Risk Manager
What Should you Audit?
The Risk Manager leverages multiple methods to identify auditing opportunities, such as the OIG (Office of Inspector General) coding rules.
Machine learning and workflow automation of medical code auditing are the future. ReviewMate innovates the industry by intelligently assisting the auditor with reasonable insights from robust historical auditing databases in real-time.
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What Is Risk Manager?
Risk Manager is a compliance module designed to solve the biggest question middle-cycle revenue managers face today: “What should we audit?”
Risk Manager is a tool that allows audit managers to identify records with compliance issues or to help identify reimbursement opportunities. This can be accomplished in one of two ways:
- Using Artificial Intelligence (AI) to leverage industry standards or,
- Enter rules manually to identify certain conditions that should be audited.
Artificial Intelligence Platform
ReviewMate is one of the largest databases for medical code auditing systems. Over the past decade, we have processed millions of accounts and gathered hundreds of thousands of code recommendations. All of this data was vital to our data scientists, who developed this innovative machine-learning capability to assist users in finding audit opportunities to stay in coding and billing compliance.
How does it work?
ReviewMate contains an adaptive rule engine that automatically updates the sets of conditions identifying future opportunities. The adaptive rule engine can flag records and assign risk scores to assist auditors in focusing on certain reviews and paying attention to specific errors previously identified. The AI model will help in predicting accounts that are not compliant or those identified with risk factors.
Risk Manager can find patterns based on customizable parameters that organizations can tailor to their needs. Read below to learn how ReviewMate captures that intelligence:
Machine Learning Sources
- Based on the coder trending errors.
- Based on your own organizational trending errors.
- Based on trending errors from our Insights database if you opt into the ReviewMate Community.
- In some cases, the coder might not have a specific trending error, but the overall performance of a coder can play a role in identifying risks.
- Based on known industry standards and trends.
Risk Manager
For example, if the coder repeatedly codes the principal diagnosis A419 (Sepsis, unspecified organism) incorrectly, resulting in an incorrect MSDRG or APRDRG which possibly could lead to compliance issues or/and incorrect reimbursement, the system will identify all related accounts meeting these conditions and automatically flag them for further review. Another example is coder performance monitoring. If a coder’s accuracy rates drop below certain thresholds, then the ReviewMate AI module will automatically flag a higher percentage of their coded records until their accuracy rates improve. The system will perform similar adaptive engine updates for the other sources of Machine Learning listed above.
The pattern detection technology which leverages historical and current data, and specifically data captured from your own auditing environment, enables ReviewMate to provide an intelligence prediction model unique in the marketplace.
Adaptive Accuracy Rate Warnings
Using Machine Learning, ReviewMate can identify when coders are having problems with specific codes. When coder accuracy drops, our Machine learning (ML) engine flags record with these codes and route them to the auditing department for further review. Once coder accuracy improves, the system removes these codes from that routing.
Record Type Classifications and Risk Scoring
Unlike other products, ReviewMate can classify records and assign a severity score to give management a complete map of currently available risks in the database.
- Risk Scores: You can assign a relative integer value as a risk value to identify the severity of the risk being identified. Accumulative risk scores will be given to accounts with more than one risk match.
- Flags: Help you easily classify records and help drive workflow automation. Risk Manager advantages over other products in the marketplace:
Risk Dashboards
View and analyze commonly occuring coding faults and communication errors at-a-glance. Common risks propogate data directly into easily configurable displays for taking action on. Heatmaps easily distinguish problem areas without lifting a finger. By simply tagging each risk the auditor would like to keep relevant, the system will intuitively prioritize and notify the auditor.
These aggregated findings also export perfectly into custom reports, Coder Report Cards, and other dashboards.
