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Top 4 Clinical Charge Audit Trends in 2024

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1. Trends Seen in the Increase of Downgrades for Emergency Department Level Visits

Many payers are developing proprietary algorithms for determining their own Emergency Department Levels for payment. These algorithms often times use a combination of diagnosis codes, presenting problems, procedures, and treatments performed. Managed Resources can provide comprehensive support in addressing payer downgrades of billed Emergency Department level charges. Our expertise ensures that all services and procedures are accurately documented and billed at the appropriate levels to reduce the risk of missing items resulting in payer downgrades. 

2. Trends in Missing/Inaccurate Infusion & Injection Charges in Emergency & Observation Claims

Accurate Injection and Infusion charging and Observation charging are critical to a healthcare facility. Properly capturing and billing these services ensures that the facility is reimbursed for the full scope of care provided. Inaccurate or incomplete charges can lead to significant revenue loss and financial discrepancies, undermining the facility’s financial health. Precise I&I and Observation charging helps maintain compliance with payer guidelines and reduces the risk of audits. Managed Resources’ Registered Nurses can provide industry leading support for accurate I&I and Observation charging

3. OIG is Proposing an Inpatient Rehabilitation Facility Nationwide Audit for 2024

As published by the Office of the Inspector General (OIG):

“Inpatient rehabilitation facilities (IRFs) provide intensive inpatient rehabilitation therapy for patients who have complex nursing, medical management, and rehabilitation needs that require hospital-level treatment in an inpatient environment. In fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The Centers for Medicare & Medicaid Services (CMS) has consistently found high IRF error rates through its Comprehensive Error Rate Testing program. For an IRF claim to be considered reasonable and necessary, it must meet certain coverage and documentation requirements. We issued a nationwide audit of IRF claims in September 2018, Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements (A-01-15-00500), that found that medical record documentation for 175 of 220 sampled IRF stays did not support that the IRF care was reasonable and necessary in accordance with Medicare requirements. Our Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates.

“In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program. This audit will be an independent performance audit in accordance with Generally Accepted Government Auditing Standards.”

4. Trends in EMR Conversions

During new EMR implementation, charge/compliance charge audits are crucial in maintaining billing accuracy and regulatory adherence. With the transition to a different EMR system, the risk of missing charges, incorrect cost centers, and missing J Codes/HCPCS codes can increase due to system errors or improper workflows. Charge audits help identify and correct these issues, ensuring that all services provided are accurately billed, ensuring timely and proper reimbursement. Post-implementation audits ensure that healthcare facilities can optimize their billing processes, enhance revenue integrity, and maintain compliance in an increasingly complex regulatory environment. Managed Resources can provide both charge audits and compliance audits to ensure charging integrity.

Charge Audit Program Assessment

Learn how to improve revenue cycle operations, increase revenue recovery and maintain compliance with a free charge audit program assessment from the team at Managed Resources.

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