Why Coders, Managers, and Auditors Don’t Always See Eye to Eye

In search of good collaboration among stakeholders.

For many years I’ve been surprised at the various levels of disagreement between staff involving both outpatient and inpatient coding in the physician and hospital settings.

Having worked in a production environment, with the need to maintain a good quality score of at least 95 percent, which was the standard even as far back the mid 1990s until today, but now in a more managerial capacity, the topic isn’t less prickly, but really has become more focused in the need for good collaboration among stakeholders.

Depending on your organization and role in this arena, you may not even have time to think about collaboration. And while we’re probably all familiar with the definition of this word – collaboration – “the action of working with someone to produce or create something,” we may not be familiar with another secondary definition:

• “Traitorous cooperation with an enemy.”

That’s the sentiment many coders feel about audits and auditors, but also how managers feel, because of their need to direct the workflow of coders, respond to upper management, and account for audit results. We might refer to this as a symbiosis fail. What is meant to be a mutually beneficial relationship ends up becoming tragically complicated and dies over time because one of the partners in the relationship is harmed or perceives harm, while another benefits and grows.

Coding as a product must be tested. There is no doubt about this, but your level of agreement with the statement may depend upon your desire to be agreeable and/or your capacity for growth. No matter our age, we have periods of adjustment to how we relate to our work efforts being tested. Some individuals are more adept with their skill sets in productivity, quality, or both, which can make the playing field quite unlevel for others. Let me provide an example:

Years ago, in a production environment at one organization, our coding staff were paid based upon their productivity AND quality. However, quality had really been a secondary concept, certainly not the hot topic of today. And human nature being what it is, with a desire to see dollars for work efforts, some individuals cranked out hundreds of records a day with little thought paid to the quality of their efforts. This occurred with practically no consequences – or so they thought. Other individuals were able to perform at even four times that rate, coding as many as 500 encounters a day, but also had high quality on a continuous level. These individuals were no-nonsense in their approach, often working with their headphones on, never conversing with colleagues, not talking during their breaks or moving from their desk until they had completed their desired quota for the day. My personal efforts were average, and my quality was good, so I wasn’t going to be making a fortune in this coder production environment.

When the compliance police did come knocking, the organization began to realize their need for good quality first, in order for clients to keep the monies gained through these efforts. But it was too little, too late, and fines and penalties were levied, resulting in losses of clients, personnel, and company reputation – and then all things changed. 

From this story anyone can see the need for coder testing in the form of quality and compliance training, and how productivity must become embedded within process change, software enhancement, and a holistic approach to coding.

Similar examples in organizations across the country continue to emerge to this day – possibly not as extreme, from the coding perspective, but they still occur, nonetheless. And I became convinced that we not only needed continuous testing in the form of auditing in our industry, but better auditing, education, and a greater sense of professionalism. Consider some of my reasons why:

• The providers we code for have spent hundreds of thousands of dollars on their professional careers to become doctors, nurses, and licensed healthcare practitioners of all kinds.
• The hospital organizations we serve want to provide the best care to patients in their communities, and spend millions of dollars with minimal profit margins to continue providing that care, all while remaining competitive in their specialized lines of care to various patient populations. These healthcare entities also are licensed and contracted to maintain various oversight protocols related to basic health guidelines, along with being cognizant of a greater need for quality and price transparency.
• Doesn’t it seem obvious that organizations and individuals that train professionals to become certified as coders turn those candidates into the best coders they can be? Their certifications and licenses say “professional” on them, and I believe we should live up to that moniker.

Auditing and testing have become the way in which we continue to realize the potential we have for providing these services in the healthcare field. A colleague who long ago worked for a Medicare Administrative Contractor (MAC) once had a need for certified coding staff at their field offices in the state where their regional offices were. The remote coding boom hadn’t yet begun, and so the candidate pool for basic employees consisted of staff members who only had experience working in the local food service industry. While anyone can start a new career and build it from the ground up, I certainly wouldn’t recommend this as the main method for building a coder/auditing department.

Think of auditing and testing in another way. Imagine you’re looking forward to your upcoming vacation and have scheduled your travel, booking airfare ahead of time and arriving at the airport on the appropriate day to fly to your dream destination. You arrive at your gate and the gate attendant makes an announcement that the plane you’re flying on has been having some mechanical issues with an engine, but it is being repaired. After a delay, the attendant announces that all is well and boarding begins. You take your seat and think nothing further about it, and later take off and arrive at your destination safe and sound. Have you ever had the following thoughts?

• I hope they have tested the engine appropriately, so it doesn’t fail mid-flight.
• I hope the repair crew is properly trained to complete the repairs.
• Did the repair staff involved have a productivity goal to meet during their work schedule today?
• I wonder if the repair staffers have professional certification and continuous education?

I think you see where I’m going with this hypothetical scenario. Testing an engine ensures that it can be trusted to function under the stresses placed upon it, and within the parameters for which it was designed. Auditing of the staff involved in the job ensures that repairs are performed to manufacturer specifications, that workers have necessary skills to provide the service, and that they receive ongoing education related to all the design specifications for the engines on which they are certified to work.

In an auditing role, I get to investigate all of the parties involved with patient care. I see the documentation issues that may appear and the need for improvement on that front. The need for process improvement change becomes apparent based upon my interactions with various staff, hardware, software systems, and the electronic medical record (EMR) and encoding products being used. My detective hat adjusts when I see things that are non-compliant and require appropriate communication to management executives – and of course, I’m constantly gathering data to share with staff concerning my findings, with the intent to encourage learning, teach a skill, point out areas of opportunity, highlight trends, and give kudos to those doing an outstanding job.

It isn’t meant to be an adversarial relationship, but our humanity sometimes gets in the way, with personality conflicts arising and occasional failure to properly communicate results in a way that isn’t negative and stressful, while highlighting the need for excellence. I once had the experience of being involved with audit staff from multiple companies as a coder myself, as a manager, and also as an auditor, providing those services back to others. I worked with colleagues who are great communicators, with a very easygoing way of sharing information. I’ve learned from them, I’ve adjusted my style over time, and hopefully I’ve grown in roles such as that. The opposite is also true, in which I’ve at times received negative, degrading, and humiliating feedback from staff members and organizations, and watched auditors from various companies stumble around with their results in unprofessional ways, sharing data that would never be thought of again beyond that meeting, simply because of the style and manner in which the information was relayed.

On occasion, the auditor is confronted with one’s own unique set of challenges, which they must face with politeness and respect. Examples of this include the reason for their visit on-site for a review. I have showed up on-site for visits at hospitals and physician practices for years, at times being met with surprise for my encroachment upon their territory, and have come face to face with the drama of office politics. Sometimes I was met with skepticism by physicians and board executives of hospital organizations concerning my work, and thus would sit and provide a summary of findings (and sometimes the details) of my audit results, which sometimes offended staff involved. 

• Physicians were always offended that I had the audacity to point out their copy-and-paste errors in the pre-EMR era of transcription – and in our post-EMR era of all things being electronic. They were also often offended by my insight into government regulatory guidance in relation to compliance.
• Office staffers were offended by my presence because they had to pull records or provide access, set aside space for reviews, gather staff for meetings, and essentially let me look behind the curtain where the wizard is hiding.
• Executives were offended by my directness concerning the state of affairs within their organization concerning the project I was hired to complete. Sometimes they believed a good steak dinner would soothe the audit beast in me, and would set up an evening to try out the local fare. This never worked. 

As professionals, we can’t let offenses change our desire to help organizations and individuals be the best they can be for their clients: patients in need of healthcare. 

Auditors also face similar productivity challenges regarding their work, with their organizations occasionally selling projects that are cumbersome and clunky. They have new software platforms to utilize and navigate, processes that are unfamiliar, and managers who provide their constant oversight, whether needed or not.

And now, in a manager capacity, my desire for testing and auditing is as strong as ever. Why? It’s because I need great staff to deliver a great product. The staff I work with deserve my best, and the clients I work with deserve the best of my staff. Auditing and testing promote informed decision-making for current staffing needs, appropriate career transitions for those currently within the organization, and acclimation for individuals who desire to join. All the coders I work with desire education and training. They want to learn and grow, and I want to see them succeed. Auditing helps them accomplish that too. Testing their capabilities sets the bar a little higher, showing them the need to stretch themselves in their career. It allows us all to see our strengths and weaknesses for what they are, and helps formalize a plan to adjust and adapt.

As a director in the coding arena, I rely upon audits to tell me how good a candidate is. Coder testing prior to employment can accomplish a certain goal. And a resume with a lot of experience is great. But auditing shows me how well my candidate knows the basic, intermediate, and/or advanced levels of coding. It saves our clients revenue by allowing them to hire qualified individuals, and it saves our organization revenue in onboarding and probationary employment phases.

Of course, there are other things that my management team monitors that auditing and testing can’t quantify: work ethic, adjustment to company culture, remote work environment, professionalism, and integrity, to name a few. 

Our mandates and roles may be different. Our goals and directives are probably more symbiotic than we know. And our mission is likely identical, in a fashion – support the healthcare space, ultimately, providers and organizations that provide patient care, and do it with purpose and excellence.