Strengthening Physician Billing Compliance in a Multi-Institutional System Richard St. Onge, Associate Vice Chancellor for Health Affairs CJ Wolf, MD, Assistant Systemwide Compliance Office 2011 HCCA Compliance Institute Orlando, FL Overview of Discussion Factoids of The UT System History of the Medical Billing Compliance Advisory Committee Guiding Principles Leveraging Technology Looking ahead 2 1
University of Texas System $12 billion annual budget; 202,240 students, and 85,200 employees Nine academic universities Six health institutions (4 medical schools) UT Southwestern Medical Center (Dallas) UT Medical Branch (Galveston) UT Health Science Center Houston UT Health Science Center San Antonio UT MD Anderson Cancer Center (Houston) UT Health Science Center Tyler 3 UT Health Institutions $7.7 billion for six health institutions $4.3 billion annual revenues from clinical enterprise $1.5 billion annual research expenditures 4 clinical translational science awards 5.2 million outpatient visits 1.5 million hospital days Over 7,000 providers, 50,000 total employees Approximately 10 million claims annually 4 2
Yesterday Executive Vice Chancellor for Health Affairs is responsible party for billing compliance programs Established Medical Billing Compliance Advisory Committee Office of Health Affairs actively engaged Directors of billing compliance programs Pursued strategic agenda 5 Today Leveraged interest in software to facilitate and streamline billing compliance activities for professional services Professional billing audit software utilized by all health institutions since 2007 Office of Health Affairs contributed one-third of the startup costs System-wide approach reduced license, implementation and ongoing fees for every participating institution Guiding Principles Optimization Strategies 6 3
Billing audit software benefits Increased productivity for billing reviews Improved education efforts Enhanced management of billing review cycle and employees Quicker identification, escalation and tracking of potential issues These benefits created the UT System policy 7 Guiding Principles Oct. 5, 2000 OIG Compliance Guidance for Physician Practices Federal Register Vol. 65, No. 194, pages 59434-59452. Baseline review within 3 months (p. 59437) 5-10 encounters (p.59437-59438) At least annual, more frequent if problems identified (p.59437-59438) Sample selection (high $/high volume; risk approach) 8 4
Guiding Principles Prompt return (within 60 days) of overpayments (p. 59438; PPACA) Qualified reviewers and access to medically trained personal as needed during the review (p.59437, 59440) Documented corrective action plan for repetitive non-compliance (p. 59438, 59441, 59444) 9 Guiding Principles Appropriate communication of results to supervisors and accountable parties (p. 59442, 59438) Focused education, including tailoring training to results of the review (p. 59442) 10 5
Review summaries Review summaries 12 6
Billing audit software Consistency among reports Easy identification of overpayments and underpayments Providers expectations being met Competitive nature enhances the culture of compliance. 13 Specialty profile options Audit case profiles based on high risk areas Example shared by Doug Arrington, Director of Billing Compliance at U. T. Southwestern Medical Center - Dallas Radiology example focused on risks such as ultrasound (Office of Inspector General) and facet joint injections (Local Medicare contractor) 14 7
Specialty profile options 15 Sample Physician A 16 8
Sample Physician B 17 Looking To The Future Continue networking U. T. System Super Users to promote best practices and software functional enhancements Enhanced usage of data mining tool for supplemental reports Explore new strategies to leverage technology investment Implement hospital audit software 18 9
Questions Now? Later? cwolf@utsystem.edu 512-579-5017 19 10