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.
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.