The Best Defense is a Good Offense

Transcription

1 The Best Defense is a Good Offense A Game Plan to Manage Various Audit Types in Today s Audit- Happy World Prudence Budemer, BSN, MAIOP, RN CHRISTUS Health Director, Clinical Reimbursement Revenue Cycle Business Services

2 International Catholic, faithbased, not-for profit health system comprised of almost 350 services & facilities, more than 50 hospitals and longterm care facilities, 175 clinics & outpatient centers and dozens of other health ministries & ventures.

3 CHRISTUS Locations CHRISTUS operates in 6 U.S. states, 6 states in Mexico & Chile

4 Over 350 medical facilities owned/managed 25,000 Associates $5 billion total assets 4,500 staffed beds 9,000 physicians

5 Jointly sponsored by the two religious congregations of the Sisters of Charity of the Incarnate Word in Houston and San Antonio

6 The mission of CHRISTUS Health is to extend the healing ministry of Jesus Christ

7 CHRISTUS Health Core Values Dignity Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. Stewardship Wise and just use of our talents and resources in a collaborative manner Excellence High standards of service and performance Integrity Honesty, justice and consistency in all relationships Compassion Service in a spirit of empathy, love, and concern

8 Are You Ready for Some Football? Audit Entities Vs. Providers

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10 The Game Plan Review of Current State/Process Gather all Players to Identify Roles/Responsibilities Create a Flow Chart of the Process Develop Concise Policies & Procedures Develop a QA Plan Communicate

11 Current State/Process What is working well? Identify obstacles to process Variations in different audit processes Each process flow needs to be identified for each audit type Understand roles of those involved

12 Picking the Right Players Coach Creates the playbook and holds players responsible Quarterback Calls the plays based on the playbook Receivers Catch the ball when thrown to them Running backs Runs with the ball when handed to them Punter Kicks the ball back to the other team or scores a field goal

13 Picking the Right Players Coach = Senior Leader/Champion Quarterback = Coordinator Receivers = PFS Running Backs = ROI Punter = Appeal Nurses

14 Picking the Right Players Who Needs to be on the Team? Coordinators HIM PFS Appeal Nurses ROI CM What Position will they Play? Need to understand their roles/responsibilities Do they understand the game? Need to understand the whole process & the roles of the players

15 Play Plans MIC HUMANA EQUICLAIM ZPIC RAC MAC UHC CERT BCBS HDI PERM HIM PFS ROI ROI HIM PFS APPEAL NURSE CM DATA ENTRY COORDINATOR APPEAL NURSE

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17 Flow Chart of Process Visual of work flow Should be detailed Steps outlined Responsible party identified Decision points Flow chart for each audit type As much as possible keep processes consistent

18 The Play Book Policy & Procedures Written course of action Should reflect flow chart processes Include time frames, responsibly parties, expectations Review annually and update as needed

19 Play Ball Follow the game plan Use P&Ps and work flows as guides Work with audit entities Deadlines You will win some and lose some Always play by the rules

20 Calling the Plays Everyone has to work toward the same goal Consistent and frequent communication To the team To leadership Come together to make improvements

21 The Game Is Over, So What Now?

22 The Game Is Over, So What Now? Critique the game tapes Did we follow the plan? Did we have the right players? Do we know the root cause that triggered the audit?

23 Develop a QA Process Monitor data entered into the tool for accuracy and completeness Random selection monthly Track and trend results Identify Root Causes Go back the problem area and educate Track and trend results Remediate as needed

24 Get Back in the Game Take the findings from the game tapes and practice, practice, practice Continue to look for ways to improve documentation front end Work with coding to ensure accuracy of the DRGs

25 Key Takeaways Know the game plan Follow the play book Build the right team Call the plays Monitor results to improve processes Practice, practice, practice

26 Let s Get Ready to Rumble