what’s an audit….really….? - kmc university
TRANSCRIPT
7/19/2018
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Fill Your Audit
Toolkit for Today’s Practice
Presented by:Kathy Mills Chang, MCS-P, CCPC,
CCCA
What’s An Audit….Really….?
Known Violations:
Per OIG
Submitted claims for services that were never provided
Submitted claims for medically unnecessary services
Offered incentives to patients to receive unnecessary services
Provided services without a valid chiropractic license
Falsified patient records, and
Billed for chiropractic services but provided services not covered by Medicare (e.g., massage and acupuncture)
Inducement Violations
•Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law]
•No more than $15 per item or $75 in the aggregate annually•Even one free examination, x-ray, or therapy is a risk
OIG Makes Recommendations
to CMS Through Findings and
Published Reports
CMS Takes Recommendations Under Advisement
CMS Does or Doesn’t
Pressure MACs to Manage
Errors
MACs Audit and Put Pressure
Downward on the Providers
Providers Don’t Heed Advice and
Show Improvements
The Process When Something Smells Fishy!
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Outliers Are Audited & Made Example
The Collection Coach
2013 2014 2015 2015
“Establish adequate policies and procedures
to ensure that chiropractic services billed to
Medicare are medically necessary, correctly
coded and adequately documented.”
2016
First…Just a Few Charts or Visits
•They’ll ask for a representative sample
•That looks like a simple records request
•Fumbling this ball has grave consequences
You May Hear Nothing….Until…
Then, They Ask for it All!!
A Records Request…Now What?
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Why Me?
• Payment Recovery/Recoupment
• Overpayment results in excess expenditures due to
• duplicate submission of the same service or claim,
• payment to incorrect payee,
• payment for excluded or medically unnecessary services, or
• a pattern of furnishing and billing for excessive or non-covered services, as determined in an audit or review. First….Breathe!
• It’s not if…it’s when
• Roll with it
• Medicare is mandated to do CERT Reviews
• Expect them to affect up to 75% of the profession
Ask Yourself These Questions
• Hmmmm…why would they be asking for these records?
• What has the billing looked like to them?
• Is the coding out of order?
• Have I sent them anything yet?
• Could there be external factors?
• What’s KMC University’s phone number?
What Might Be the Trigger?
• Overutilization
• Unspecified codes
• Unusual errors
• Billing errors, like lack of Box 14 changing
• Patient compliants
• Your number came up
Why It LOOKS Fishy…
Steps to Be a Ninja with Records Requests
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1) Know What The Carrier Expects
Each carrier can list specific requirements like:
• P.A.R.T• Mechanism of Trauma
• Any documentation supporting Medical Necessity
• Contraindications
• Copy of ABN
• Non-covered or experimental codes
Aetna Medical Review Policy
Aetna’s Deeper Dive on ART
2) Get The Request Into Proper Hands It’s OK to Ask for Help!
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3) Review the Request for Records
• Pay close attention to the information that is requested.
• Does it meet HIPAA guidelines?
• Are there restrictions in the patients chart?
• What are the dates of service being requested?
• Do you need an extension?4) Carefully Review the Documentation
• Always review documentation prior to sending
• Never alter records after the fact but OK to add dated addenda
• Make sure your documentation shows the patient’s progress or clearly explains why there is no progress yet
• Is it obvious yet?
5) Organize the Materials
• Include all appropriate documentation to support your treatment
• Organize your materials so the chronology of the story is easy to follow with an obvious conclusion –they must allow the service! Organize Your Thoughts
and Your Material
• Episodes of care in the time period are from oldest to newest
• History, exam, DX, TX Plan, daily visits, re-evaluations, daily visits, (repeat as necessary)
• Discharge (!)
6) Tell The Patient’s Story…With a Case Summary
• Use your case summary letter to tell the story
• Place this “story” on top of the records requested
• When multiple records or patients are included, send a cover letter for all
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7) Finalize Your Submission and Check Your Work
✓ Case Summary
✓ Signature Log
✓ Attestation of Records
✓ Abbreviation Key
✓Number the pages
✓ Relevant Policies
✓ Initial Visit of Episode
✓ Daily Office Visits
✓ Re-Evaluation Notes
✓OATs
✓ Discharge Visits
✓ Scans or Exam sheets
✓ X-ray Reports
Doctors MUST Be Final Sign-Off!
• Doctor’s name and signature on the claims
• Only the Doctor knows things nobody else does
• Team members can do heavy lifting, but Doctor must be final sign-off
• Final, Final should be KMC University Specialist!
8) Your Policy and Procedure Must Govern Your Practice
Records Request Policy Records Request Sample Procedure
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Receiving the Records Request Obtaining Information Requested
Preparing Requested Information Outliers Are Audited & Made Example
The Collection Coach
2013 2014 2015 2015
“Establish adequate policies and procedures
to ensure that chiropractic services billed to
Medicare are medically necessary, correctly
coded and adequately documented.”
2016
Let’s Take a Poll!
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I’d Prefer to Avoid Audit….Now What?
Recognize That It May Just Be Your
Turn!
Master Episodic
Care
46
Keep Track of Visits Per EpisodeConduct Internal Audits
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Conduct Regulary Documentation Audits
Review EOBs Monthly • Set “Random EOB
Review” monthly • Randomly select a
handful of payments and EOBs from the prior month, or since the last time you reviewed them
• Review for patterns that could expose you to an audit
Conduct Regular Coding Audits
Take Time To Properly
Train All Team
Members
