Defining CAPs, Their Importance, and How Technology Can Lend a Hand

By Dana Finnegan

As third-party and internal payment integrity and compliance audits ramp up, healthcare organizations need to put in place proven processes that guide immediate and effective actions in the wake of problematic findings. With the clock ticking to correct any internal processes and/or billing practices that contributed to those findings, many organizations are turning to the corrective action plan (CAP) to ensure below par outcomes are swiftly addressed and mitigated. 

Healthcare organizations that work from CAPs also find the chances of future billing compliance risks drastically reduced, and the ability to achieve revenue integrity significantly enhanced.

The Audit Environment

Audits are increasing exponentially, with the Office of the Inspector General (OIG) scrutinizing how well hospitals, health systems and other provider organizations complied with requirements tied to use of nearly $180 billion in Provider Relief Funds and with newly enacted mandates such as the No Surprises Act.  

For example, in one survey, almost a quarter of hospitals indicated that they respond to as many as 2,000 external audit-related requests every month from multiple sources. Further, while results of many of those audits are confidential, Medicare Fee-for-Service data show a 6.26% improper payment rate in their 2021 report.

A CAP should be required when a RAC and/or commercial payer(s) audits uncovers issues with billing practices. Via a CAP, the offending provider organization can act swiftly to not only remedy the immediate problem –generally by refunding the overpayments – but also to identify and address any underlying practices and/or processes that may put the organization at risk for future issues and liability. 

Also note, that audit pressure is not strictly external. Many healthcare organizations are also ramping up internal scrutiny – and are not always pleased with the findings. When looking specifically at internal audits, the Healthcare Auditing and Revenue Integrity: 2021 Benchmarking and Trends Report from MDaudit found that more than 30% of the time, audit outcomes are unsatisfactory and have not met acceptable thresholds.

Enter the CAP

Given the current state of the audit landscape, it’s clear that CAPs are more essential than ever. They provide healthcare organizations with a road map to improve the circumstances or conditions that contributed to the problematic audit findings and allow organizational leadership to look for additional areas in need of improvement.

A CAP is simply a standard process for correcting the root cause by detailing all the necessary steps relating to responsibilities, communication, and how high-risk ‘offenders’ will be educated, trained, and held accountable for better outcomes during future audit periods.

Critically important when faced with significantly high numbers of unsatisfactory audit results, healthcare organizations that aren’t implementing CAPs are going to find themselves in a never-ending loop where the problematic findings continue because they don’t have a plan to correct the root-cause of these mistakes.

Technology to Streamline the Process

Implementing and streamlining CAPs is good business. Automating as much of it as possible is better business. 

A growing number of savvy healthcare organizations are starting to employ a variety of technology solutions to manage CAPs better – through automation of many core tasks, such as communication, deadline management, task assignment and completion, and even optimizing the reporting process. 

For example, automation can help with such CAP components such as:

• Task management to ensure tasks are assigned to responsible parties and are addressed in a defined timeframe.
• Document management and storage to enable a repository for all the collateral and documentation that needs to be passed between stakeholders during the CAP process.
• Reporting and dashboards to visually track CAPs and their outcomes.
• Audit workflows for added visibility into results, progress, and all corrective action steps taken post-audit.
• Follow-up reporting and post-audit debrief and pre-planning for future audits.

Ultimately, streamlining CAPs ensures that all follow-up activities are carried out swiftly and accurately – empowering healthcare organizations to mitigate further tangible financial and compliance risks associated with problematic audit findings. Technology can help plan for, mitigate, and respond to audits while revealing gaps and weaknesses so faulty practices can be corrected. 

CAPs are an essential element of any audit response strategy. They provide the needed road map to help address any future audits and improve the circumstances or conditions that are contributing to any incidents flagged in the audit.

Dana Finnegan is the director of market strategy at MDaudit, a leading healthcare technology provider that partners with the nation’s premier healthcare organizations to improve revenue, mitigate risk and reduce operating costs.