Although the cost of inpatient hospital stays continues to rise, health plans are finding that their inpatient claim auditing programs are returning less value. They’re also facing challenges such as provider abrasion resulting from requesting too many medical charts to validate those claims, which makes it more difficult to successfully retrieve medical records. We talk with Cotiviti product director Jena Reilly about how health plans be more selective and focus on pursuing medical records that will actually return value back to the plan.
Can you start off with a quick summary of what clinical chart validation is and what steps are involved in the process?
Clinical chart validation is the review of inpatient paid claims data and their associated medical records in order to validate that those claims were paid correctly. Our primary focus is on diagnosis related group (DRG)-type claims, and this consists of three components:
- Documentation, which really means, "does the medical record contain the necessary information to support the claim payment." For example, is there missing information like "diagnosis A on the claim is not documented in the medical record."
- Coding, which translates to "does the diagnosis code and/or procedures on the claim match what's in the medical record." For example, diagnosis A is the primary diagnosis on the claim data, but the medical record supports that diagnosis B should be the primary diagnosis.
- Clinical, the diagnosis and/or procedure codes on the claim supported by the clinical information in the medical record. Is diagnosis A documented in the medical record, but clinically it's not supported, so the auditor needs to remove diagnosis A and possibly add another diagnosis that is supported?
What trends and challenges are we seeing in the industry when it comes to auditing inpatient claims?
We're seeing an increase in inpatient spend by about 5 to 10 percent over the last four years, which leads to a higher cost for our clients. Couple that with the challenges we're facing with provider abrasion and the general industry impact where providers are participating in those inpatient audit programs, and even convincing our clients to allow them to opt out of the program.
What the most effective way for health plans to ensure that they are selecting the right charts to pursue, and what kinds of technology can help?
We have found that our analytics-driven chart selection is the most effective way to hone in on the right charts that we want to pursue for our inpatient audit program. Things like machine learning models and leveraging our historic audit results—balance that against our clinical insights—and that's really what drives our precision in chart selection.
What kind of expertise is needed to be effective at clinical chart validation?
Once we've selected those claims for audit, our medical professionals with a deep understanding of evidence-based medical literature and that connection to proper coding, which really translates to registered nurses, coding professionals, and physician oversight, can identify inaccuracies requiring a clinical perspective.
How do we take health plans’ individual needs and policies into account in performing clinical chart validation?
During our implementation, we collaborate with the client to understand their inpatient policies and their provider contracts. This allows us to identify provider contractual agreements, like one provider is excluded from Medicaid audits, or another provider can only be audited within 120 days of the paid date, things that are really provider distinct.
Additionally, we conduct policy reviews with the client's medical director, in conjunction with our medical director, truly translating, understanding, and collaborating between the two, so that we know if we have a policy like transplants and the client isn't favorable for us to review transplant cases, we would exclude that from our selection. Another example is sepsis. There are three distinct criteria out in the marketplace on how to review sepsis claims, and each client applies one, two, or three based on their expertise, so it has to be very flexible and fluid.
Providers have different preferences when it comes to how they should be contacted to request a chart. What information should be considered before initiating a retrieval request?
One thing we evaluate before going into what we call a chart retrieval cycle on a monthly basis is identifying if the client already has the charts in-house. Typically, our clients have internal audit programs, and those internal audit programs request charts for their purposes. We like to leverage what they have in-house obviously to reduce provider abrasion—a provider gets a little annoyed from time to time if multiple entities are asking for the same chart.
We also evaluate whether or not the provider might be interested in using a web portal. Sometimes, it's a lot easier than mail or having to print or write a record to a CD. Finally, we see if we have experience with that particular provider in other arrangements. Providers cross health plans a lot, and so we try to leverage if we might be receiving charts from a provider via fax for one client, we'll leverage that same type of retrieval method for another client. We also evaluate what other divisions internally are acquiring charts and what methods are they using.
In summary, our analytics-driven chart selection, accompanied by our clinical insights and coupled with our client and provider customizations really allows us to deliver a successful inpatient audit program.
Podcast music credit: "Inhaling Freedom" by Nazar Rybak, HookSounds.