Quality Assurance Techniques for the Revenue Cycle. Top 5 Things to Know for CE: Disclaimer 3/31/10

Transcription

1 Quality Assurance Techniques for the Revenue Cycle Are You Prepared for an Audit? Judi Rooney, RN, MSHL, CHC Chartwell Home Therapies, LP Cindy Watson, Director PFSC Coram Specialty Infusion Services Top 5 Things to Know for CE: 1. Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance. 2. Carry the Evaluation Packet you received on registration with you to EVERY session. 3. If you re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable. 4. Pharmacists and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go. 5. FOR CE: At your last session, total the hours and sign your Statement of Continuing Education Certificate form. Keep the PINK copy for your records. Place the YELLOW and WHITE copies in your Evaluation packet Make sure an evaluation form from each session you attended is completed and in your Evaluation packet Put your name on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center Disclaimer Every reasonable effort has been taken to ensure that the educational information provided in today s presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each organization. 1

2 Program Objectives Describe why we are accountable for sound revenue cycle practices Understand why a Revenue Cycle Quality Assurance Program can benefit your organization. Describe Quality Assurance best practices that have been proven successful. Recognize three (3) common unfavorable audit results and how to avoid them. Who is Watching Us? DHHS OIG DOJ USAO CMS FBI IRS DOH FI DME MAC SAGO MFCU USPS Beneficiaries Community Referral Sources Payers Accrediting Bodies Why Are They Watching Us? Balanced Budget Act Federal False Claims Act State False Claims Act Civil Money Penalties Act US Federal Sentencing Guidelines HIPAA Anti-kickback Act and Stark Law DME MACs Medicaid Anti-Fraud Campaigns And if that isn t enough... 2

3 Why are they watching us? Deficit Reduction Act of 2005 CMS Medicaid Integrity Group Medicaid Integrity Committee - Audits HealthCare Fraud Enforcement and Prevention Team A.K.A. HEAT American Recovery and Reinvestment Act of 2009 Federal Enforcement and Recovery Act of 2009 A.K.A FERA May 20, 2009 Reverse False Claims provision Appropriates $490 million for anti-fraud enforcement Amends criminal code provisions for fraud ZPIC Zone Program Integrity Contractors RAC Recovery Audit Contractors Are You Prepared? The best approach is a pro-active approach!! Quality Assurance of the Revenue Cycle A Two Prong Approach Auditing Monitoring * A combination of both yields the greatest benefit Is QA Just One More Thing to Do? Effective QA Program Goals: One of the primary goals is prevention Determine the effectiveness of your revenue cycle practices Identify risk areas or vulnerabilities Identify negative trends Determine areas for improvement Implement corrective measures to minimize problem areas Determine education needs Identify new or amended policy and procedure needs 3

4 It Can t Hurt but Can It Help? Program Expectations: Enhance internal controls Obtain an assessment of employee compliance Identify and/or prevent unethical or criminal conduct Improve internal communication Minimize financial losses Reduce exposure to criminal, civil or administrative penalties/cost benefits Safeguard payer relationships Promote consistency Empowers employees Ultimately - Protect your Organization! QA Best Practice It Takes Two! Auditing Component To ascertain the validity and reliability of information from analysis of findings based on a sampling of work done (ex. - claims) retrospective vs. prospective Conducted periodically by unbiased party Types - Routine, Focus, Probe Keep in mind Extrapolation Routine audits should include the entire revenue cycle! Auditor requirements Monitoring Component Present state of awareness of the effectiveness of an activity Conducted on a perpetual basis Usually conducted or reviewed by management Should include the entire revenue cycle Effectively used to determine: Productivity, compliance, time management Auditing Best Practice Scope include all risk areas along revenue cycle Risk assessment Determine vulnerabilities Frequency Size of organization, resources available and past history of compliance Consider intermittent focus reviews Sampling - statistically valid sample Review period Dollar value Universe of claims Sampling type Encounter, direct, 100%, random, strata sampling RAT-STATS 4

5 Auditing Best Practice Techniques Interview, observation, document review Audit Tools Documentation tracking Interview questionnaire Corrective Action Plan Issue, responsible party, corrective action, avoidance action, DOC, over/under payment Data Aggregation and Analysis Determine error rates Opportunities for improvement Report aggregated statistical and analytic summary Monitoring Best Practice Monitoring rational Staffing Needs/Justification Staff Productivity Staffing Weaknesses Effectiveness of orientation/training Education needs Compliance with policy/rules/regulations Policy needs Data for staff evaluation purposes Kudos and demerits Communication Monitoring Best Practice Determine areas of interest/risk Clearly identify monitoring expectations and parameters Who, when, what, where and why Involve any aspect of revenue cycle Provide tools for easy monitoring avoid timely tracking Assess often Identify negative trending Determine education needs Implement policy or procedural changes Seek management support 5

6 Monthly and New Biller Audit Log 6

7 Collector Management Audit Log Monitoring Elements-Back End Collector Feedback Communication Follow Up Education Trending Regular Management Review of Results 7

8 Let s Recognize These Practices 1. Required Supporting Documents 2. Pricing and Calculation Errors 3. Use of Modifiers Remember Your Goal Your approach can dramatically effect outcome! Auditing and monitoring should be nonpunitive! Internal Audits are an Opportunity - Gift wrap your negative findings! 8