The most frequent question we hear from our clients: How are other companies doing that?

There is a need for a forum for the discussion and sharing of audit best practices, insights, benchmarks, and challenges on common audit topics of interest.

Datamethod hosts a free Audit Webinar Series to help address that need… to give you a place to hear what others in like positions are doing – how they are managing their QA work – to build a forum for an open exchange of ideas covering ‘all things audit’.

Below are upcoming webinar topics that are scheduled, including a brief description of the goals for each session and access for event registration.

We are happy to schedule a custom webinar session for your team on any of the below topics.

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    Webinar Topics

    Auditing Benefit Configuration

    • Our research indicates that a typical member is impacted by 5 to 8 configuration changes each year
    • 27% of Benefit Configuration errors result from incomplete or incorrect plan and product documentation
    • With ever increasing levels of auto-adjudication, Configuration impacts everything – payment integrity, service levels and regulatory compliance
    • An estimated 42% of Benefit Configuration errors result from inadequate testing
    • Over 70% of Financial Claim Errors relate to incorrect Benefit or Pricing Configuration.

    Corrective Action Plans – When Process Workflows Really Matter

    • Corrective Action Plans vary based on their scope and purpose.
    • A CAP plan model will be different based on the business need – a Regulated CAP, defined by some federal or state agency – a Business CAP, which may be defined by the company or leadership and, a Condition-specific CAP which may stem from internal audits and/or regressive testing protocols.
    • On average, a CAP requires 41 different ‘touches’ from its identification through to remediation and final closure.
    • Average turnaround time for CAP handling is 53 days from identification through to final closure.

    Audit Results – What’s Important to You?

    • Audit Purpose drives reporting results – specifically those differences that result between ‘Regulated vs. Non-Regulated’ audit segments
    • On average, over 85% of audit staff are generally working on support of Regulated Audit tasks.
    • Typically, the focus of Regulated Audits is aimed at providing accuracy and/or quality metrics for the organization
    • Non-Regulated audits are generally more directed at specific opportunity or financial issues.

    What Are You Auditing and Why?

    • Rules for selection of the right sample are typically dictated by:
      • Audit Scope and Purpose
      • Regulated Audit Requirements
      • Specific Company Policies
    • Over 75% of clients incorporate some form of Stratification segment in their audit sampling protocol.
    • Common ‘Gotcha’s that impact sampling and selection for audits include issues like:
      • Adjusted Claims
      • Denied Claims
      • Population ‘Exclusions’

    Audit Selection – Random vs. Stratified Sampling – What’s the Impact?

    • Most Regulated Audits require some form of an ‘End-to-End’ audit protocol. Often the actual audit controls are split between departments. On average, 43% of companies have their Audit Team conduct the full scope of an end-to-end audit, while 22% of companies divide the individual audit steps into various departmental control.
    • 3-7% of all Member and Provider calls to Customer Service identify new operational or system issues in Claims, Config and Enrolment processes.
    • 68% of organizations have found that conducing routine structured audits overseeing their Appeal and Grievances had helped to build more effective workflow and compliance practices.

    Provider Contract Configuration Audits

    • Configuration is critical as ‘auto-adjudication’ rates manage over 80% of claims payments
    • On average, each member is impacted by 5 to 8 Configuration Changes per year
    • Typically, 100% of Configuration Changes are tested:
      • 30% are tested by the Config department, pre-production
      • 70% tested in production
      • Additional 27% performed a Separate Claim Audit to validate Config settings / changes
    • The average Configuration Analyst can complete 2 to 5 Contracts per Day.

    PrePayment Audits – There’s More than High Dollar Claims Swimming in This Pool!

    • Typically, 10% of Audited Claims are managed in a PrePayment protocol.
    • On Average, 33% of Audited Dollars are reviewed in a PrePayment audit process.
    • PrePayment audits are identifying an average of 2% Financial Error Rate on Claims in excess of $25,000
    • PrePayment auditing requires a sensitive balance to manage overall clam timeliness.
    • Average audit turnaround on PrePayment work is about 3 business days.

    Error Category Selections – Do You Really Know What’s in your Audit Errors?

    • As Much as 50% of Audit Errors are Categorized Incorrectly or Inconsistently by the Audit Staff.
    • On Average of 25% of Audit Errors are Categorized Using a Code of ‘Other’ or Nondescript / Non-specific Categories – Not very helpful when trying to prepare remediation or results reporting.
    • Incorrect Error Categorization can Lead to as much as 28% More Work – through increased appeals or delays in Recovery / Remediation.

    Appeals and Rebuttals – Preventing Error Runaround

    • On average, about 25% of claim audit errors are appealed (responder doesn’t agree with error)
    • Over One Quarter of audit staff time is spent on managing Appeals and Rebuttals
    • Appeals take between 35% to 55% more work to complete
    • Nearly 20% of appeals stem from poor or incomplete audit error notes and documentation

    Auditing Adjustments

    • On average, 3% to 5% of claims posted are adjustments to an original claim.
    • 70% of adjusted claims are positive – paying more to the provider.
    • Nearly twice as many errors are found in adjusted claims than the original claim processed.

    Audit the Auditor

    • Only 50% of health plans perform ATA audits on a routine, scheduled basis.
    • 25% to 50% of auditors select incorrect or inconsistent Error Categories for classification