2024 Compliatric Webinar Series - Reviving Compliance Reviews-Why Audits Matter Now More Than Ever.pdf

Watch the webinar here! https://attendee.gotowebinar.com/register/8325473899803555680?source=Web

With the Public Health Emergency now (hopefully) in the rearview mirror, most governing bodies and payers are ramping up compliance efforts. The PHE was revealing in many ways, offering a new lens for areas of fraud, waste and abuse. FQHCs have perhaps the most responsibility in this arena, with the additional burden of HRSA compliance to maintain CHC status. And with a steady build toward Value-Based Reimbursement methodologies, documentation quality has never been more valuable to your revenue cycle’s bottom line.

1. Reviving Compliance
Reviews: Why Audits
Matter Now More
Than Ever
Meri Harrington, CPC, CEMC

2. About BCA, Inc.
•Formerly Brown Consulting Associates,
Inc.
•Celebrating 35 years in 2024!
•Provide auditing services, education
(clinicians, coders, front office staff,
board members and CFOs), revenue
cycle support, and more to a primary
audience of FQHCs nationwide
•Core Values: Integrity, Servant
Leadership, Community, Efficiency, and
Wholeheartedness

3. Agenda
•Audit Program Timeline during the PHE
•HRSA Requirements for FQHCs/On- Site Visits
•OIG Recommendations
•Audit Scope and Effective Action Plans
•BCA Partnership with Compliatric for External Audits

4. Audit Program Timeline During the PHE
Suspended pre- payment and post-payment
reviews by:
•Medicare Administrative Contractors (MACs)
•Supplemental Medical Review Contractors (SMRC)
•Recovery Audit Contractors (RACs)
30 Mar. 2020
MACs/RACs resumed post-payment medical
reviews for DOS prior to March 2020
Aug. 2020
MACs began review of DOS after March 2020
June 2021
Targeted Probe and Educate resumed
Sep. 2021

5. OIG Recommendations
•OIG recommends annual documentation audits
Annual Documentation Audits
•Regularly evaluate services for coding accuracy and medical necessity
Medicare Fraud and Waste
•Incorporate into annual audit scope for Medicare and Medicaid
OIG Work Plan
•Continuous training for staff on OIG updates to improve adherence to best practices
Training and Education

6. OIG Work Plan
Use the Work Plan to:
Evaluate associated services for accuracy and efficiency
Educate staff members on findings of OIG work plan to improve
knowledge and awareness
Are you reviewing what OIG is investigating and looking for how those might impact your internal
functions?
Checking OIG for Medicare List of Excluded Individuals & Entities

7. HRSA Compliance Manual
Chapter 16 Requirements
“The health center must make and continue to make every reasonable effort to collect
appropriate reimbursement for its costs on the basis of the full amount of fees and
payments for health center services without application of any discount when providing
health services to persons who are entitled to:
•Medicare coverage under title XVIII of the SSA
•Medicaid coverage under a State plan approved under title XIX
•Assistance for medical expenses under any other public assistance program, grant
program or private health insurance or benefit program”

8. Chapter 16 Demonstrating Compliance
“The health center has billing records that show claims are submitted in a timely and
accurate manner to the third-party payor sources with which it participates in order to
collect reimbursement for its costs in providing health services consistent with the
terms of such contracts and other arrangements.”
How do we ensure timeliness?
How do we ensure accuracy?
How do we prove our diligence to be timely and accurate?

9. Third Party Payers
•Expectation to conduct internal
documentation and coding audits
•Incomplete or inaccurate
documentation
•Coding errors
•Lack of medical necessity
justification
•Insufficient supporting
documentation
•Adherence to payer billing
guidelines

10. Documentation Quality in VBC
Accurate Diagnosis
Coding
•Regardless of
model, provides
most accurate risk
adjustment
Comprehensive Care
Documentation
•Full scope of care, all interventions
and care
management
Timeliness of
Documentation
•Compliance and patient care
Impact on Quality
Metrics
•Documentation directly influences
performance scores
Support Continuity
of Care
•All care providers
have access to
patient records for
care coordination

11. BCA Partnership with Compliatric
Audit results loaded into the software without client intervention
Metrics to monitor outcomes, recommendations, frequency of audits
Notification and reporting on audit due dates
Securely store recordings of provider trainings, if desired
Policies revisions resulting from audit findings can be accessed

12. Considerations for Internal
Audits

13. Types of Audits
•Clinician peer review
•Coder peer review
•Process analysis or chart audit
•Coding and documentation review
•Billing cycle audit

14. Define your goals:
What are you curious about?
Evaluation and
Management
Coding Accuracy
Documentation
Quality
Documentation
Timeliness
Diagnosis Coding
Accuracy
Risk RevalidationQuality Metrics
Appropriateness
of Care Delivered
Whether
protocol/process
is followed

15. Define your goals:
Who are you curious about?
Front office
Medical
assistant
Nurse Physician/OQHP
Coding Billing Revenue Cycle Payer

16. Define your goals:
How will this information be used?
Component of internal compliance program?
Corrective action process:
Education for those falling below a pre-determined threshold
Re-audits?
Accountability if no improvement seen?
New provider sign-off?
Performance review/raise/promotion

17. Decisions to Make:
When to audit
•For physicians/OQHP, pre-submission vs. post-submission
•For other staff, what metrics are affected by results?
•Medical assistant/nurse – do results impact processes, performance
increases, performance measures?
•Biller/Coder/Rev Cycle – do results impact processes, performance increases,
financial forecasting, contract renegotiations?
•Payer – do results impact financial forecasting, contract renegotiations?
•For performance measures, how will results inform/determine
responses?
•Perhaps a quarterly review when processes, revenue opportunities are
impacted

18. Random vs Targeted
Records
•Risks and benefits of random record selection
•Truly blind record selection
•Payer agnostic
•May not capture trends
•Risks and benefits of targeted record selection
•Consistent with production patterns
•Sampling of typical encounters
•Errors found may apply to multiple encounters
•Provider believes that what they are doing is correct
•Easy fix for multiple encounters
•If post-submission, may require a rebill vs. policy to correct
moving forward

19. Data Analysis For
Physicians/OQHP
•Production analysis
•If there are variations, are there good reasons for them?
•Diagnosis analysis
•Unspecified diagnoses vs. complex conditions
•If there are variations, are there good reasons for them?
•Timely signatures
•What is organization policy?
•What is CMS’ policy?
•Percentage signed on time vs. average length of time from visit
to validation
•Denial codes
•How often and why? Trends?

20. What metrics will
help in other areas?
•Coding – number of claims? Consideration for difficult
providers?
•Billing – number of denied/rejected claims worked?
Consideration for whether payer calls are required?
Appeals?
•Nursing staff – performance measures? Documentation
of administrations, etc.?
•Front desk – rejections for insurance verification,
additional tasks assigned?

21. Consider how
data is best
presented
•Visual aids
•Charts
•Goals vs. current status – include baseline
•Comparisons
•Between peers
•Other CHCs in our network
•National data/thresholds
•How will the data be used over time?
•Accessibility
•Evidence of adherence to policy

22. Sharing Outcomes
•Anonymous results vs. identified
•Embarrassment
•Healthy competition
•Consider your goals, then determine
presentation
•Part of compliance program
•Document purpose, process, outcomes
and actions
•Determine when to revisit audit process
•Consider OIG, HRSA, other national
recommendations/protocol

23. Planning Education
•Who – who will you educate and who will
deliver education
•When - preplanned group meeting, what time
of day
•Where – virtual? Meeting room?
•How – Group or individual? Both?
•Why – What are you working to accomplish?
How will you measure success?
•What – Presentation? Individual reports? Do
you need a signature that the education has
been delivered?

24. Pairing with External Audits
Unbiased, external lens with
FQHC experience
•Discrepancies between internal and
external findings?
•If not, allows vetting of process
•If so, allows education opportunities to
both provider and coder/auditor
Look for education as part of
your contract
•Don’t just check the box – take action
•Internal staff may not have capacity or
feel comfortable in delivering
education to providers
Allow experts to apply industry
standards
•Overlooked guidelines/guideline
changes
•Benefit from payer audit findings for
other entities

25. BCA
Partnership
with
Compliatric
•Let us help you get back in compliance
•External, unbiased audits by certified coders
•Auditors experienced in FQHC billing, coding, auditing
•Audit administration automated for you
•Well-versed in multiple value-based care models
•Diagnosis and procedure coding reviews

26. Questions?
26
We offer on demand training, see us at:
www.bcarev.com
T: 208.736.3755 www.bcarev.com