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.
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.
As we face the third year of the global pandemic, hospitals and health systems are desperate to shore up bottom lines that have been battered by ongoing financial losses projected to exceed $100 billion in 2021. The key to undoing some of the financial damage is optimizing revenue flow and reducing compliance risk, which requires an understanding of the exact driving forces behind the devastating losses.
For many healthcare organizations, the primary problem can be traced to bundling errors, COVID-19 claim denials, and a range of coding issues.
That’s according to Hayes’ inaugural auditing and revenue integrity report, Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report, which analyzed more than $100 billion worth of denials and $2.5 billion in audited claims. It found that bundling errors were the top culprit behind the 34% of inpatient hospital charge initially denied in 2021, each with an average value of $5,300. Internal auditors also identified a significant number of concerns centered around disagreements between procedure codes and diagnoses, contributing to 33% of all internal audits containing “disagree” findings.
Understanding the Drivers
The report is based on a review of professional and hospital claims, including current charge and remit data sent to all payer types, audited in the company’s revenue integrity platform, MDaudit Enterprise, during the first 10 months of 2021. It includes more than 900 facilities, 50,000 providers, 1,500 coders and 700 auditors from U.S.-based acute care and children’s hospitals, academic medical centers, healthcare systems, and single and multi-specialty physician groups.
In terms of denial trends, the report identified bundling as the top category for both inpatient and outpatient hospital 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.
Under- and over-coding were also identified as problematic. In terms of revenue risk, audits indicate that under-coding created underpayments averaging $3,200 for a hospital claim and $64 for a professional claim. In terms of over-coding, Medicare Advantage plans and payers in particular are under heightened scrutiny for expensive inpatient medical necessity claims, drug charges, and clinical documentation to justify the final reimbursement.
Hayes, makers of integrated compliance and revenue integrity platform for the nation’s premier healthcare organizations, announced that it has entered a strategic partnership with ThoughtSpot, the leader in search and AI-driven analytics, to develop solutions that empower healthcare organizations to proactively manage and mitigate revenue and compliance risks.
Hayes’ flagship revenue integrity software platform, MDaudit Enterprise, is a powerful, cloud-based risk monitoring solution used by the nation’s foremost academic medical centers, hospitals and physician groups.
MDaudit is an enterprise-class platform that enables organizations to efficiently monitor medical claims for billing and coding accuracy, ensuring compliance with government and commercial payer requirements and maximizing the attainable level of revenue.
The platform accelerates productivity for revenue cycle and compliance professionals by providing workflow automation, risk monitoring, built-in analytics and benchmarking capabilities – all in a single, integrated platform. In the market since 2003, MDaudit is currently used to audit one in eight providers in the U.S.
The partnership will focus on integrating healthcare billing, compliance and revenue integrity domain expertise from Hayes and ThoughtSpot’s search and AI-powered platform into a single, comprehensive enterprise solution.
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,