Helping organizations manage the audit process

Healthcare Audits and Enterprise Content Management (ECM)

7 steps to minimize pain

So many audits so little time… Medicare

QIO (Quality Improvement Organization)

CERT (Comprehensive Error Rate Test)

RAC (Recovery Audit Contractor)

ZPIC (Zone Program Integrity Contractors)

MAC (Medicare Administrative Contractors)

PSC (Program Safeguard Contractor)

MedicaidMIP (Medicaid Integrity Program)

PERM (Payment Error Rate Measure)

MFCU (Medicaid Fraud Control Unit)

OIG (Office of Inspector General Audits)

Ancillary AuditsPermedion (Independent Medical Review Organization)

1st Step to Minimize Pain… Form Audit Team• Audit Coordinator / Team Leader / Project Manager

- Outside consultant or Internal Auditor

• Patient Financial Services/Revenue Management

• HIM / MR

• QA / Compliance

• Coding Specialist

• Admin / Management

• Medical Staff

• Case Management

• Clerical staff

2nd Step to Minimize Pain… Response strategy

• Over 11 agencies may audit an individual organization– If audited by a ZPIC, OIG or FBI – need an attorney ASAP

• FBI – no prior notification – they will come knocking on your door

• Internal Audits/Review– Identify if you are in compliance with audit guidelines/rules– Review processes (coding, etc.) – be proactive– Identify corrective actions to implement for compliance

• Know where previous improper payments have been found• Know if you are submitting claims with improper payments

– Learn from past experiences

• Attend Coding courses

3rd Step to Minimize Pain… Establish Response Process to Auditors• Implement procedures to promptly respond to audits and

medical record requests– Who will be in charge of each stage of the process?– Generate practice letters, verify response times– Identify staff responsible for medical record requests

• Initiate responses within the identified timeframes/deadlines– Claim $ could be lost – Lose appeal rights– Potential fines / loss of reimbursement

• Keep track of denied claims and correct identified previous errors

• Contractors / reviewers typically staff specialists to identify errors– Certified coders– Nurses and/or Therapists– Physician(s)

• RAC specific info– CMS – New Issue Review Board provides greater oversight– RAC Validation Contractor

• Provides annual accuracy scores for each RAC • If a RAC loses at any level of appeal, the RAC must return the

contingency fee

4th Step to Minimize Pain… Ensure Claim / Process Accuracy

• Adhere to the auditor’s medical record submission requirements

• Prepare to respond to the auditor’s additional documentation requests

• Limit the number of additional documentation requests

• Most auditors will accept paper medical records– Some will accept medical records via CD/DVD

• Send medical records in a tamper-proof package– Strongly suggest that all medical records be sent via

trackable carriers

5th Step to Minimize Pain…Medical Record Submission

• History

• Presenting Problem

• Medical Decision Making

• Examination

• Counseling

• Coordination of Care

• Time

Documentation needed…

6th Step to Minimize Pain… Review websites

• Review CMS and ancillary audit websites– Ensure compliance with requirements and avoid submitting

incorrect claims– Look to see what improper payments have been found in OIG and

CERT reports • OIG reports: www.oig.hhs.gov/reports.asp • CERT reports: www.cms.hhs.gov/cert

• RAC Specific information– CMS / Medicare RAC site– AHA RACTrac

7th Step to Minimize Pain… Identify the Appeal Process

• Identify guidelines for appeals– Internal or external resources

• Agree upon criteria for the following:– When to appeal– How to initiate appeal– Identify trends for future claims generation

– Appeals can cost organizations $ by hiring legal representation and can take years for a determination

• Is it worth the cost to an organization to appeal?

RAC Program Update Awareness

• OnBase RAC = RACTrac Compatible Vendor

• New issues will be reviewed by the CMS and a RAC Validation Contractor - updates on websites

• Permanent program is expected to be more aggressive

• RACs will be required to pay back contingency fees when an adverse determination is overturned upon appeal

• Maximum look back period is 3 years - October 1, 2007

• A Medicaid RAC Audit program is on the horizon…

Schedule… Implementation nationwide January 1, 2010

Audit Limit Freq. MR Request Response

MR Reimburse

Discussion Period

Collect $ Appeal Rights

Mult.Audits

RAC 200 inpt 45 days 45 days $0.12/page 15 days 41st day 5 levels No

MAC Unknown

Unknown Unknown Unknown Unknown Unknown 2 levels Unknown

PERM Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown

ZPIC Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown

CERT None Any 30 days Unknown Unknown State Regulated

2 levels Yes

PSC Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown

OIG Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown

QIC Unknown

Unknown

MIC/MIP None State Regulated

State Regulated

None State Provider MIC

State CMS

State Regulated

State Regulate

d

Yes

MFCU Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown

Permedion None Any 30 days N/A State Regulated

State Regulated

2 levels Yes

Audit Limit Freq. MR Request Response

MR Reimburse

Discussion Period

Collect $ Appeal Rights

Mult.Audits

RAC 200 inpt 45 days 45 days $0.12/page 15 days 41st day 5 levels No

MAC Unknown Unknown Unknown Unknown Unknown Unknown 2 levels Unknown

PERM Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

ZPIC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

CERT None Any 30 days None Unknown State Regulated

2 levels Yes

PSC Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

MIC/MIP None State Regulated

State Regulated

None State Provider MIC State CMS

State Regulated

State Regulate

d

Yes

MFCU Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

Permedion None Any 30 days N/A State Regulated

State Regulated

2 levels Yes

OnBase RAC Solution• Designed to manage the provider’s appeal process to the RAC

auditor and the denial of medical claims– Task Management

• Track responsible employee assigned to each task– Configurable Parameters– Upload Claim History– Tracking functionality

• Shipping information• Expected completion dates / appeal timelines• Medical record request costs• Interest due on recovered funds• Communication with RAC personnel

• Dashboard Views:– Administration/Management– Financial – Risk Analysis– Process Improvement

References• CMS releases details on 2009 permanent Recovery Audit Contractors (RACs) program. Retrieved

Jan. 21, 2009. http://www.mgma.com/policy/default.aspx?id=23052

• Frequently Asked Questions. (Jan. 25, 2008). Retrieved Jan. 21, 2009, from http://www.aha.org/aha/content/2008/pdf/080125-racfaq.pdf

• Healthcare Compliance Quarterly Insights: Surviving RAC. Retrieved Jan, 22, 2008. http://www.hfma.org/forums/healthcare/Healthcare_Compliance_Tips_RAC_Audit.htm

• Center for Medicare & Medicaid Services (CMS) Recovery Auditor Contractor (RAC) Program, AAHAM Position. Retrieved 12/1/2008. http://www.txaaham.org/files/AAHAM%20Position%20Paper%202008.pdf

• Pennsylvania Physicians Facing CERT Audits. http://www.pamedsoc.org/CERT

• How to Survive a Medicare Audit. (May, 16, 2009). Retrieved October 13, 2009 from http://www.aace.com/advocacy/socio/HowtoSurviveaMedicareAudit.pdf

• Legal Note: Medicaid Integrity Contractors. (August 17, 2009). Retrieved October 13, 2009 from http://www.arkhospitals.org/Legal%20Note%20Archive.pdf/08-17-09%20Legal%20Note.pdf

• Medicaid Integrity Program Provider Audit Fact Sheet (November 2008). Retrieved October 13, 2009 from http://www.aparx.org/members/documents/MIPprovauditfactsheet-Nov2008.pdf

• Potential NCD Topics (July 30, 2008). Retrieved November, 2, 2009 from http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=19

• CMS RAC Review Phase-in Strategy (6/24/09). Retrieved November 2, 2009. http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf

• Medicare-Medicaid Data Match Program . Retrieved November 3, 2009.

nampi.org/members/2007presentations/MediMedi.pps

• Hospital Payment Monitoring Program (HPMP) Compliance Workbook (January 2006). Retrieved November 4, 2009. http://www.hpmpresources.org/Portals/1/Tools/HPMPCompWkbk_03-2008.pdf

• “Data mining programs” intensify scrutiny of Medicare claim.  National Psychologist, Vol. 17, No. 5, p. 9.. Retrieved November 5, 2009. http://www.centerforhealthyaging.com/Medicare_Audits_NP.htm

• Medicaid Integrity Program A to Z. Retrieved November 6, 2009.

www.wsha.org/files/119/MIP_A_to_Z_for_Providers_Aug%2009.pdf

• Recovery Audit Contractors (RACs) and Medicare, The Who, What , When, How and Why?. Retrieved November 19, 2009. http://www.cms.hhs.gov/RAC/Downloads/Recovery%20Audit%20Contractor%20(RAC)%20Program%20Slide%20Presentation.pdf

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References continued…

time to make a difference.