Analysis by Michael McGowan
Shortcuts are popular and frequently useful. They can also be misleading and dangerous. In the world of payment denials and appeals where I spend most of my time, a popular new shortcut is the audit tool. I am seriously concerned about those who might rely too heavily on such checklists and feel obligated to issue a warning.
Chart audit tools are basically checklists that claim to help you make your charts and visit notes “denial proof.” They cannot possibly live up to that claim. Here is why.
I have reviewed several of these tools after they were forwarded to me by highly motivated and well-meaning individuals. They all work every bit as well as they are supposed to work and they are all to be avoided.
Chart audit tools are supposed to help home health care agencies defend themselves against the very real threat of post payment reviews, which have been hitting agencies at an alarming rate recently. Such reviews may come from the RHHI, RAC, CERT, MAC or any of a number of state and federal agencies and contractors. Their purpose is to find reasons to take back payments agencies have already received.
So far, it sounds good. Fight fire with fire by auditing your own charts before the government does. Use a fast, easy-to-understand checklist to find chart documentation weaknesses and fix them. The problem is, the analogy does not work. While you are fighting with fire, government auditors are fighting back with microscope and scalpel.
Watch one of these post-payment reviewers after they knock on your door, demand to see forty or fifty charts and expect you to provide a desk and chair and a quiet place to examine them. Whether they are accreditation surveyors, state health department surveyors or federal contractors, you do not see them using chart audit tools.
You will see them read each chart, using trained judgment to capture the “context of care.” They take notes as they go, in order to be better able to write up deficiencies later. Notice them filling out requisite data collection worksheets that are required by CMS to be submitted with survey results.
They work this way because they know the regulations specific to the type of survey activities they are tasked with: post-payment, compliance, etc. Their eyes are trained to detect nuances and logical inconsistencies, not merely missing signatures and date entries.
Checklists do not operate at, are not capable of, this level of expertise. They rely on identifying only the technicalities of whether or not an activity took place somewhere within the continuum of care during an episode but have no chance whatsoever of understanding the “context of care.”
Letters of Death
Too many agencies will spend more than $100k per year on Quality Assurance personnel yet routinely get massacred during a post payment review. Other than a false sense of security, what exactly are the owners of these agencies getting for their money? In my experience, they get binders full of audit tools that have been used to audit charts, waved proudly by audit tool proponents who defend their practice to the death.
Unfortunately, death is what follows when binders are replaced in their hands by letters from CMS demanding three to five million dollars. I have seen dozens upon dozens of scenarios such as this just during the last 4 months, Medicare payment suspensions imposed under 42CFR 405.371 which could have been fully avoided.
So where did their audit tools fail them?
Audit tools are good for:
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Utilization Review Audits
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OBQI & OBQM Activities
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Compliance with pathways for re-hospitalization targets, etc.
In addition to those uses, audit tools are somewhat useful for COP audits. They are not, however, complete enough for use in a comprehensive audit. This is the reason so many G-tags, L-Tags, etc. and COPs are discovered during survey activities.
At the bottom of the list are financial surveys, where audit tools are useless. Financial auditors are not focused on the context of what is going on in the chart. There is no tool that will compile information from the Social Security Act, Code of Federal Regulations, Medicare Benefit Policy Manual, Local Coverage Determinations, accepted medical practices, and a host of subjective clinical decisions.
Dealing with Doubt
I expect the reader may tend toward the same disbelief that my clients express when I first lay out my reasons for concern about audit tools. I will therefore conclude this article with a description of the standing offer I make to my skeptical clients.
Perform your own audit, use your audit tools and the theory you have gathered from seminars. Scrub the daylights out of your charts. When you are confident your charts are clean, invite me to perform a mock survey, using the same methods and tools state and federal contractors will use when they come to your agency. If I cannot find thousands of dollars in payment denials, you will be entitled to $5,000 worth of consulting services. If I do, you pay for the mock survey.
I am able to pose this challenge – one I am yet to lose – because I have learned my craft through defending a few thousand charts in court for clients over the past five years. I have lived in the world of denials and appeals in the intensity of a demonstration region, Southern California, the land of Fraud and Plenty.
I have gained more intimate knowledge and hands-on experience with a dysfunctional system than most consultants would choose to acquire. The Medicare payment denial and appeals playing field is brutal at best, and downright bloody when it gets down to the core of the battle, but it has taught me how auditors think.
They think like clinicians, using judgment instead of shortcuts. Those who plan to survive a real survey are well-advised to do the same.
