THE MEDICAL AUDITOR A rare gem

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By Ms. Mercy N. Bukania

It was another lazy afternoon, where the sun was overhead and steaming hot. I had finished my petty errands in one part of the city and was too lazy to use public means to my next destination. Instead I chose to get the services of online taxis’ since they are much more dependable than before; upon scrolling my phone and pressing a few buttons, the taxi driver arrived in what seemed like seconds.

While in the taxi, I had an interesting discussion with the driver who opened up on some of the challenges he was encountering with our healthcare system. He informed me that his mother had just been discharged from hospital but he was not satisfied with the quality of services that had been rendered to them while she was there. One of the questions I candidly asked myself was; as an auditor, can I also add value to healthcare systems? Is it farfetched? This challenged me to think about the state of medical auditing in Kenya. What is it all about? Is it relevant? Should the internal audit profession pay attention to this field? While conducting my research on the pertinent issue, I came across a job vacancy for a hospital in Kenya that required the services of a medical auditor, however the only competences required were ‘5 years in the healthcare industry’.

I therefore asked myself whether this would suffice to enable the hospital improve its healthcare systems or was this enough? Was there need for more competencies to understand the complex nature of healthcare terminologies and practices? I decided to conduct a small research on the medical auditing field and found that there appears to be no specific professional institutions in Kenya that have a focus in this field however in the United States of America there are institutions that define the practice.

There could possibly be more countries that implement the practice however, I found this particular one intriguing. For instance, the American Academy of Professional Coders (AAPC) states that quality health care is based on accurate and complete clinical documentation in the medical record. The best way to improve your clinical documentation and the livelihood of your health care organization is through medical record audits. They are necessary to determine areas that require improvements and corrections. The key objectives of an audit is to enable a healthcare provider to provide efficient and better delivery of care as well as improve their financial health. Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by physician documentation. Once areas of weakness are revealed through an audit, you can present the audit findings with recommendations and identify opportunities for training where necessary to improve operations in the health care organization.

What Is Medical Auditing and Why Perform One? According to the American Academy of Professional Coders (AAPC) medical auditing is a process that entails conducting internal or external reviews of coding accuracy, policies, and procedures to ensure you are running an efficient and hopefully liability-free operation. It further gives the following reasons for performing medical audits;

a)To determine outliers before large payers find them in their claims software and request an internal audit be done.

b)To protect against fraudulent claims and billing activity

c) To reveal whether there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.

d)To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

e)To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door

f )To remedy under coding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures

g)To identify reimbursement deficiencies and opportunities for appropriate reimbursement.

h)To stop the use of outdated or incorrect codes for procedures i) To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness.

The question that profoundly lingered in my mind was; is there a certification for a medical auditor in Kenya? Well, not one that I have encountered in my career as an auditor. However, in the United States of America, the Certified Professional Medical Auditor (CPMA) is a credential with a focus on Medical auditing which is a critical piece to compliant and profitable physician practices. Whether its Recovery Audit Contractor (RAC) audits, private payer denials, or just peace of mind, more physicians plan to have audits conducted regularly. The risks of being non-compliant with documentation and coding are too great. The benefits of which are to enable the certified practitioner to use their proven knowledge of coding and documentation guidelines to improve the revenue cycle of nearly all healthcare practices. Certified medical auditors demonstrate expertise in:

  • Medical documentation, fraud, abuse, and penalties for documentation and coding violations based on governmental guidelines
  • Coding Concepts
  • Scope and Statistical Sampling Methodologies
  • Medical Record Auditing Skills and Abstraction Ability
  • Quality Assurance and Coding Risk Analysis
  • Communication of Results and Findings
  • The Medical Record Exploring opportunities for medical auditing

The American Academy of Professional Coders (AAPC) and the American Association of Medical Audit Specialists (AAMAS) offer numerous certification options for medical auditors. Both professional associations require exam candidates to be members of the organization in order to take the exams. The exams cover similar domains, or knowledge areas, including medical record standards and documentation, coding and documentation compliance, and auditing functions. The certified professional medical auditor and certified medical audit specialist are some of the key certifications offered for medical auditing. Is it possible for a similar opportunity to be explored in Kenya to improve our healthcare systems? I leave that to you the reader to ponder over. The Certified Professional Medical Auditor (CPMA) According to the AAPC, the Certified Professional Medical Auditor credential does not require documented experience as a medical auditor, but at least two years of experience in medical auditing is strongly recommended, as AAPC says this is a difficult, high-level exam. The association suggests that candidates have prior coding certification before attempting this exam, as well as significant experience with a variety of audits, including E/M services, compliance, regulatory information, coding, modifiers, and the National Correct Coding Initiative (NCCI).

The CPMA exam consists of 150 multiple choice questions, with domains covering medical record standards and documentation, compliance, coding and reimbursement including E/M coding, audit scope, statistical sampling, and validation. A third of the exam tests medical record auditing abstraction skills over 24 cases, including surgery, physical therapy, radiology, psychiatry, hematology and oncology, and infusion services. In the Kenyan context, there are various existing professional bodies which auditors can choose to be members of, however, there is no specific certification that focuses on medical auditing and more so on the technical aspects of the medical field. Is this a field auditors should explore? As an auditor and a frequent user of healthcare systems, I believe auditors can play a key role in improving the efficiency and effectiveness of healthcare systems. Although auditors who currently work in the medical field possess the necessary skills and competencies to offer auditing and assurance services, I am of the opinion that there is still more value that the audit profession in Kenya can add to the medical field in Kenya through the initiation of a robust medical auditing programme. marceybukania@gmail.com

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