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DSS / Medicaid AuditsClosed – June 2017
CONNECTICUT MULTISPECIALTY GROUP, PC (2014)
GROVE HILL MEDICAL CENTERS, PC (2015)
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DSS / Medicaid AuditServices from 01/01/2011-12/31/2013
CONNECTICUT MULTISPECIALTY GROUP, PC
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Audit Conducted at Corporate OfficeSeptember 2014
u Original Sample: 100 Records
u Included: Office, In-Patient, SNF and Dialysis Services
u Medicaid Group: Internal Medicine 004170833u Allergy,
Endocrinology, Geriatrics, Hematology/Oncology,
Hospitalists, Infectious Disease, Internal Medicine, Nephrology,
Pulmonology, Rheumatology
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Audit Findings Returned October 2015
u Errors Found in Sample: 19 (out of 100 Records)
u Amount of Overpayments Found: $709
u Extrapolated Overpayment Amount: $246,013
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Exit InterviewDecember 2015
Each record was reviewed and discussed.Each record was
individually disputed with the DSS Representatives.
In Attendance:u Michael Deshaies, DOu Jarrod Post, MDu Mark Vye,
CEOu Cindy Kisselburgh
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DSS Final Report January 2016
u Remaining Errors Found in Sample: 16 (from 17)u Amount of
Overpayments Found: $573u Extrapolated Overpayment Amount:
$198,831
u Request for hearing by Starling Legal Counselu Challenging
findings on individual recordsu Challenging method of extrapolation
and requesting
data files for statistician review
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DSS FindingsSpecific Errors Identified
u E&M Servicesu 14 of 16 Errorsu 88% of Errors
• 6 Office • 6 In-Patient Hospital• 2 Skilled Nursing
Facility
Place of Service
• 1 Up-coded• 11 Down-coded• 2 Disallowed
Level of Service
• Denial for 2nd administration code during same visit• Claim
processing issue with Medicaid paying primary
in error
Other than E&M
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What did we learn?
u E&M Coding can be SUBJECTIVE – don’t leave it up to the
auditors!u Clearly document the medical necessity for all of your
encountersu A comprehensive history requires at least 4 HPI
elements, at least 10
systems reviewed, and a medical, family and social historyu A
comprehensive examination requires 8 organ systems (no credit
for
body areas)u High level medical decision making requires 2 out
of 3 of the following:
u At least 4 diagnosis points; at least 4 data points; or a high
risk for morbidity/mortality
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DSS / Medicaid AuditServices from 07/30/2012 – 07/29/2015
GROVE HILL MEDICAL CENTERS, PC
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Audit Conducted at 300 Kensington OfficeAugust 2015
u Original Sample: 100 Records
u Included: Office and In-Patient Services
u Medicaid Group: Pediatrics 004195930u Included six
physicians
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Audit Findings Returned August 2016
u Errors Found in Sample: 35 (out of 100 Records)
u Amount of Overpayments Found: $1,592
u Extrapolated Overpayment Amount: $825,665
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Exit InterviewJanuary 2017
Each record was reviewed and discussed.Each record was
individually disputed with the DSS Representatives.
In Attendance:u Michael Genovesi, MDu Marc Ramirez, MDu Mark
Vye, CAOu Mindy Tompkins, Esqu Cindy Kisselburgh
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DSS Final Report April 2017
u Remaining Errors Found in Sample: 21 (from 23)u Amount of
Overpayments Found: $708u Extrapolated Overpayment Amount:
$233,786u Request for hearing by Starling Legal Counsel
u Challenging findings on individual recordsu Challenging method
of extrapolation and requesting
data files for statistician review
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DSS FindingsSpecific Errors Identified
u E&M Servicesu 11 of 21 Errorsu 52% of Errors
• 10 Down-coded• 1 Disallowed
Level of Service
• Vaccine/administration not documented• Developmental screening
not documented
Other than E&M
• Incorrect vaccine billed• Duplicate billing
Billing Errors
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What have we learned?
u Department of Pediatrics now on AllScriptsu Custom templates
created for developmental screening interpretation and
discussion
u Custom templates created for vaccine counseling and
immunization orders recorded in chart with administration date
u Custom templates created for oral evaluations and
documentation of fluoride administration
u Documentation of time spent counseling and coordinating care
more easily captured with built-in statement option
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DSS / Medicaid AuditsClosed – June 2017
CONNECTICUT MULTISPECIALTY GROUP, PC (2014)
GROVE HILL MEDICAL CENTERS, PC (2015)
