Hayes Review: February 2010

Risk-Based Auditing with MDaudit™ Professional

By Nira Mahesh, Carrie Walters and Susan Horahan

MDaudit Professional is Hayes’ audit software for physicians. The following questions were asked by Hayes consultant, Nira Mahesh, and answered by MDaudit team members, Carrie Walters, RHIA, and Susan Horahan.

Nira:  How does MDaudit Professional accommodate risk-based auditing?

Carrie:  The most common type of risk-based audit would be a scheduled provider-based audit where future audits are determined on prior audit outcomes.  In this type of audit, providers with poor outcomes can be audited more frequently and providers with positive outcomes can be audited less frequently, allowing organizations to build audit pathways that will allow them to focus on educational activities where they are needed most. 

Using the diagram listed below, an organization could build a pathway to determine subsequent audits for the provider.  In this example, the blue boxes represent types of audits and audit frequencies and the pink and yellow boxes represent outcomes.

Click the chart to view an enlarged version.

Nira:  How does MDaudit select cases for a provider’s audit?

Susan:  The auditor can build audit case profiles, to drive the audit case assign function, permitting MDaudit Professional to suggest a set of cases to be included in the audit. For example, audit case profiles can be built to select specific CPT codes, payors, etc. Multiple audit case profiles can be built to tailor the case selection to a specific provider specialty.

Nira:  Are there other ways to perform a risk-based audit in MDaudit Professional?

Carrie:  There is the flexible audit function as well.  Flexible audits are organizational-wide audits that can be focused on specific risk areas, such as specific procedure codes or ranges, diagnoses codes, place of service, etc.  Typically this type of audit is done on a more ad-hoc vs. scheduled basis.  Flexible audits can be based on known or perceived risk and are initiated via a variety of sources; compliance hotline, payor request, OIG Workplan, etc.  

Nira: How can users report on the results?

Susan: MDaudit Professional’s combined reports allow the client to identify the types of audits that were performed in a given period of time.  For example, a user can identify the number of providers that received a ‘Semi-Annual - Review 1’ audit in a particular quarter or year. Reports are also available at the provider level to demonstrate improvement over time.

Reports can also be used to analyze the organizations compliance effectiveness and can help identify areas of focus for the next year or quarters’ work plan.

MDaudit Professional has also added a new feature, available with our next release, which allows for bell curve reporting, as well as a user-defined alert mechanism to identify provider outliers compared to normative data. The bell curve reporting feature compares E&M service billing patterns for providers to a normative data source such as CMS or UHC data. 

Nira: Where can readers go to find more information on MDaudit Professional?

Carrie: There is more information here on our website. The best way to really understand MDaudit Professional is to schedule a demonstration. You can do that by emailing us at mdaudit@hayesmanagement.com.

Nira Mahesh uses her eight years of experience in the medical industry, including scientific research, to help clients with eMAR installations, end user support and training.

Carrie Walters, RHIA, is a project manager on the MDaudit Professional support team.

Susan Horahan is a project manager for MDaudit Professional implementations.