Payment integrity audits–the process of ensuring that payments to providers are accurate–can be a costly and time-consuming proposition for providers. Payers or their third-party vendors routinely audit claims to ensure providers applied appropriate care, utilization, and billing codes.

But how abrasive is the process? And are there any ways to minimize the impact on payer-provider relationships? Change Healthcare commissioned Frost & Sullivan to look into this issue. The results are eye opening and informative for both payers and providers.

On this episode of the Change Healthcare podcast, Dave Cardelle, vice president of Payment Integrity and Coding Advisor Solutions at Change Healthcare, shares what was learned from the research. Here’s what was covered:

  • What drove the research into DRG audits, and what was involved (03:29)
  • Top-line research takeaways (07:33)
  • How the payment audit process works (13:24)
  • Is potential damage from audits to provider relationships rooted in cost, administrative burden, or time requirements? (17:01)
  • How providers can tackle the volume of payers’ medical record requests (21:13)
  • How to improve the audit process (23:28)
  • Provider sentiment on pre-submission notification (27:30)
  • How payers can evolve their payment integrity programs to improve provider relationships (31:21)
  • The medical record request process (34:01)
  • Many providers have no idea what payment audits cost their organization (36:59)
  • Who’s outsourcing, and why (38:38)
  • Payers’ use of “stacked vendor” auditing processes and the risks (39:36)
  • What payment audits costing payers and providers (43:15)

Episode Resources

  1. Dave Cardelle’s bio
  2. Research: The Impact of DRG Audits on Provider Sentiment and Abrasion
  3. Change Healthcare Study Reveals Impact of Payment Audits on Payer-Provider Relationships
  4. Change Healthcare Coding Advisor
  5. Frost & Sullivan

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