Cerebral is a virtual mental health care provider with a mission to democratize access to quality care for all. With multiple full-service monthly subscription plans to choose from, members have online access to therapists and prescribers.
Visits are conducted via video chat, members can send direct messages to their care team, and members can have medications delivered directly to their homes.
problem
Unfortunately, Cerebral’s chart audit process was entirely manual, time-consuming, and costly.
The manual internal audit and monitoring process required hundreds of hours spent each month by a team of clinical auditors who were responsible for individually identifying notes to audit, selecting a sample of clinicians to review, creating issues or topics to review for adherence or compliance, and working through the process to ensure previous audit findings were not repeated within the environment.
“To get a relevant selection sample, the manual monthly build required reviewing hundreds of clinician calendars and appointments, identifying and copying medical record links into the EHR, and locating actual session notes for review,” said Julia Dolan, associate director of behavioral operations at Cerebral.
“Outcomes and observations were recorded separately in separate documents, analysed and summarised in reports for management and individual clinicians, and finally summarised separately for senior management and executive leadership within the company,” she continued.
This process was not only time consuming but also prone to human error, and required auditors to pay close attention to detail to successfully complete and score provider audit findings.
“We had to enter clinician names and medical record numbers into the scoring template we used to record feedback,” explains Dolan. “Naturally, this created classic audit hazards, such as name mismatches, incorrect links, and failing to apply audit components to medical records.
“We focused on continuous improvement and iteration to improve the quality of audit feedback, recognised gaps in our manual processes and worked diligently and proactively with available resources – no small task for clinical management,” she added.
suggestion
Vendor Brellium offered AI-powered chart review technology designed to simplify the management of unstructured clinical records by leveraging artificial intelligence to perform comprehensive, real-time audits. The technology aimed to address a major pain point in healthcare management: the inefficiencies and errors of manual clinical documentation.
“The core function of the system is to proactively screen all unstructured clinical notes for various types of errors and inconsistencies that may impact patient quality of care or insurance claims, including determining patient mood, successes and successors, evidence-based interventions, and whether treatment goals are measurable and time-bound,” Dolan explained.
“Specifically, the AI has been trained to identify clinical errors and point out trends that require attention,” she continued. “This preventative analysis also aims to significantly reduce the risk of claim denials and the need for costly rework by enabling billing and coding errors to be identified and corrected before claims are submitted.”
Additionally, by automating the review process, the technology can reduce the time providers spend on manual audits by 98%. While traditional methods typically allow for thorough review of only a small percentage of patient encounters, this AI-driven approach has enabled Cerebral to expand the percentage of notes reviewed and increase the scope of reviews, while also significantly reducing the labor-intensive task of manual screening, reducing the time spent by 78%, she said.
“This significant efficiency gain has freed up significant resources, allowing providers to reallocate their time and effort to more patient-centered activities and other administrative areas,” she noted.
Rising to the challenge
In December 2023, Cerebral began using an automated chart review process within its behavioral care division. Faced with the challenge of processing thousands of therapy session records each month, Cerebral needed a scalable system to ensure compliance with internal quality control and compliance requirements, as well as insurance mandates, without the unsustainable burden of manual review.
“Our clinical team worked directly with the vendor to deliver a customized AI system that integrated Cerebral’s unique format for session notes, timing of services, and our insurance partner’s specific audit requirements,” Dolan explains.
“After building individual question sets and parameters for each note template type, Brellium's system automatically screens session notes from Cerebral's EHR and highlights any necessary adjustments. This significantly reduces resources spent on administrative audits, allowing more time to be spent on patient care while also reducing the risk of financial loss due to insurance cancellations,” she said.
result
Within six months of implementing AI technology, Cerebral achieved a dramatic 81% improvement in meeting key insurance standards and reduced the time spent on medical record audits by 78%, demonstrating significant operational efficiencies.
Additionally, between March and June 2024, Cerebral saw an 8% increase in its clinicians' average audit score.
Advice for others
“AI-powered chart audits allow us to scale our document audits in an objective and operationally efficient way,” says Dolan. “This allows Cerebral to more efficiently see trends and error patterns through accurate data feedback that may be missed during manual audits.”
“As a result, we can more easily identify areas for improvement and more effectively deliver additional education to our entire clinician team in a meaningful and effective way to drive continuous improvement,” she continued.
She concluded that AI-powered chart auditing has significantly improved the efficiency of Cerebral’s workflow and improved the quality of note documentation.
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