Audit Management Solutions Overview. Wednesday, January 8, 2014 By Dawn Crump, MA, CHC, SSBB VP of Audit Management Solutions

Transcription

1 Audit Management Solutions Overview Wednesday, January 8, 2014 By Dawn Crump, MA, CHC, SSBB VP of Audit Management Solutions

2 Agenda Auditor Overview Audit Impact Importance of AudaPro to the Client Financial Impact of Audits Pre-Payment Audits esmd Education and Issues

3 STATE AND FEDERAL AUDITORS U.S. Department of Justice U.S. Department of Health & Human Services CMS Centers for Medicare & Medicaid Services OIG Office of Inspector General Medicaid Medicare ZPIC Zone Program Integrity Contractors MEDICAID RAC Medicaid Recovery Audit Contractors MIC Medicaid Integrity Contractors PERM Payment Error Rate Measurement MAC Medicare Auditor Contractor CERT Comprehensive Error Rate Measurement RAC Recovery Audit Contractors Prepayment Probe (targeted reviews)

4 Making Sense of the Soup: Auditor Medicare Recovery Audit Contractors (RAC) Improper Payments Medicaid Recovery Audit Contractors (RAC) Improper Payments Quality Improvement Organizations (QIO)- Quality of Care, DRG s and Medical Necessity Fiscal Intermediary/ Medicare Administrative Contractor (FI/MAC)»PROBE Audits Improper Payments, Medical Necessity

5 Making Sense of the Soup: Auditor Comprehensive Error Rate Testing (CERT) Improper payments made by the MAC Medicaid Integrity Contractor (MIC)- Fraudulent patterns; appropriate utilization of Medicaid Zone Program Integrity Contractors (ZPICs)-Fraudulent activity; UPIC (Unified Program Integrity Contractor)

6 Making Sense of the Soup: Auditor Medicare HMO/Advantage Plan Audits Improper payments Commercial Payer Audits Improper payments Payment Error Rate Measurement (PERM) Medicaid audit that happens only once every three years for a given state

7 Lifecycle of an Audit Payor review identified Each stage requires an exchange of information either paper,electronic or both. Most of this communication is currently in paper format Final exchange of payment based on appeal outcome Appeal Decision communicated ADR request issued Record submitted for review Appeal initiated/ Re-bill initiated Result /Findings communicated Repayment requested (Demand)

8 Audit Reviews/Request Methods Prepayment: Claim submitted not yet paid The longer it takes to submit the chart, the longer the delay in reimbursement Post payment: Claim submitted and paid Complex: Records requested ( ADR, ROI) Automated: Denial and Demand all-in-one Informational/Semi-Automated: Like an automated request but requires records to defend (records are not part of maximum RAC limits- not reimbursable)

9 Audit Reality Facts from Recent AHA RACTrac Survey Audits are increasing- Over 1 million records reportedly requested by RACTrac submitting hospitals Records request have increased by 13% since first quarter 2013 Hospitals are appealing 47% of all denials Appeal process can take over 3 years 9

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11 Potential Financial Impact of Audits What are the dollars at risk for take back? 251 requests/year ( bed hospital) = $2,151, requests/year ( bed hospital) = $4,029, requests/year ( bed hospital) = $6,618,356

12 What are Audit Management Solutions? End to end solutions for providers to manage any type of audit Consultative services to assist providers in efficient/effective management of audits using HealthPort s tools and services

13 Audit Management Solutions Roles

14 Spaghetti Diagram of System Audit Process

15 Optimized Audit Management Solution

16 AudaPro and Audit Management Solutions: Why should it matter to my Customer? Single solution to manage organizational audits Efficient use of staff Ability to report and improve audit risk and financial impact View and approve for ROI Useful access for all levels within organization C-level dashboards Response reminders Assignment functions

17 AudaPro and Audit Management Solutions: Why does it matter to my Customer? AHA RACTrac reporting (benchmarking) Reporting and analysis of audit impact EHR integration (appeals) Dispute (duplicate) monitoring No limits on what to track Unlimited audits Unlimited users

18 AudaPro and Audit Management Solutions: Why does it matter to me? Adds more value to the customer Enhances the ROI relationship C-suite level branding of HealthPort name More intensive to terminate AudaPro services Clients gain efficiencies with AudaPro and ROI combined Integration with multiple hospital services Case Management Physicians Finance Revenue Cycle Compliance

19 Audit Management Service Levels Five Supported Service levels RACPro Complete ** RACPro Basic ** AudaPro Complete HIHPro+ HIHPro ** Legacy solutions cannot be purchased today

20 Pre-Payment Audits, Commercial Audits and Managed Care Audits What should you do if a facility contacts you about tracking other audits and they do not have AudaPro? Call Client Sales

21 Pre-Payment Audits, Commercial Audits and Managed Care Audits Legacy RACPro customers will need to upgrade to AudaPro if they wish to incorporate Pre-Payment audits into the system RACPro can only accommodate one delivery address Even if the delivery address is the same, for example with a Pre-Payment RAC, it could change Help Desk has been notified to send requests to add new audits directly to sales RACPro cannot send records electronically through esmd or through the RAC Direct Connection

22 Legacy Solutions RACPro Complete Audit tracking for Medicare RAC post-payment audits RACPro Basic View & approve for Medicare RAC post-payment audits Important: Sunsetting Customers using either platform requests to add audits should be directed to Client Sales Client Sales is actively pursuing upgrade opportunities with these clients RACPro solutions cannot send records electronically

23 Current Solutions AudaPro Includes all features of HIHPro+ Complete audit management Reporting and dashboards Electronic delivery HIHPro+ Includes all features of HIHPro Increased audit management View and approve Electronic delivery HIHPro Basic audit management Electronic delivery AudaPro HIHPro+ HIHPro Release of Information

24 Audit Management Solutions goal More AudaPro clients AudaPro HIHPro+ HIHPro

25 HealthPort AudaPro Process Flow Audit Request Received at Facility AudaPro User Enters Request on esmd Activated Audit Type AudaPro Software Request Pushed to esmartlog Records Captured in SmartLink Transmitted to HealthPort Processing Center FedEx Delivery Confirmation ROI Requests Pending List Reprocess No Approve? *If Not Picked Up Within 5 Days of Due Date, Records Sent by FedEx to Contractor Electronic Delivery Confirmation Yes HealthPort Sends Records to esmd

26 esmd esmd (Electronic Submission of Medical Documentation) Designed as part of National Health Information Network HealthPort was first vendor to complete testing Why use esmd? Electronic Transmission = True Delivery Confirmation Eliminate Paper/Postage Important Only Health Information Handlers (HIHs) can access esmd Systems/ESMD/index.html?redirect=/esmd

27 Direct Connection to RAC Auditors (different from esmd) Dedicated bi-directional connection HealthPort receives electronic request file from the RAC and sends the records back to the RAC electronically Facility still receives a paper copy of request letter Only available in RAC Regions C & D Region C is audited by Connolly Region D is audited by HealthDataInsights (HDI)

28 Direct Connection for RAC Audits Available Region C - Connolly Region D HDI

29 RAC Regions Changing in 2014 Assignment of RAC Territories Not Yet Made Link: Programs/Recovery-Audit-Program/Future-Changes.html

30 AudaPro Issues You May Encounter Records requests entered late into AudaPro Users needing more training Disapproved records not being monitored Custom audit types built incorrectly can impact Mailing addresses Prepayment tracking Turn around time tracking Dispute (duplicate) monitoring Mailing options

31 Educational Opportunities Understand the key benefits of AudaPro and ROI integration for long term client satisfaction and retention For existing AudaPro clients, if you have new users: Review basic AudaPro training Contact AudaPro Support for internal training On new implementations Join basic user training call Make mandatory for on-site staff to join when implementing

32 Who to contact for AudaPro Issues AudaPro dedicated direct line number: AudaPro dedicated Support Team address: Strategy or Customer retention concerns Dawn Crump P

33 Things to Remember: Audits are here to stay and constantly changing Audits are very costly to providers AudaPro is a leader in the audit management software arena AudaPro with HealthPort ROI services can create best practice in audit management Service recovery efforts that infringe on the benefits offered by AudaPro may impact future service and revenue opportunities

34 Questions? Questions?

35 Additional Information Additional Information on Government Audits RAC Information Programs/recovery-audit-program/index.html?redirect=/rac/ Contractors accepting esmd transmissions Data-and-Systems/ESMD/Review-Contractors.html Medicare audit contractors by state Programs/provider-compliance-interactive-map/ Medicaid audit contractors by state Medicare Administrative Contractor (MAC) map Contracting/MedicareContractingReform/Jurisdiction- Maps/Primary_AB_MAC_Jurisdictions_MAP.pdf

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37 THANK YOU! Contact information: