Revenue Cycle

8 tips for quality control auditing

Patient Access Weekly Advisor, October 8, 2008

The quality assurance team at Community Regional Medical Center in Fresno, CA used hard numbers to show the need for automated quality assurance software for its facility. Whether you use a similar approach or not, here are some helpful tips and reminders from healthcare consultant Steven Orvis as you think about your quality assurance program:

1. Eliminate subjectivity on front end. Software providers can create lists of customized services that physicians regularly provide. When a service is ordered, staff members enter a diagnosis code, and the software determines whether it meets medical necessity. It can also generate an Advanced Beneficiary Notice (ABN), as necessary. The advantage of having this as part of the front-end tools is that it is hard to train or expect staff to make medical necessity determinations, and this eliminates subjectivity.

2. Get it right before the visit. Software is available that will match members to their health plans and benefits, so that this can be done before the visit, and reduces or eliminates insurance verification errors.

3. Customize your own rules. Registration scrubber software automates much of the review process and lets users build edits and rules. The rules allow users to automatically check for required fields. The systems can also take this information and build worklists for the auditors.

4. Comply with HIPAA early. HIPAA provides an electronic standard for eligibility verification. The best practice is that eligibility verification occurs during the scheduling process, or pre-registration.

5. Beat the billing scrubber. Failure to review the accuracy of registration data before the billing scrubber review will delay the billing of the claim.

6. Do not disregard training. The best software system in the world cannot replace good, strong, face-to-face training. You need an adequately-trained team, including tools and processes for formal and consistent QA and training.

7. Create registration fields if choosing manual approach. A manual QA process involves an auditor, spreadsheets, copies of face sheets, insurance cards, and Explanation of Benefits (EOBs). The auditor should create a list of registration fields that affect a clean claim and review each field against the documents provided. You can review approximately 100-150 registrations per day. The auditor would then document the errors and identify the problem areas and training needs. This is labor-intensive and time-consuming.

8. Monitor performance. You need to track and monitor the overall adherence to and effectiveness of the QA process for at least six months. This will ensure that there is a working process, consistent reporting, and a reasonable accuracy target.

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