Key Features in Health Insurance Audit Management Systems

Contractors issue about 2 million requests to healthcare providers for medical records each year. This data comes from the Centers for Medicare & Medicaid Services (CMS). Review contractors often fulfill these requests through laborious manual processes. This usually involves mailing the request for documents to the provider. The provider then prints medical records, compiles documentation, and submits it to the contractor by mail or fax.

The common sense solution is technology. A comprehensive, integrated audit management system can be the backbone of your audit activity. However, finding an ideal technology-based solution that fits your needs can take a bit of research upfront. 

What is Healthcare Audit Management?

Healthcare audit management is the systematic process of auditing a healthcare organization. It involves planning, tracking and executing audits. These audits can be external, prompted by government and commercial payers. Or they can be internal through quality reviews and performance assessments. 

Audits ensure regulatory compliance, optimize reimbursements and identify areas for operational improvement. The right software solution helps hospitals handle the audit process more efficiently. The result is better outcomes for everyone and less stress for the management team.

Why Are Healthcare Audit Management Solutions Important?

Healthcare audit management solutions provide a singular platform to oversee multiple audits. These tools help by streamlining workflows and automating many manual tasks. There are several benefits, including:

• Reduced risk of errors
• Adherence to audit deadlines
• Better regulatory compliance 
• Fewer costs associated with penalties or noncompliance
• Prompt responses to emerging internal issues
• Secure management for huge amounts of data

Healthcare Audit Management Solution Key Features

Full Automation

One of the primary benefits of audit management software is the automation of tedious and time-consuming tasks. Automation streamlines audit response from data collection to document submission. It also reduces the likelihood of manual errors. Automated notifications and reminders help ensure every audit stays on track. These features help by providing real-time updates to relevant team members.

Complete Workflow Management & Real-Time Work Lists

A robust solution provides end-to-end workflow management. This allows teams to track each step of the audit process easily. The most valuable features for audit teams include:

• Status models: All team members should know the progress of an audit response in real time. Real-time work lists enable team members to see which tasks are pending, which are complete, and what needs immediate attention.
• Intuitive work queues: Relevant staff should receive auto-generated, real-time work lists. These let them know what they should be working on and when to avoid any downtime in the audit response process.
• Activity notifications: Staff should be notified immediately through the software when they must begin their role in the audit response process. Avoid communication hassle with physical inter-office memos or flooded inboxes.
• Electronic document repository: The system should merge all the latest communications and relevant electronic documentation. These documents should be searchable and accessible to all authorized staff.

These features let teams move on from cluttered stacks of medical documentation with manual processes. They pave the way for more streamlined case management using the right technology.

Customization for Different Types of Audits

Not all audits are created equal. The federal government manages Medicare audits with one set of rules. Meanwhile, Medicaid audits can vary from state to state. They can even vary between different contractors conducting the audits. Commercial audits can be wildly different depending on the contents of your contract with each payer.

That’s why great audit management software allows for customization. You should be able to adjust based on the type of audit and the requirements within your audit contract. Customizable rules, templates, and form options let you adapt the software to fit your organization’s needs. The result is time and resources saved with improved audit efficiency.

Integration with Other Solutions & Interoperability

Interoperability with other healthcare solutions across your organization’s technology ecosystem is crucial. Consider your electronic health records, billing software and compliance platforms. An audit solution that integrates with EHR software reduces data silos and improves accuracy. This is because information can be shared across platforms in real time without manual data entry.

There are a few specific integrations that are exceptionally helpful. First, the software should allow for integrating outside, applicable systems that show a clear view of at-risk dollars in real time. Accurately reporting on denied dollars gives a much clearer picture of the hospital’s overall financial health. These reports, such as those for dollars at risk vs. dollars that have already been recouped, are better than looking at individual claims.

Secondly, a good software solution should work with esMD to receive and submit audit documentation from CMS at a minimum. It should also provide custom electronic interfaces with specific commercial payers. This is provided they are willing to accept electronic documentation.

Robust Security, Compliance, & Data Integrity

Protecting patient data is one of the most important elements of audit management. A good audit management solution should emphasize compliance and security. Software should specifically include features that meet regulatory standards like:

• HIPAA: Law that protects patient data in the U.S. 
• GDPR: Law that protects personal data for EU citizens.
• SOC 2: Framework that provides data security standards for organizations.

Solutions should also include advanced security features such as data encryption. Other examples include role-based access control and automatic security updates. These protections help maintain data integrity and reduce risks of unauthorized access.

Remember, untrained staff weaken security measures by not following protocols. Some software also includes built-in training systems. These include eLearning reminders and policy acknowledgments. They also include reports that show which employees have completed assigned training modules on time.

Real-Time Reporting, Comprehensive Analytics, & Custom KPIs

Effective audit management requires data-driven decision-making. Your solution should organize comprehensive reporting on clear dashboards that staff can share. You should be able to track key performance indicators (KPIs) of your choice. And you should be able to track them with customizable, autogenerated reports and dashboards. This method provides valuable insights into audit trends and outcomes.

Audit Trail & Internal Audit Capabilities

A good audit management solution provides a clear audit trail that records every action taken during the audit process. This trail is invaluable in disputes or follow-up actions, providing a complete history of who did what and when. Auditors appreciate organizations that show detailed logs and clear resolutions in case management. 

Keep in mind that audits are not always external. Training features and internal audit capabilities allow you to assess areas for improvement. This proactive strategy comes into play before an external audit occurs.

Additional Features to Consider

Simple, User-Friendly Interface

A simple, intuitive interface helps new users and relevant stakeholders get up to speed quickly. As a result, it reduces training time and errors. Look for a solution with clean navigation, easily accessible features and clear instructions.

Offline Accessibility

With healthcare teams often on the move, offline access is a valuable feature. Look for a solution allowing users to access audit information and perform tasks, even offline. This flexibility ensures that audits can continue seamlessly in remote locations or on the hospital floor.

Desktop & Mobile Auditing Interfaces

Switching between desktop and mobile interfaces provides flexibility. This feature benefits team members needing to access the system in different environments. A solution with both interfaces allows auditors and team members to work efficiently, whether in the office or on the go.

Flexible Scalability For Your Hospital

Your audit management solution should grow as your hospital or health system grows. Scalable solutions accommodate additional users, audits and data without sacrificing performance. This scalability ensures your software investment meets your organization's auditing needs long-term.

Regulatory Change Alerts & Updates

Healthcare regulations change frequently, and keeping up can be a challenge. A good audit management solution provides automatic updates. It also includes alerts for expiring licenses and regulatory changes. It helps your organization stay compliant without manually tracking every detail.

How to Avoid Feature Overwhelm

For a hospital that has relied on manual processes, investing in a solution that provides all of the above overnight seems difficult. It might sometimes seem like it's not even worth attempting. With so many features available, it's easy to feel overwhelmed. 

Start by identifying your audit team's primary needs. Determine which features align closely with your organization's goals. During this step, focus on automation, integration and security. Avoid unnecessary add-ons that may complicate the software without adding value to your workflow. A solution that prioritizes your team's most pressing needs will be more effective than one loaded with features that go unused.

You can start using some things in this article at a time. A hospital that uses manual processes could spend six months adjusting to one feature. For example, enhanced case management and automation within a customizable interface.

Help staff improve daily productivity with notifications, efficient workflows and automated data entry. Once management decides that end users are comfortable, the team can explore additional features. Those might be electronic document submission and reporting. Over time, the team fully integrates into the system and begins tracking relevant metrics to improve processes. Take your time—there's no need to rush!

Choosing the Right Healthcare Audit Management Solution

The decisions don't stop at a solution's technical requirements. Your vendor must understand the complexity of the audit landscape. They must be able to facilitate the continued evolution of required processes.

This means finding an expert vendor who doesn't just anticipate potential impacts on the workflows. They must proactively make improvements to continue driving seamless and efficient audit management.

Do you need a vendor with these qualities that can provide all the audit management software features mentioned above? Look no further than Office Ally's Audit & Denial Tracker. 

Audit & Denial Tracker is a cloud-based audit management platform. It supports Medicare, Medicaid and commercial payer audits. It is the most powerful audit management and response solution available today. 

Click here to learn more about how Office Ally’s Audit & Denial Tracker can simplify and optimize your audit management.