Auditing and reporting are – and have long been – a significant part of administering healthcare. Organizations ranging from CMS to large and small payers require their healthcare delivery partners to track and report on activities that affect member populations and costs. Unfortunately, this adds administrative work to an already-overloaded workforce. Without the right tools to improve reporting and streamline the audit process, staff members can quickly feel overwhelmed with all they have to accomplish to meet Medicare Advantage, Medicaid, accountable care organization (ACO), and commercial payer requirements.
The Centers for Medicare and Medicaid Services (CMS) gets a lot of attention for the extensive administrative requirements to participate in programs like Medicare Advantage, Medicaid, and capitation in ACOs. But over the last decade, many commercial payers have rolled out their own capitated payment programs with similar reporting requirements. Many also have a similar audit structure to ensure compliance for provider organizations participating in these programs.
These additional administrative requirements add to a frustrating workload for clinical and nonclinical staff. It can also lead to potentially severe penalties for organizations that cannot produce an audit trail of required activities.
The wide range of organizations participating in capitated payment programs also complicates reporting and compliance. Unsurprisingly, every payer has its own unique requirements for tracking and reporting on things like encounters, utilization, authorizations, and denials. These requirements can be very detailed, down to the font you have to use in denial letters or the way words wrap at the end of each line for authorization communications.
Keeping track of these specific requirements, and complying with them for every patient in a capitated payment program, is time-consuming for staff. Since requirements can regularly change, keeping up with the specific date to switch from one letter format to another or what language to use in denials adds more complication to an already overwhelming process.
But organizations must be able to demonstrate in regular audits that they meet all the requirements set forth by the payer. Compiling this information is another time-consuming task, particularly when the required information in an audit can come from multiple places within an organization’s software platform.
Cedar Gate’s Capitation Adjudication software has been around for decades, providing organizations with tools to seamlessly administer capitated payment programs. It also provides the tools healthcare delivery organizations need to satisfy a wide range of compliance and reporting requirements. That includes:
Audits are another hurdle for organizations participating in capitated payment programs, whether it’s through CMS or commercial payers. These can be onerous and difficult for staff, particularly when it requires extensive manual work to compile all the necessary items for auditors to review.
Fortunately, there are ways to simplify the audit process. Cedar Gate worked with payer clients administering capitation programs to discover the specific items they wanted to see during an audit, then built a software module to streamline data collection and presentation. The auditing and compliance module pulls together all the necessary information (by payer) into a succinct dashboard. Auditors can quickly verify compliance with documentation, utilization, and encounters. Information is stored in a format that cannot be modified or altered, giving payers confidence that it has not been manipulated.
Additionally, the underlying data to support the audit is housed in Cedar Gate’s NoSQL database. Auditors and staff assisting with the audit process can dig into the data to generate whatever reports are necessary without waiting for a response from IT, pushing out information to appropriate users based on predefined roles and data security protocols. Custom configurations provide reports in whatever format a health plan or payer needs.
With Cedar Gate’s composable software, organizations participating in capitated payment models can comply with a wide variety of payer requirements. The self-service design, backed with support from capitation experts who have worked in this alternative payment model for decades, provides the tools to succeed.
