Audit
Today, most hospitals perform manual, spot checks of their coded and claims data after it has already been sent off for billing. The result is missed and delayed reimbursements.
Pre-bill auditing is the process of proactively mitigating risks by implementing an auditing process earlier than in many current auditing cycles to ensure accurate reimbursements, overall revenue integrity, and reduced costs. A thorough audit of relevant CC/MCC codes, severity of illness (SOI) levels, and a validation of APR and MS-DRG values ensure that once a chart is under pre-bill review, a hospital is able to increase the likelihood that a claim will be accurate, paid and accepted. This provides value to healthcare facilities in the form of both cost and time savings. Pre-bill auditing proactively addresses the potential for costly take-backs and denial risks by improving initial claim submissions.
Pre-bill auditing acts as a way to identify opportunities to improve reimbursement accuracy that can result in revenue for hospitals. In US hospitals, the average rate of claims denial in large hospitals (200 to 400 beds) is 10.58 percent. High denial rates among small, medium and large hospitals leave room for opportunities for hospitals to reduce their risk of denials by accurately capturing cost and payments in the first round of claims.
Current processes are inefficient and leave gaps that result in missed and incomplete claims, as indicated by the high claims denial rates. This is because pre-bill auditing has not yet been implemented effectively across the US. A key factor contributing to this issue are the low hospital clean bill rates that reflect the percentage of error-free claim submissions that are a result of factors such as high claim denials, low revenue integrity, and patient payment errors. To counteract this issue, hospitals must implement new technology using healthcare revenue cycle management (RCM) process transformation to resolve many of the current claims issues that result in missed opportunities, impacting hospitals and RCM teams.
Issues within the current auditing process in US hospitals include:
It is clear that many hospitals lack the resources, time, and budget to enforce denial prevention resulting in large amounts of money left on the table. Therefore, hospitals are unable to capture the benefits of pre-bill auditing in their health system.
There is no doubt that claims denials are a rising issue for all healthcare organizations. As the percentage of denied claims continues and missed reimbursements continue to rise, hospitals can use pre-bill auditing to gain the following benefits:
The above benefits can improve the way that current RCM teams are conducting auditing processes and that it is advantageous for hospitals to utilize efficient pre-bill audit processes.
Semantic Health employs proprietary AI to automate secondary reviews of all coded and claims data with reference to the supporting unstructured clinical documentation in EMRs. This has significantly improved clinical documentation and coding processes across major hospitals.
By employing its platform, Semantic Auditor, high-value data quality opportunities in the documentation and coding can be flagged for review as they arise. Pre-bill auditing is used to uncover past and new reimbursement opportunities, in turn, saving hospitals time and money.
Semantic Auditor achieves this by sourcing data quality opportunities and assessing the impact that is reflected in the overall relative weight value. This provides auditors with the knowledge needed to scout out data quality opportunities to ensure accurate reimbursements and thoroughly access CC/MCC cases, SOI levels, and validation of APR and MS-DRG values and help hospitals increase the likelihood of claim acceptance. Auditors are able to save time by driving efficiencies in the audit process while hospitals can accurately and effectively ensure more accurate reimbursements and relative weight values.
Have you ever wanted to increase the accuracy of coded data for billing? With Semantic Auditor, your team can review 100% of coded data alongside clinical documentation and find the gaps: missed or unspecified codes, a more accurate principal diagnosis, or codes that don’t have enough evidence to support them. Most importantly, the technology enables auditors to perform this secondary review in real-time, before the data is sent to billing. This means that you can prevent revenue leakage and protect revenue integrity: get paid completely, faster, with less work.
How are you addressing denials at your hospital?
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Semantic Health helps hospitals and health systems unlock the true value of their unstructured clinical data. Our intelligent medical coding and auditing platform uses artificial intelligence and deep learning to streamline medical coding & auditing concurrent with patient admission, improve documentation quality, optimize reimbursements, and enable real-time access to coded data for secondary analysis.
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