Services are denied and hospitals are not receiving their entitled reimbursement. Or, maybe, they are violating Medicare’s compliance guidelines and receiving over-payments. Either way, these are critical issues. The combined revenue loss and compliance risk have created a significant challenge for CFO’s, Compliance Officers and other management level personnel in the reimbursement revenue cycle. With ever-increasing focus on governance, risk and compliance, HIPPA pressure, ever-changing payer requirements, and complex regulations, internal audit departments are facing escalating pressure and heavier workloads.

APC AuditPro™

APC AuditPro™ is the first and best solution to perform internal outpatient audit functions for Medicare encounters. This first of its kind program tabulates revenue impact and logs each audit in compliance with Medicare guidelines.

APC AuditPro™ is the ultimate solution to your expanded oversight and compliance initiatives as it is:

  • Comprehensive – No need for multiple solutions
  • Easy to Use – Fast and user-friendly
  • Efficient – Reduces risk
  • Empowering – Allows internal auditors to be confident
  • Encompassing – Increases financial bottom-line
  • Powerful – Correct and timely information
  • Precise – Accurate results
  • Productive – Enhances efficiency 
Quick – Reduces time and cost in audit process
  • Reliable – Consistent and dependable audits

APC AuditPro™ process is easy to use:

Flexible and Powerful

  • APC AuditPro™ can either be installed locally to run in a stand-alone Windows environment; or, installed on your secure server and accessed through a Web Interface.
  • Medicare data is updated on a quarterly basis, or as necessary automatically.
  • APC AuditPro™ can house an unlimited amount of audits and claims.
  • Each audit houses the sample of claims determined by you.
  • Medicare data is stores perpetually, and the reimbursement calculations are time sensitive to the date of service of the claims in each sample set

Facilitates Audits

  • Each Encounter (Claim) houses the Account #, Medical Record#, Date of Service, Bill Type and Payor.
  • Each claim can be categorized as: Ambulatory Surgery – ASU; Emergency Department – ED; Diagnostic – OPD; or Observation – OBSV.
  • Through Tabs and Check Boxes, auditors can identify what they found wrong with the claim (Claim Analysis).
  • Comments can be entered in the comments fields.
  • Claims data can be imported electronically or manually entered.
  • Each Encounter has 3 parts: Coded Claim; Submitted Claim; Corrected Claim.
  • Coded Claim comes from a combination of the HIM coding face-sheet and the itemized bill where it was coded and charged into the internal systems of the facility.
  • Submitted Claim comes from the UB-04 data, sent to the FI and represents what was actually paid.
  • The Corrected Claim comes from the auditor after reviewing the chart and entering the line items representing the documented services provided.
  • APC AuditProTM then drives the appropriate reimbursement calculation for each individual encounter and the entire sample set

Completes Internal Audits

  • Following the reimbursement calculations for the individual claim, as well as the sample set, the auditor can check off what was wrong with the claim; and add general comments.
  • At any of the 3 levels, the auditor can add comments that can be used as a reference for training purposes.
  • After all of the claim data is entered for the audit sample, the auditor can run multiple reports ranging from Accuracy Rates to APC Impact.
  • The main report groups all 3 levels of each claim with the APC and Charges Impact for each claim and can then be printed, exported, and archived.
  • This log can be used in maintaining compliance under the Medicare Program.
  • Provides Reporting

APC AuditProTM provides for a number of reports including:

Claims Details Report

  • Displays each time a record is audited
  • Displays what was internally coded, submitted or paid, along with your corrections
  • Shows the claim analysis with the auditor’s comments, plus the revenue and charge impact
  • Reports can be used for departmental education, RAC reporting and appeal writing, and compliance archives
  • May be exported to Excel or archived as a PDF

RAC Threshold Report

  • Helps you prepare and identify specific areas that leave you vulnerable to the stranglehold of the RACs
  • Allows you to be prepared and armed with real information useful to prevent penalties and paybacks involved with RACs
  • Gives you and your team more time to perform re-audits to validate corrections