Stay ready for NCQA and CMS audits with these record retrieval strategies

Even though preparing for an audit can be one of the most stress-inducing activities an organization goes through, healthcare organizations in particular know that they are a regular part of operations. Every year, health plans have to prepare for the National Committee on Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) audits and to validate the accuracy of risk adjustment and HEDIS data.

To make sure you’re prepared and avoid the panic-inducing rush audits often entail, make sure your medical record retrieval process is accurate, efficient, and fast. To make retrieval smoother, ensure the accuracy of your data, and provide comprehensive reporting when the time for an audit comes around, consider implementing advanced technology. Here’s what to consider when looking for medical record retrieval technology that will keep your health plan audit-ready all year.

Why staying prepared for NCQA and CMS audits is critical

Health plans know just how important CMS and NCQA audits are to their financial sustainability. Still, understanding just how much of an impact an audit can have on your bottom line is important to building consensus around preparedness strategies.  

Starting this year, all Medicare Advantage plans will undergo RADV audits (Risk Adjustment Data Validation). The process is meant to ensure plans receive payments align with the level of risk in their member population, estimated through the risk adjustment process. Unfortunately, inaccurate payments can happen unintentionally when the data you provide to CMS is inaccurate or incomplete.  

When findings of inaccurate risk adjustment data occur that have resulted from overpayments, the penalty can add up to hundreds of millions of dollars in recoupments. Plans are subject to other penalties that can result from inaccurate risk adjustment data from both the False Claims Act, which can result in fines of 3X the overpayment amount plus $11,000, and the Department of Labor, which often results in penalties up to $2,700 per violation.

NCQA also conducts annual audits to verify the accuracy of the your HEDIS measures. Inaccurate HEDIS data can result in inaccurate payments tied to Star Ratings. They can also lead to the loss or downgrade of your accreditation.

Compliance with CMS and NCQA rules and regulations, and the ability to verify the integrity of your data during an audit, is about far more than checking a box. Avoiding penalties, reputational damage, and loss of accreditation is critical to your health plan’s sustained success.  

What are the key steps in the medical record retrieval process?

Because the accuracy of the data you provide to CMS and NCQA during initial submissions and audits is so important, every health plan needs a sophisticated data management strategy in place. Medical record retrieval is foundational to this data management strategy.  

The medical record retrieval process begins with ensuring that all of your provider data is up to date so that you can automate provider outreach. A provider scrub here is essential, making sure you account for any provider consolidation or other changes. Then, automated provider outreach, at customizable cadences, can efficiently deliver packets to providers for easy record submission. Providers should then be able to securely submit their records, with data capture, document routing to the correct member, and validation of the data.

The retrieval process can be a huge lift, requiring a significant investment in staff time and advanced technology. To stay audit-ready and ensure a high level of data integrity, health plans need powerful and efficient strategies for audit-ready record retrieval.

Your CMS audit checklist for advanced record retrieval

Artificial Intelligence (AI) in healthcare and intelligent automation can take medical record retrieval from stressful to simple. Using advanced technology to power everything from provider outreach to data validation, you can enhance your data integrity to stay ready for CMS and NCQA audits.

Begin by automating provider outreach to free up and focus staff time.

Health plans that begin the process of provider outreach early in reporting season will be more prepared for submissions and audits, saving valuable staff time. To be prepared right out of the gate, use intelligent automation to generate and deliver provider packets. Intelligent automation can also help to identify chases based on specific criteria, allowing automated follow-up statements.  

AI-powered technology can also flag validated addresses so that staff can focus their time and attention on potentially inaccurate addresses. Being able to group providers according to their location, volume, and responsiveness can help prioritize chases to improve turnaround times. Finally, integrated pend management allows you to assign a dedicated team to handle volume sites or unresponsive providers. Integrating AI and intelligent automation into the outreach process makes the retrieval process more efficient and allows staff to focus more on data integrity over manual tasks.

Make sure your retrieval solution allows for multiple, seamless options for data exchange.

It’s also critical that providers have flexibility in how they upload records. This makes it easier for providers to respond quickly, improving turnaround times. Then, all submitted data has to be seamlessly integrated into one centralized system. Powerful retrieval solutions should allow for secure portal upload along with mail, fax, or email, depending on provider preference.

Additionally, any reliable retrieval solution should offer seamless integration with leading EHRs, making automated, digital retrieval simple. This option results in incredible time-savings for health plans and providers both, making retrieval something that can run in the background as opposed to draining limited time and resources.

Prioritize security in medical record retrieval.

Audit-ready retrieval solutions not only simplify the entire process, they do so while making data security a top priority. Even as you offer flexible options for data exchange, every option must be highly secure and HIPAA-compliant. This entails enabling proper access controls, using encrypted data transfers and digital storage, and maintaining accurate audit trails with access logs.

Going even further than HIPAA, record retrieval technology partners should be HITRUST-CSF certified, offering even more stringent security standards for protected health information (PHI). When you have peace of mind when it comes to the exchange of critical PHI, you can experience expedient, audit-ready data exchange while minimizing security risks.

Implement technology that centralizes data for cohesive reporting.

Finally, audit-ready medical record retrieval entails integrating data sources into one, holistic view. First, technology should be able to pull data from disparate EHRs and combine data points with differing unites of measurement into one default format. Retrieval technology should also be able to pull any relevant data from unstructured clinical notes using natural language processing. Then, using the power of AI, it should seamlessly route documents to the right member profile.

When there are any inconsistencies in the data, including potential data gaps or errors, you should be able to rely on your retrieval technology to flag them. That way, staff can focus on validating errors, not on the time-consuming task of integrating data from disparate formats. This process helps reduce errors and improve data accuracy, making audits smoother and less likely to result in penalties.

Finding the right medical record retrieval partner

As you consider technology partners to help you stay NCQA and CMS audit-ready, look for solutions that can help you implement the CMS audit checklist for record retrieval above. Introducing AI and intelligent automation, advanced data security, as well as flexibility and a high level of data integrity make a significant difference in audit preparations while also saving staff time.

Powerful, audit-ready record retrieval technology should help you:

• Improve outreach efficiency by 50%

• Save over 1,400 hours of staff time

• Process over 96,000 pages an hour

Check out our case study demonstrating the power of advanced medical record retrieval in simplifying audit preparation and learn how Learn how Reveleer’s retrieval technology can keep you audit-ready year-round.