MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to retain revenue and reduce risk, announced today the retirement of its long-time president and CEO, Peter J. Butler, effective Mar. 31, 2023. Stepping into the CEO role will be the company’s current COO, Ritesh Ramesh.
Butler will continue serving on MDaudit’s Board of Directors and as an investor, advising on future investments and growth opportunities for the company. He has been with MDaudit for 30 years, including the past 16 as president and CEO.
“My tenure with MDaudit has been truly rewarding, but it is time for me to pursue my personal goals,” said Butler, who was the visionary behind the company’s successful transition from consulting to technology. “By remaining on the board, I get the best of both worlds; the opportunity to start the next chapter of my life while supporting Ritesh as he guides MDaudit’s continued innovation and strengthens its position at the leading edge of the revenue integrity marketplace.”
Ramesh joined MDaudit in 2019 as CTO and played an integral role in the company’s conversion to a technology organization focused on supporting the healthcare industry’s evolution toward revenue integrity. In 2021, he was recognized by the Globee Awards as Chief Technology Officer of the Year in the 16th Annual IT World Awards and in 2020 won Silver in the 8th Annual CEO World Awards, Executive Achievement of the Year for Information Technology Services category. Ramesh was promoted to COO in 2021 and has been leading MDaudit’s customer and technology teams to fuel the company’s growth and ongoing innovation in the revenue integrity marketplace.
“It is an honor to take the helm of MDaudit and build upon our mission of delivering innovation through technology-enabled healthcare revenue integrity,” said Ramesh. “We have a great culture, growing customer base, and a market leading platform. We will continue to focus on delivering the next-generation tools and innovative partnerships that transform revenue cycle management and compliance strategies and empower our customers to strengthen revenues and stay ahead of regulatory risks.”
Maintaining an organization’s revenue integrity should be a constant activity for compliance and auditing staff. Consider that, despite falling claim volumes in Q3 compared to the first two quarters of 2022, the average denial per claim increased by as much as 9.6%, according to the 2022 MDaudit Annual Benchmark Report. Lag days between claims submission and initial payer response also rose by as many as 6.5 days during the same period.
For health information management (HIM) professionals, this should serve as a wakeup call to make every claim count. Increasingly, organizations are using “risk intelligent” auditing to continuously monitor risk, detect anomalies, and automate workflows to bring efficiencies to formerly manual processes. Organizations that make resolving accuracy issues in billing and coding operations a priority can help retain between 15% and 25% of overall revenue. Revenue retention is going to be as critical as revenue growth for healthcare organizations going into 2023.
Read on to learn how to help your organization keep more of its hard-earned dollars.
Leveraging data to drive outcomes
Not long ago, coding, billing, claims, and auditing processes often operated independently of one another and employed tedious and manual workflows. These processes slowed claims submissions, payments, and auditing functions that help organizations maintain compliance and monitor revenues.
These time-consuming and cumbersome processes became more problematic during the pandemic, when the very foundations of the traditional care experience were upended by a novel disease and the rise of the virtual patient visit. While providers continue to recover from these shocks to their organizations, federal payers have ramped up their efforts to ensure the accuracy of claims.
During FY 2023, the federal Health Care Fraud and Abuse Control (HCFAC) Program and the Medicaid Integrity Program will receive nearly $2.5 billion, an increase of $80 million from the previous year. Inclusive of medical review, Medicare program integrity activities had a return on investment (ROI) of $8 for each $1 spent. With such an attractive return, don’t be surprised that the breadth and depth of these activities continues to increase.
Organizations can support risk-based compliance and revenue integrity by utilizing risk intelligent auditing to mine their billing and remit data to identify billing compliance and revenue risks. The same tools can unearth key metrics focused on current risk areas to monitor provider billing patterns and even benchmark them against peers. Risk intelligent auditing helps prioritize efforts to develop corrective action plans, educate stakeholders, mitigate the need for audits, and prevent future revenue losses.
With 82% of 2022 claims denials associated with Medicare, and third-party audit volume rapidly climbing, hospitals and health systems are under intense pressure to protect and grow revenues.
These were among the key findings of the 2022 MDaudit Annual Benchmark Report released today by MDaudit, the healthcare technology company that harnesses the power of analytics and its proven track record to allow the nation’s premier healthcare organizations to retain revenue and reduce risk.
“Our analysis suggests that the post-pandemic era has given rise to a new phenomenon for healthcare. Medical spending is more discretionary for consumers impacted by inflation, driving dramatic reductions in revenues generated by physician office and hospital visits for the third quarter of 2022,” said Peter Butler, president and CEO, MDaudit. “Exacerbating this situation is the need to successfully defend against more third-party audits amidst chronic personnel and resource shortages.”
Driving Smarter Audits
Payers are investing in predictive modeling and artificial intelligence (AI) tools to scrutinize claims more closely before adjudication to reduce improper payments. The 2023 Department of Health and Human Services budget requests $2.5 billion in total investments for the Healthcare Fraud and Abuse Control and Medicaid Integrity Programs, $900 million of which is allocated for discretionary spending to advance technologies to scrutinize payment accuracy — up $26 million from 2022.
This should be a concern for healthcare organizations – and the push compliance leaders need to find more efficient ways to retain at-risk revenues. Per the MDaudit analysis:
Billing compliance leaders mustleverage data and analytics as catalysts to proactively detect risks and perform audits for corrective action. Data-driven, risk-based audits (up 28% in 2022) can complement the annual compliance plan to ensure effective audit scope coverage.
By deploying prospective (up 31% in 2022) and retrospective auditing methods, compliance teams can drive cross-functional initiatives that mitigate compliance and revenue risks.
A key element of a successful revenue defense is to help compliance teams become more efficient in managing external payer audit requests to retain at-risk revenues. The role of billing compliance needs to be increasingly data-driven and cross-functional, as well as serving as a business partner to other teams including coding, revenue integrity, finance, pharmacy, and clinical, to meet changing and more complex risks. The MDaudit analysis also found that:
The Centers for Medicare and Medicaid Services (CMS) has made no secret of its intentions to crack down on fraud, abuse, and waste, throwing more budget dollars into audits, heightening program integrity oversight of Marketplace plans, and exploring new methods of using advanced technology to conduct more rapid and thorough documentation reviews.
Historically, as CMS goes, so do commercial payers, putting healthcare organizations in the crosshairs of an unprecedented level of third-party external audits. To emerge relatively unscathed, organizations need to put in place proven processes that guide immediate and effective actions in the wake of adverse findings.
With limited time to correct the internal processes or billing practices that contributed to the problems, many organizations are turning to corrective action plans (CAPs) to streamline and accelerate their response to unfavorable outcomes. Those that do also realize the added benefit of having their chances of future billing compliance risks significantly reduced while their ability to achieve revenue integrity is enhanced.
The Audit Environment
The signs of an aggressive audit environment are everywhere. The Department of Health and Human Services (HHS), in its 2022 budget, allocated a staggering $2.6 billion to halting fraud, abuse, and waste in its Medicare and Medicaid programs – up from $180 million in 2021. A primary target is Medicare medical review of fee-for-service claims – which CMS has likely increased due to a robust rate of return to the Trust Funds (estimated to be more than $9-to-$1, based on a three-year rolling average).
The Office of the Inspector General (OIG) has also ramped up its scrutiny of how well provider organizations complied with requirements tied to the use of nearly $180 billion in Provider Relief Funds and with recently enacted mandates such as the No Surprises Act. One survey found that almost 25% of hospitals respond to as many as 2,000 external audit-related monthly requests from multiple sources. While results of many of those audits are confidential, Medicare Fee-for-Service data show a 6.26% improper payment rate in their 2021 report.
When audits by commercial payers identify problems such as overpayments, they may require the provider organization to generate and implement an actionable CAP for the relationship to continue. And while a CAP is not required when a RAC audit uncovers issues with billing practices, the offending provider organization should act swiftly to not only remedy the immediate problem – generally by refunding the overpayments – but also to identify and address any underlying practices or processes that may put the organization at risk for future issues and liability.
Audit pressure isn’t just external. Many healthcare organizations are also ramping up internal scrutiny – and they’re not always happy with the findings. When looking specifically at internal audits, the Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report from MDaudit found that more than 30% of the time, audit outcomes are unsatisfactory and have not met acceptable thresholds.
MDaudit, the healthcare technology company that harnesses the power of analytics and its proven track record to allow the nation’s premier healthcare organizations to retain revenue and reduce risk, announced today the launch of MDaudit Revenue Integrity Suite which brings fully integrated risk capabilities and supporting workflows together on a single platform.
The only end-to-end denials analytics technology designed to pre-emptively protect against revenue leakage by identifying and resolving systemic risks based on historical data and applied insights, MDaudit Revenue Integrity Suite proactively addresses the issues that lead to costly inpatient and outpatient claim denials.
“Up to 80% of denial dollars can be traced back to just 20% of denied claims – denials that are rooted in systemic issues that MDaudit Revenue Integrity Suite eradicates with a unique blend of retrospective diagnostics and predictive analytics,” said Peter Butler, president and CEO, MDaudit. “This is not just another in the industry’s long line of software that does little more than highlight coding inaccuracies without identifying the cause of denials. Rather, MDaudit Revenue Integrity Suite creates a closed-loop feedback process between insights, action, and outcomes to manage high-impact denials, making it a powerful vehicle for driving improved overall revenues.
Powered by sophisticated analytics, augmented intelligence, and expertise in providing proven revenue cycle management services and solutions to the nation’s leading healthcare provider organizations, Revenue Integrity Suite is the latest offering from MDaudit that delivers industry-leading innovation to improve outcomes through actionable analytics and empower healthcare organizations to achieve unparalleled efficiency, reduce compliance risk, and retain more revenue. MDaudit technology delivers powerful workflow automation, risk monitoring, and built-in analytics and benchmarking capabilities – all in a single integrated cloud-based platform.
MDaudit Revenue Integrity Suite gleans insights from historical data and applies them proactively to address potential denials for reasons that are either medical necessity, pricing, or treatment-related, including specialty drug and durable medical equipment (DME) utilization, thereby resolving the issues that cause high-dollar hospital claims to be denied. It features a powerful analytics engine that proactively identifies financial and clinical issues with high-value services as they are seen by payers, reducing the costliest denials and payment delays, and improving revenue and days in A/R.
By identifying, prioritizing, and addressing denial risks that have the greatest financial cost, MDaudit Revenue Integrity Suite optimizes and targets internal resources for maximum impact. It also:
Provides greater visibility of revenue risks across revenue integrity, revenue cycle, billing compliance, coding, clinical documentation, and other teams.
Supports improved financial decisions, forecasting, risk management, and strategic use of internal resources.
Informs retrospective and prospective audits, driving continuous billing compliance, coding improvements, and stakeholder education.
“In today’s macro-economic environment, healthcare organizations are necessarily hyper-focused on achieving sustainable revenue and profitability,” said MDaudit COO Ritesh Ramesh. “Their needs drive MDaudit’s continuous search for technology-enabled approaches to ensure these organizations can keep the revenue they earn with greater predictability and less risk.”
He continues: “MDaudit Revenue Integrity Suite tackles this critical problem with an innovative, data-driven, and cross-functional approach that exceeds the capabilities and ROI of the traditional solutions in this space.”
As payers step up efforts to identify and recoup improper payments, hospitals and health systems require innovative solutions to mitigate the potential threat these reviews pose to the bottom line. To meet this need, Hayes, a leading healthcare technology provider that partners with the nation’s premier healthcare organizations to improve revenue, mitigate risk and reduce operating costs, has launched External Audit Workflow to streamline management of external audit responses.
“The volume of external audits is rising exponentially as the Centers for Medicare and Medicaid Services and other payers search for every dollar they can recover from over-coded or otherwise improperly filed claims,” said Peter Butler, president and CEO, Hayes. “To protect their hard-earned revenues and reputations, healthcare organizations need a strong first line of defense – an external audit management process that is collaborative, efficient, and comprehensive. That is Hayes’ goal with the launch of MDaudit Enterprise External Audit Workflow.”
MDaudit Enterprise External Audit Workflow simplifies and automates time-consuming and inefficient manual processes for tracking third-party audit requests, including commercial payers, Recovery Audit Contractors (RAC), Targeted Probe and Educate (TPE), and Comprehensive Error Rate Testing (CERT). Its flexible process templates and reporting tools deliver operational efficiencies and insights on potential risks and provide a consistent and repeatable audit response process.
With External Audit Workflow, hospitals and health systems gain access to tools that bring together all their external audit management activities into a secure HIPAA-compliant SaaS-based platform.
Bundling errors continue to wreak havoc on hospital bottom lines in 2021, causing 34% of inpatient charge denials with an average value of $5,300 each. That’s according to an auditing and revenue integrity report analyzing more than $100 billion worth of denials and $2.5 billion in audited claims released today by Hayes, makers of MDaudit, the industry’s leading integrated auditing, billing compliance and revenue integrity platform for the nation’s premier healthcare organizations.
Focusing on denial trends, bundling was the top category for both inpatient and outpatient charge denials – the latter of which had an average value of $585 for each denied claim. The top reason was that the benefit had been included in a previously adjudicated service or procedure. Professional services had a first-time denial rate of 15%, led by claim submission/billing errors and carrying an average value of $283 each, while COVID-19 claims continue to attract higher denial rates from both commercial and federal payers.
“With the pandemic driving projected losses over $100 billion this year, hospitals and healthcare organizations are under intense pressure to optimize revenue flow and reduce compliance risk,” said Peter Butler, CEO, Hayes. “Gaining control over denials by focusing on both auditing and training providers and coders to improve documentation is a logical first step – particularly given that 43% of rendering providers and 27% of hospital coders fail internal audits and auditors have ‘disagree’ findings about 33% of the time. Left unaddressed, this is a huge revenue and compliance risk for organizations.”