable outcome has become the default and has exacerbated the problem - begetting more audits, expending costly resources and locking up cash flow. The claim denies, and we appeal. The appeal denies, and we appeal to the next higher level. Most suppliers eventually secure a favorable response, but everything in between is a costly, expended effort. As long as this cycle continues, audits will increase.
If you want fewer audits you have to make a fundamental change: stop APPEALING them and start WINNING them at first pass. By adapting the strategy to make first pass wins our predetermined goal, we can engage the fast track to a materially different outcome: audit reduction, faster payments, reduced man power and the golden prize - EXEMPTION. So how do we accomplish this task?
- Track incoming audit requests to ensure that properly assembled responses get out the door in time for a formal decision. By keeping tabs on incoming audits and the timelines for response, you avoid unnecessary denials for non-response. Missing deadlines catapult you into the appeals cycle.
- Be critical of your records before submission. Ensure that your documentation meets the burden of medical necessity by leveraging the LCD and documentation checklists provided by the MACs. While assembling the response, train your staff to look at the packet from an auditor's perspective. Don’t expect the auditors to turn a blind eye to errors. Suppliers that take the time to vet their own documentation and outline a logical path to approval are more likely to secure a favorable decision out of the gate.
- Use separator sheets in the first assembly of the audit response to produce a consistent outcome.Separator sheets identify critical documents and their contents. There are so many reasons why this simple strategy makes a big difference in outcomes, but the main reason is that every packet from every supplier is different. So we need to streamline our unique documents and associate them with the consistent terminology used by the auditors.
- Invest the time to outline a logical path to approval. Through the appeals process we do a much better job at pointing out WHY our documents matter and we emphasize material points after we are provided with an error citation from failed submissions. So while yes, the same documents are used, we present them DIFFERENTLY in appeals. Adapt your presentation earlier in the process using lessons learned from prior audits and appeals.
These guidelines seem simple and direct but are not obvious in our current processes. However, when fully embraced, you will improve your first pass results and reduce your company’s error rates. Lower error rates are the key to reduced audit volumes and even audit exemption for certain products.