16th Annual NAMAS Conference

So, You Got "The Letter"Retrospective payer audits wield a significant influence on your organization.

Prior to addressing the needs of healthcare compliance to ensure accuracy and integrity in billing and reimbursement processes, it is essential to grasp the workings of the payer audit system thoroughly.

Our session commences with identifying the key stakeholders and their roles as audit requestors. However, each audit requestor pursues distinct objectives and operates differently. Therefore, we will examine and contrast their objectives, methodologies, and areas of focus. Additionally, we will explore the implications of these audits for healthcare providers, including potential financial impacts, compliance obligations, and effective response strategies.

"Where do we go from here?" Receiving a recoupment letter from an insurance company can be daunting as it signals the need for a strategic response to ensure compliance and mitigate financial impact.

In our session, we will delve into effective strategies for navigating this challenge, placing a strong emphasis on collaborating with the Compliance Committee to adopt a comprehensive audit approach. Participants will learn how to formulate a strategic audit plan tailored to address recoupment letters, with a focus on achieving both regulatory compliance and financial recovery. We will also discuss the legal implications associated with audits triggered by recoupment letters and emphasize the critical role of the Compliance Committee in devising audit responses that align with compliance standards and organizational policies.

Additionally, the session will explore various factors that influence the decision-making process when selecting audit approaches, whether it involves utilizing internal audit capabilities, engaging external auditors, or invoking attorney-client privilege with legal counsel. Lastly, attendees will identify the specific roles and responsibilities that Compliance Committee members hold in audit preparation, spanning from initial assessment through to the implementation of corrective actions. discrepancies and implementing corrective measures.

"Who's on First, What's on Second."
Receiving a notification from a payer initiates a critical phase that demands a meticulous approach to ensure compliance and financial stability.

This session provides a comprehensive, step-by-step guide to structuring audits in alignment with specific audit scopes and payer policies. Participants will learn how to effectively define and refine audit scopes to address the specifics outlined in payer notifications. Practical methods for incorporating National Correct Coding Initiative (NCCI) edits, and Current Procedural Terminology (CPT) guidelines into audit procedures will be explored, enhancing accuracy and compliance by identifying and addressing coding discrepancies.

Best practices for integrating Clinical Documentation Improvement (CDI) strategies specific to ICD-10-CM coding will also be covered, ensuring thorough documentation review essential for compliance and optimized reimbursement. Essential techniques for conducting comprehensive documentation reviews will be emphasized, focusing on thoroughness and compliance with payer guidelines to mitigate audit discrepancies. Participants will gain insights into effectively applying payer-specific policies and coding guidelines during audit processes to ensure audits are conducted accurately and in alignment with payer expectations.

The session will also explore the optimal use of coding and compliance tools to streamline audit workflows, enhancing efficiency, accuracy, and overall audit outcomes. Through practical insights and real-world examples, attendees will be equipped to confidently navigate payer notifications, leveraging structured audit approaches that uphold compliance and financial integrity.

"When Things Get Real" focuses on the critical steps in reporting audit findings and developing actionable plans based on those findings.

Participants will learn essential techniques for compiling and presenting audit results effectively to stakeholders. This includes strategies for creating comprehensive action plans encompassing education, disciplinary actions, and potential refunds for overpayments.

The session emphasizes the importance of engaging stakeholders and ensuring transparency throughout the audit process. Participants will gain insights into effectively communicating audit findings to relevant parties, fostering understanding and collaboration. Key topics covered include understanding the processes for handling overpayment refunds and implementing compliance education initiatives based on audit outcomes.

By the end of the session, attendees will be equipped with practical skills and strategies to navigate the complexities of reporting audit findings, developing actionable plans, and promoting compliance within their organizations.

In the session "Making the Best Better," participants will explore strategies for continuous improvement in compliance processes to mitigate future audits effectively.

Key topics include developing strategies for continuous monitoring and risk assessment to preemptively address potential audit triggers. Participants will also learn how to leverage technology and data analytics to enhance compliance monitoring and management, promoting proactive identification and mitigation of compliance risks.

The session will emphasize the importance of fostering a culture of compliance and continuous learning within the organization. Attendees will gain insights into implementing continuous improvement initiatives that integrate data-driven decision-making and enhance overall compliance efficacy.

Participants will be equipped with practical tools and approaches to drive continuous improvement in compliance processes, foster proactive compliance management through technology and analytics, and cultivate a culture that prioritizes ongoing learning and adherence to regulatory standards.