Claims Audits: RACs, MACs, MICs...

Today the volume and complexity of audits and appeals has grown too high, too fast to manage.

Reactively, you know you need an automated workflow solution to increase the efficiency and accuracy of all your claims-based audits. But to get out ahead — to proactively reduce your audit risk — you need to add predictive analytics and you must keep up to date with the daily changes to the regulations.

Start with Business Intelligence / Predictive Analytics

Use business intelligence to not only proactively mitigate your audit-related risk, but also to uncover coding, compliance and reimbursement risks and opportunities hidden in provider claims and other detail data:

  • Underpayments and overpayments due to coding and/or documentation
  • Recovery audit targets
  • Quality issues
  • Medical Necessity targets
  • CERT, MIC, MAC, PSC, and OIG targets
  • CC/MCC Capture Rates
  • Underbilled and unbilled services (Lost Charges)

Track any Claims-Based Audit from letter to last appeal.

To truly manage the entire life cycle of all your financial audits, you’ll need to track and manage the decision workflow through every appeal:

  • Maintain audit trails for all correspondence, detailing claim-level tracking from initial request through multiple levels of appeal
  • Focus the efforts of audit response teams on the overall process, eliminate redundant manual processes, and document the audit impact for facility management and board members
  • Detect, analyze, report on, and predict trends using standard and customized reports for every level of detail throughout the audit process

Ensure program integrity and minimize denials.

You need real-time updates on regulatory changes and updates to ensure program and revenue integrity, including:

  • Electronic coding content for HCPCS, CPT®, NCCI, ICD-9-CM, ICD-10-CM, ICD-10-PCS, GEMs, APC, Physician Fee Schedule (RVU), MS-DRG, MUEs, PQRS Cross Coding, and Drugs (NDC)
  • Payment groupers/calculators for RVU, IPPS/MS-DRG, OPPS/APC, SNF, LTCH, IPF, IRF, Physician Fee Schedule/RVU, and payment system final rule e-books
  • CMS Manuals and FAQs, Comprehensive archives of Medicare Transmittals, MLN Matters and Job Aids
  • Medical necessity resources including NCDs and LCDs for all payers, including archives.,
  • Specialty libraries for Health Reform, HIPAA, Part D, Stark, EMTALA, Quality, Coding Guidance, MMA and PPS
  • State health care regulations, legislation and Medicaid manuals

Wolters Kluwer has partnered to develop a complete end-to-end software solution for efficiently and effectively managing the entire process for all financial audits, both RAC and non-RAC. Our solution will allow you to attain actual financial return on your investment without an investment in additional staff.