Moira Dolan

As Medical Director for Discovery Health Partners, Dr. Dolan meets directly with providers to help them understand how and why billing and coding errors are occurring. Her knowledge of provider networks and unique policies allows Discovery to increase positive outcomes and maintain healthy provider relationships. Dr. Dolan is a graduate of the University of Illinois College of Medicine and is an internal medicine physician certified by the American Board of Internal Medicine. Her extensive experience in medical audits includes work with the Texas Office of Inspector General and the Medicare recovery audit program.

Three benefits of physician oversight in clinical audits

As I discussed in my earlier blog post, clinical audits play a critical role in ensuring payment integrity for health plans. They help to identify where payment errors are likely and help to correct those errors.

Previously, we talked about the need to care for providers during clinical audits, reduce abrasion, and protect the payer/provider relationship. In today’s blog post, we take the discussion a step further, identifying how physician oversight plays a role in conducting medically sound audits that reduce provider abrasion and ensure defensible recoveries.

Let’s discuss three topics in more detail:

1. Reducing provider abrasion

When conducting clinical audits, health plans must consider the experience from the provider’s perspective. While there’s little disagreement in the medical community that clinical audits are necessary, they can be tedious and expensive.

There are a few techniques I’ve used to help deliver a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Education and transparency can have a significant impact on enhancing the provider experience. Clearly communicating expectations, requests, deadlines, and the plan’s findings go a long way toward improving the payer-provider relationship.

By being involved in these audits, I have come to realize that physician oversight helps to ensure a positive provider experience. When providers know that audits are medically sound and have been reviewed by a physician, they more readily accept the outcomes of the audit.

2. Providing the clinical perspective

When payment integrity is the goal, financial decisions cannot be the primary concern for both payer and provider. With physicians involved in the process, it’s understood that finances are not the motivating factor. By involving physicians, plans have the opportunity to communicate to providers that it’s not all about money and that there is clinical consideration given to audits.

In addition, physicians can help providers understand the medical rationale behind identified payment inaccuracies. We can help communicate compliance rules and show providers where they may have gone wrong in their coding and documentation practices. Ultimately, this helps providers learn from the audit and are more compelled to change their behavior.

3: Ensuring medically defensible recoveries

Whenever a clinical audit leads to the recovery of overpaid funds, the health plan must ensure that all clinical audit outcomes are defensible. Physician oversight helps ensure that audit decisions are made with clinical objectivity.

This is particularly true with medical necessity discussions. With high-dollar claim reviews and DRG validations, physicians collaborate with coders in developing review algorithms. In responses to appeals, physicians can review the audit decision and provide the clinical justification for the outcome.

In the end, physician oversight in clinical audits helps health plans ensure they are effective and reduce any abrasion that might be experienced by the provider. The physician can engage in peer-to-peer discussion with the provider and help them understand audit decisions from a mutually agreeable clinical perspective.

Learn how Discovery Health Partners can help you enhance the medical validity of clinical audits.

Moira Dolan, M.D., is Medical Director for Discovery Health Partners. She is a graduate of the University of Illinois School of Medicine and has been a practicing physician for over 30 years. Dr. Dolan maintains a private medical practice in Austin, Texas.

Moira Dolan, M.D.Three benefits of physician oversight in clinical audits
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Caring for providers during clinical audits

For today’s health plans, clinical audits play a critical role in ensuring the financial health of the organization. They can help a plan control costs, comply with government regulations, and meet financial requirements. Fundamentally, clinical audits help to identify where payment errors are likely. There are many flavors of clinical audits—reviews for high-dollar claims, medical necessity, hospital bills, DRG validation, and skilled nursing care are among some of the most common.

Effect of clinical audits on providers

Whatever the flavor of the audit, it’s likely that clinical audits can create provider abrasion. As a medical director, I have experienced clinical audits and understand the reasons for the discontent. There’s little disagreement in the medical community that clinical audits are necessary, yet tedious and expensive.

In fact, nearly a third of providers report a negative experience with payer audits, according to a recent study by Frost & Sullivan. Providers report that their negative experience stems from factors including a high volume of medical requests, the prevalence of technical denials, and the high administrative costs of audit compliance.

More than 92% of survey respondents tie provider abrasion to the volume of medical requests. And 50% of providers consider clinical validation audits and DRG coding to be very or extremely labor-intensive. This is a critical factor given that labor intensity has a direct impact on administrative costs.

Improving the payer-provider relationship during audits

The good news is that any dissatisfaction in the clinical audit process is not irreparable. I have learned that provider-friendly techniques can go a long way toward delivering a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Recognizing that clinical audits have the potential to cause provider abrasion is the first step to reducing discontent. Beyond that, communication and education are key.

Clear and transparent communication throughout the clinical audit process can have a significant impact on enhancing the provider experience. By clearly communicating expectations, health plans can alleviate provider unease with the audit process and mitigate the adversarial impact and stress related to clinical audits.

Providers are more likely to be amenable to the audit when they clearly understand requests, deadlines, and the plan’s findings. When they know what to expect and understand that the communication lines are open, providers are more likely to have a positive experience.

Similarly, education is an important tool in reducing provider abrasion. Perhaps the most valuable element of clinical audit education is helping providers understand how to change their behavior to reduce the impact of audits. Health plans can educate providers on the need for preventative measures in situations related to high-risk targets. Education can also include helping providers understand how to implement a proactive approach to address recurring problems.

Ultimately, with frequent and transparent communication and education throughout the clinical audit process, health plans can help providers view the plan in a favorable light and experience the audit without undue stress. With a positive clinical audit experience, payers and providers can work together to reduce the potential for post-payment recovery today and in the years to come.

Learn how Discovery Health Partners can help you enhance the provider experience in clinical audits.

Moira Dolan, M.D., is Medical Director for Discovery Health Partners. She is a graduate of the University of Illinois School of Medicine and has been a practicing physician for over 30 years. Dr. Dolan maintains a private medical practice in Austin, Texas.

Moira Dolan, M.D.Caring for providers during clinical audits
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