What to Do Before, During & After Your Healthcare Audit Response

In an ideal world, an audit response process would be simple. You would receive notice of the audit, send back some paperwork and move on with your work. But anyone who has ever worked on a healthcare audit response team knows, this level of simplicity is wishful thinking.

Instead, success is in the details, and compliance is based heavily on your team’s actions before, during and after the audit. You can always create systems that promote best practices before the healthcare audit. A lot of organization and a little elbow grease can set you up for successful audit responses far into the future.

What to Do Before an Audit Response

Prepare, prepare, prepare

Developing a solid compliance program is the first step in preparing for an audit. A comprehensive program:

• Helps identify potential risks
• Trains staff on procedures
• Ensures the hospital follows federal and state regulations

Outline a clear audit response plan, including the roles and responsibilities of your audit team. Also, include timelines for each step of the response and contingency plans in case auditors request more information. After initial training, introduce regular refresher sessions. You should also conduct mock audits to prepare for actual responses.

Establish Your Audit Team and Define Their Roles

Start by defining roles within the audit response process. A good team, at minimum, consists of:

• A documentation lead with access to medical records
• The project manager must ensure that all paperwork is sent on time. 
• A doctor or nurse who can provide a clinical perspective to create a complete picture, if needed
• A quality assurance team member to review all information before it's submitted

Of course, you can include more than four people on the team. Include as many employees as your organization needs to send a timely, complete audit response.

Set Up the Appropriate Technology for the Audit Response

How can you use technology to ease communication between the teams you've set up and maintain predefined deadlines? Do you need triggers or automated checks to support your quality assurance process?

Some teams use several spreadsheets or offline systems to track audit response procedures. We recommend investing in technology designed to handle tracking from day one. A good software package supports all team members and can make or break your success in responding to the audit on time and correctly.

Leverage Electronic Audit Notifications

Traditionally, initial audit notifications are notoriously tricky to keep track of. The government sends audits via paper letters, unlike commercial entities. They use a mix of website posts, paper letters, and electronic communication. Some organizations with thousands of locations only handle audits through a few central offices. The burden of simply organizing audits to get them in the right hands can significantly cut into the time you have to actually submit the audit.

To handle this, opt into electronic notifications whenever possible. Electronic audit requests are relatively new in healthcare. However, they are infinitely faster and more efficient than awaiting a paper letter.

Conduct a Proper Risk Assessment

A risk assessment lets you identify vulnerable areas in your processes that might trigger audits. Use practice and actual audits to address issues before they become more significant problems.

Analyze past federal and state audit results and examine high-risk departments or coding practices. After conducting mock audits, assess the results and identify any areas for improvement in internal systems and processes. 

Utilize a Centralized Documentation System

Audits often require submitting massive amounts of documentation. A centralized system for document storage and retrieval can help your audit team access necessary records quickly and easily. This system should integrate with your hospital's Electronic Health Records solution (EHR system) to streamline the process.

What to Do During an Audit Response

Start Tracking Your Audit Immediately

If you couldn’t opt into electronic communications or are still working on it, you may receive notice of the audit via a paper letter in the mail. Unfortunately, the clock starts ticking as soon as they print the letter.

Whether you're using software or a spreadsheet system, log the audit and kick off the response process immediately. For letters, track the issue date, the date you received the letter initially, and the date it is being entered into your tracking system. That way, you can keep track of any time lost between issue, receipt, and starting the process and work to cut that time down in the future.

Assemble & Activate Your Audit Response Team

Once an audit is triggered, activate your audit response team. They should respond quickly and accurately to requests for more information. Communication between team members and stellar audit leadership are crucial. Along with organized project management, they help avoid any lapses that could delay your response.

Ensure QA Reviews Are Thorough

Establish your QA review for a complete and thorough audit response. Skipping a review can mean spending the extra money to appeal after a denial. So, ensure your QA reviewer understands and confirms that the audit response tells a complete story.

Everyone on the team should have time to review all gathered documentation for the response. The designated QA reviewer should check last and work with the project manager to ensure all information is submitted in full and on time.

Transparently Communicate with Auditors

The auditor is not the enemy. It’s much easier to work with them than against them. Transparent communication can create a smooth audit process. For example, during the audit process, auditors often request more information. They may also raise questions about specific documentation. Addressing these emerging issues promptly is essential to keeping the audit on track and preventing delays.

Make sure your audit response team is prepared to respond quickly and accurately to these requests. Clear and timely communication demonstrates your organization’s commitment to compliance. It also helps avoid potential misunderstandings that could lead to adverse audit findings.

And remember, communication is a two-way street. Thoroughly ask questions during the audit process rather than guessing what the auditor is asking for!

Log Document Requests & Provide Accurate Documentation

Take advantage of the centralized documentation system you established before the audit. This system can help you find and pull needed documentation easily. Keep a log of the documentation the auditor requests. The documentation helps identify patterns of often-audited procedures and prepare for future requests.

Properly Handle Sensitive Patient Data

HIPAA and EHR compliance are not just suggestions - they’re a requirement. Ensure all team members understand the importance of accurate and secure patient data management. They must also follow protocols to maintain medical record confidentiality throughout the process.

What to Do After an Audit Response

Assess the Financial Impact

The audit's financial impact will show in your reimbursement from a payer within that period. When you reimburse hundreds of accounts at once, determining the impact of a small audit can be challenging. However, it's a critical part of your response process.

The actions you should take to track audit results depend on the type of audit: Pre-pay, post-pay or denials. But with all three, you should track any submitted claims. You should also dig through monthly reimbursements to uncover any audit adjustments.

Record Your Audit Results and Measure Progress

The name of the audit game is continuous improvement. Analyzing data lets you track key performance indicators (KPIs) over time. It also allows you to adjust your audit response process as necessary.  Hard numbers are the best way to establish your performance and identify areas for improvement in future processes.

Software equipped with a great reporting tool can track your KPIs every month. It can also remind you to conduct a quarterly process review to implement any needed changes. Analyze your results independently and within your team to adjust policies moving forward.

Remember, findings, even the negative ones, are an essential part of the audit process. Organizations establish audits to ensure proper adherence to processes and regulations. A string of “lost” audits is not a judgment on your performance at work. Instead, you can use this valuable data and information. It can help you quickly and efficiently improve your hospital or health system's day-to-day performance.

Analyze the Audit Findings for Root Cause Analysis

Conduct a root cause analysis. This process identifies patterns in denied claims, documentation issues, or compliance problems. Dig deep! It's essential to look beyond the surface level for the actual cause of the issue.

Then, use the insights from your root cause analysis to create a corrective action plan. You can perform staff retraining, revise documentation practices, or implement new technology solutions. However you address these areas, it will help prevent similar weak spots from triggering audits in the future.

Establish An Audit Appeal Strategy

After you submit your audit, you should establish an appeals strategy. Treating every audit result as unique and taking the time to examine it and decide whether to appeal is a full-time job. To save time, many organizations establish criteria for audit appeals in advance. Potential strategies include:

• Appeal to every audit that doesn’t go your way. Though you won’t get every appeal in your favor, sometimes the math checks out on this strategy. If you consistently overturn a high percentage of results, it could make sense to appeal to everyone.
• Use a hybrid model based on the rationale to appeal only to certain types of denials based on the reason for adjustment. Some examples include prior authorization or standard of care.
• Use a hybrid model based on finances. This appeals only to certain audit results that exceed a pre-established financial threshold.

Of course, you will always encounter special cases or unusual audit results that need extra examination. However, agreeing on a strategy in advance can save hours that would otherwise be spent on individual results.

Plan for Future Audits

Healthcare audits are inevitable in running a hospital or health system. But your organization can navigate them smoothly and successfully with the right preparation. Continually refine your audit response process and keep your technology and staff up to date. Doing so ensures your hospital is always improving and prepared for future audit responses.

To streamline your audit management, consider investing in tools like Office Ally’s Audit & Denial Tracker. This solution is designed to enhance your audit response and ensure compliance every step of the way. Learn more about how Audit & Denial Tracker can support your audit response efforts from start to finish.