Internal Audit Revenue Cycle Risks

Transcription

1 Tuesday, December 9, p.m. Central time Internal Audit Revenue Cycle Risks Sally A. Hardgrve, RHIA Directr BKD, LLP [email protected] T Receive CPE Credit Participate in entire webinar Answer plls when they are prvided If yu are viewing this webinar in a grup Cmplete grup attendance frm with Title & date f live webinar Yur cmpany name Yur printed name, signature & address All grup attendance sheets must be submitted t [email protected] within 24 hurs f live webinar Answer plls when they are prvided If all eligibility requirements are met, each participant will be ed their CPE certificates within 15 business days f live webinar 2 // experience access 1

2 Learning Objectives Upn cmpletin f this prgram, participants will be able t: Discuss types f risk Identify areas f revenue cycle risk Describe varius prcedures that can be used t assess risk 3 // experience access Revenue Cycle Frnt End Scheduling Pre-Registratin Authrizatin Check Benefits Financial Cunseling Registratin - Admissin Middle Cding & Chart Cmpletin Clinical Dcumentatin Charge Capture Services Prvided Back End Claim Submissin 3rd Party Payment & Denials Mgmt Payer Fllw Up & Secndary Billing Patient Billing and Cllectins Accunt Cllectins and Write Offs Disclaimer: Nt intended t be inclusive f all revenue cycle functins 4 // experience access 2

3 Revenue Cycle Types f Risk Cmpliance Payer specific requirements fr billing prcess Risk in the event f pre- and pst- payment review Accuracy & Cmpleteness Charge capture Technical billing requirements 5 // experience access Revenue Cycle Starting a revenue cycle internal audit prgram Cnduct a risk assessment Identify areas f high risk in the industry Identify previusly identified risks at the facility Identify prcesses that are sub-ptimal Validate areas f risk Interviews Data mining Fcused sampling Design the internal audit plan 6 // experience access 3

4 Risk Assessment Identify Industry Risks OIG wrk plan RAC apprved issues New regulatry requirements Revisit previusly identified risks at the facility RAC findings CERT findings Frequent denials Cnsultant reprts Results frm prir internal audit activities New service lines r pst-acute subparts 7 // experience access Risk Assessment Identify subptimal prcesses Revenue & cmpliance risks Benchmarking key perfrmance indicatrs Where is manual interventin taking place? Charge capture Cding Rewrking bills Recent system cnversin Linkages Order sets 8 // experience access 4

5 OIG Wrk Plan It can be incmprehensible! Translate payment issues fr the cntractr int prvider risks We assess relative risks in the prgrams fr which we have versight authrity t identify the areas mst in need f attentin and, accrdingly, t set pririties fr the sequence & prprtin f resurces t be allcated. OIG 2015 Wrk Plan, page 4 Hw d we plan ur wrk? Wh wns the risk prvider, supplier, r cntractr If prvider, which type f prvider Decide whether the wrk plan issue applies t current billings, r histric liability New versus Established hspital based clinic visits 9 // experience access Validate Areas f Risk Interviews & survey instruments End users Clinical staff Crprate cmpliance persnnel Data mining the RACs d it! Decisin supprt Query develpment Link clinical/him & IT skills and capabilities May require utsurcing depending n hspital capabilities Fcused sampling Can als be part f the audit plan 10 // experience access 5

6 Design Internal Audit Plan Audit plan tpics: Defined & validated Objective & measurable Determine testing prcedures & required time & skills t perfrm prcedures Use data mining techniques wherever pssible Knw the prcess wner 11 // experience access What Happens Next Define expectatins fr actin after cnclusin f the prcedures Actin plan develpment Define pririties Expected timing f cmpletin f the actin plan Prject management f implementatin Prject management ffice Department head r designee Define hw results will be measured Determine when fllw up is required Threshlds fr errr rates Ptential financial impact Ptential risk t the rganizatin 12 // experience access 6

7 Middle & Back End Revenue Cycle Areas f Risk It wasn t dne at all, r services weren t dcumented Pre- r Pst- payment review by payers It wasn t cded crrectly r cmpletely Cmpliance risk r financial impact Inaccurate r incmplete CPT cde assignment LCD/NCD It wasn t billed crrectly r cmpletely Units f service, mdifiers, NPI numbers Diagnsis cde linkage with ancillary services n CMS-1500 Dates f service, 3 day windw vilatins, cde unbundling Regulatry requirements aren t met 13 // experience access Ptential Areas f Risk fr Hspital Prviders Mid-Revenue Cycle 1. Cding & dcumentatin acrss the cntinuum f care 2. Cmpliance with 2 Midnight Rule 3. Billing Evaluatin & Management (E/M) cdes in additin t minr prcedures 4. Units, J-cdes & billing fr waste fr utpatient drugs 5. Hard cded CPT/HCPCS cdes in the CDM 14 // experience access 7

8 Ptential Areas f Risk fr Hspital Prviders Back-end Revenue Cycle 1. Three-Day Windw Cmpliance 2. Prvider-Based Entities & split billing 3. Incrrect billing fr self-administered drugs 4. Medicare Secndary Payers 5. Denials Management 15 // experience access Revenue Cycle Billing f Self Administered Drugs Why is it imprtant: Limited cverage f drugs administered in a hspital utpatient setting. Plicies, IT build and manual prcesses must supprt cmpliant billing f nn-cvered, self administered drugs t Medicare utpatient beneficiaries. Type f Risk: Cmpliance Self-administered drugs are nn-cvered under Medicare Part B and shuld be billed t the patient. Inducement and Stark issues may be invked if charges are written ff. Reputatinal risks patients d nt understand when admitted versus utpatient status in bservatin r Emergency Department. Starting Pint in Assessment: Hspitals shuld have prcesses, plicies and prcedures that can be tested fr cmpliance and effectiveness f cntrls Des the facility have prcesses in place t prevent billing self administered drugs t Medicare Have rganizatin wide plicies been created and reviewed by cunsel t address billing t patient Des the IT infrastructure supprt cmpliant billing Can queries be written t cmpare the use f revenue cde 637 in utpatient claims with a predetermined benchmark? Can billed charges fr self-administered drugs be traced t patient respnsibility? 16 // experience access 8

9 Revenue Cycle Cmpliance with 2 Midnight Rule Why is it imprtant: Subjective assignment f inpatient status has changed t a 2 midnight benchmark and assumptin Type f Risk: Cmpliance Instead f simplifying patient status assignment, the new 2 midnight rule has muddied the waters. Medical necessity still trumps all Starting Pint in Assessment: Prcesses hspitals shuld have that can be tested fr effectiveness and design f cntrls Multidisciplinary apprach IT infrastructure supprts cmpliant billing Physician dcumentatin sufficient Onging mnitring What was the hspital s experience in the Prbe and Educate perid? Can the billing system and/r decisin supprt data be queried t get a snapsht f length f stay and assciated midnights? 17 // experience access Revenue Cycle Cmpliance with 3 Day Windw Why is it imprtant: Plicies, IT build and manual prcesses supprt cmpliant billing f diagnstic services prvided within 3 days f admissin t a PPS facility. Particular risk with ff-campus whlly wned, nn prvider based entities Type f Risk: Cmpliance Failing t re-bundle diagnstic and related therapeutic services int the inpatient bill can result in verpayment and nncmpliance with Medicare Starting Pint in Assessment: Prcesses the hspital shuld have that can be tested fr effectiveness and design f cntrls Is a specific plicy and prcedure in place fr bundling services prvided by whlly wned and/r perated entities int the inpatient claim Des the IT infrastructure supprt cmpliant billing Cnfirm existence f manual prcedures t bundle services prvided at an ff campus entity if necessary Query billing system(s) f main prvider and whlly wned entities. Merge by dates f service. Assess a fcused sample t cnfirm apprpriate billing f utpatient services prvided within the 3 day windw. 18 // experience access 9

10 Revenue Cycle Cmpliance with Prvider Based Designatin Requirements Why is it imprtant: Plicies, IT infrastructure, signage and ther attestatin requirements are met fr lcatins with prvider based designatin Type f Risk: Cmpliance Failing t meet the requirements fr prvider based designatin and can result in verpayment and nncmpliance with Medicare billing requirements. Starting Pint in Assessment: Prcesses the hspital shuld have that can be tested fr effectiveness and design f cntrls Des the hspital have supprting dcumentatin n file fr all prvider based entities Has an attestatin been filed with CMS fr all prvider based entities Des the IT infrastructure supprt cmpliant billing Evaluate hw lng entities have been designated as prvider based with Medicare. Has anything related t the attestatin requirements changed since the initial attestatin (IT billing infrastructure, E.M.R., relatinship with physicians) Use a survey instrument t d a mini attestatin and cnfirm entities are in cmpliance 19 // experience access Revenue Cycle Cding fr Outpatient Drugs and Drug Administratin Why is it imprtant: Dcumentatin and IT systems shuld supprt cmpliant billing f drug administratin, drug units, and J-cdes Type f Risk: Cmpliance Drug administratin cdes shuld be supprted by dcumentatin, and assigned based n CPT cding hierarchy. J-cde units shuld be assigned based n cde definitin, and represent what was rdered and administered. Inaccurate CPT/HCPCS cdes and units culd result in verpayment and nncmpliance with Medicare billing requirements. Starting Pint in Assessment: Prcesses the hspital shuld have that can be tested fr effectiveness and design f cntrls Is the unit cnversin mdule in the billing system accurately translating unit dses t billed units when required Has the rganizatin clearly identified respnsibility fr updating and maintenance f the cding and units aspects f the frmulary and pharmacy billing system Des the IT infrastructure supprt cmpliant billing Is cding fr drug administratin included in rutine cding quality mnitring Can a query be defined t identify claims with higher than average units f separately payable drugs fr Medicare utpatient services Can the unit cnversin mdule be dwnladed r printed fr review 20 // experience access 10

11 Questins? Thank Yu! Sally A. Hardgrve, RHIA, Directr

12 Cntinuing Prfessinal Educatin (CPE) Credits BKD, LLP is registered with the Natinal Assciatin f State Bards f Accuntancy (NASBA) as a spnsr f cntinuing prfessinal educatin n the Natinal Registry f CPE Spnsrs. State bards f accuntancy have final authrity n the acceptance f individual curses fr CPE credit. Cmplaints regarding registered spnsrs may be submitted t the Natinal Registry f CPE Spnsrs thrugh its website: The infrmatin in BKD webinars is presented by BKD prfessinals, but applying specific infrmatin t yur situatin requires careful cnsideratin f facts & circumstances. Cnsult yur BKD advisr befre acting n any matters cvered in these webinars. 23 // experience access CPE Credit CPE credit will be awarded upn verificatin f participant attendance Fr questins, cncerns r cmments regarding CPE credit, please the BKD Learning & Develpment Department at [email protected] 24 // experience access 12

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