All right, and this segues into my next talk, which is auditing best practices. So we're going to talk a little bit about benchmarking, GI-specific benchmarking, the internal audit process and compliance tools. We're going to go over some of the types of payer audits that you may get. And then we're going to end it with how do you respond to a payer audit. So polling question, this is a true or false. Some payers only give you 30 days to respond to an audit. Is that true or is that false? Oh, good. 86% of you say true, and that is true. So if you ever get an audit request, make sure you look, number one, look at the date at the top of the letter. It's not the date you receive it in your office. It's the date at the top of the letter. And some only give you 30 days to respond. And if you don't have the response in their office within that 30 days, guess what happens? They get to keep their money. So got to pay attention to that. All right, so let's talk a little bit about benchmarking. OK, benchmarking is to minimize the risk of an audit. Providers must be aware of and understand their utilization of E&M codes. OK, so providers should know if their use of each level is in line with benchmarking for your specialty. So there are some tools out there and some availability to where it shows you the national average for GI and what those levels of services are. And you definitely, practices should be aware of this and run your data, run a report in your practice to see what are the percentages of our levels that we submit and do we kind of fall in that bell curve. And if you've got a provider that's way outside the bell curve, guess what happens? Payers get, you know, and you guys might have actually, any of you listening in may have experienced this. You get a letter from the payer that says, you're billing too many level fours. All right, and it's kind of, we always say it's like the scare letter. It's like, they're going to scare us into coding what? Undercoding, it's like, OK, fine, I'm just going to submit twos and threes and hope I'm right. You have to know the documentation guidelines, but make sure that there's not an outlier in your practice. So here's kind of a, this shows you the national percentages of the levels of services you bill for. All right, so new patient, 201 through 205. Obviously, 201 is probably going to be dwindling down, but as you can see, 203 and 204 is our higher levels, the percentages of levels that are billed. And that, I would agree with that, level threes and fours. All right, established. Again, level three, level four are your biggest percentages. Initial hospital care, over 50%, 99222, and then you've got a 223 right after that. Subsequent hospital visits. The 66% level twos followed by three, level threes and level ones are pretty well neck and neck. OK, so you kind of have to, so again, run that report in your practice and compare it to the bell curve and make sure there's not, again, someone that's just kind of sticking out there as a red flag there, because then you'll start getting those letters. Internal audit process and compliance tools. So compliance, you have to have a compliance plan. Don't just assume everybody knows how to bill, code, all that stuff, and that's the thing, and I think that's the frustrating piece of this information that we're, you know, all this information that we're going over today, is that physicians, nurse practitioners, PAs, you didn't get this stuff when you went through your training. You went through training to take care of your patients, but unfortunately, we have to know these guidelines in order to stay compliant and keep our money. So assign an appropriate member of your staff to review your billing process and develop the compliance plan. So you should have a compliance officer. That person should be very savvy in building compliance plans and knowing how to do reviews and running those internal reports, et cetera. Include policies and step-by-step processes for responding to an audit. Review internal billing data to identify your patterns and conduct frequent coder training and provider education. So you might have coders in your practice, and they have to have ongoing training, especially if they're certified. They have to have ongoing training in order to keep their certifications, just like physicians, just like, you know, anybody in this, in the health care organization. But we have to educate our providers. We can't just keep the, hold the information at our desk and hope the physicians just guess right, okay? And that's, it's all part of communication. Again, very important for you to do internal audits. Those of you, if you can get a certified coder, sometimes they're hard to find, get a certified coder. They have to keep up with their certifications. And we always say determine how frequently that you do your internal audits. You can do in quarterly basis. Determine the type of review. Like I said, you can pick a specific level of service. You can pick a specific procedure code. You could pick a specific provider. So completely up to you. Just don't assume that everybody knows what they're doing and it all just, you know, goes through freely. That's why payers do reviews, okay? They, it's kind of like they check on you. They check to make sure you're being compliant and you're billing correctly for those services that you're rendering. All right, so also define the scope of your review as will it be prospective or retrospective? So prospective means we're going to look at information before it's billed out, okay? And that's pretty well what we recommend is we want to catch it beforehand because if you do a retrospective review, which means we're going to look at information that has already been billed, the thing is if you identify some errors, you're going to have to resubmit and do corrected claims, okay? So best practice is to perform prospective reviews, not retrospective, just so you can identify potential errors internally. Create spreadsheets of findings, okay? So one area should contain the coder's selection and then an auditor's result or it might even be just the physician's selection. So, you know, a lot of practices don't have the staff to look at every single thing before it goes out the door, so a lot of times the physician, the provider is responsible for selecting that level of service. So, again, whoever it is, make sure that we are providing that information back to them. You're educating them. Include over-coding, under-coding, financial impact, comment sections. Just make sure that you explain what is wrong with it, okay? You should have meetings, okay? If it's maybe a coder and supervisor, compliance officer, meet with the physician one-on-one, go over the guidelines, go over, you know, just making sure that we all are kind of on the same page. Identify problems. So it may not be a physician error. It could be a keystroke, data entry area, coder error, poor documentation. Again, it's just education and making sure that we stay compliant. Determine corrective actions to avoid improper payments. Track and research denials. A lot of this information comes from the denials that we receive. So, you know, if you've got providers ordering endoscopic procedures for diagnosis codes that are not payable, that are not medically necessary, supported for medical necessity, and we've been talking about that all day, we have to make sure and communicate that back to that provider so they don't keep doing it. You know, if we don't tell the providers what denials we're getting, what, you know, information to do, they're not going to know. They're not going to correct the problem. Very important to keep up-to-date on payer policies, okay? So local Medicare contractors. Those of you listening, you should know who your Medicare contractor is. Get on their website. They have great information. You know, obviously a lot of them are easier to navigate than others, but they have really good, most of the Medicare contractors out there have really good modifier information, like appropriate use and inappropriate use with examples. They've got, again, local coverage determinations as to what diagnosis codes are approved for a specific procedure or monitored anesthesia care, things like that. Very good resources. They even have Q&A sections, and you can get a lot of information just reading their Q&A, so take some time to familiarize yourself, someone in the practice, familiarize yourself with your local Medicare carriers, okay? So print your LCD. So, again, share this information. If you've got a provider ordering a procedure with a diagnosis code that's not payable, don't just keep that information at your desk and write the charge off and go about your business. You have to explain that to the provider, okay? Review OIG annual work plan. They tell you, if you get on their website, they tell you what they're looking at for audit areas. Monitor recovery audit contractor progress and updates, okay? They also all have websites. Communication is key, okay? Billing coding managers should communicate payer policy changes to the staff. Coders and billers need to communicate with each other to make sure we're all consistent, we're all doing the same thing. Everyone, everyone must communicate back to the provider. They can't fix mistakes if they don't know about them, and that's just critical. So types of audits, all right? So you've got a compliance plan, you're doing internal auditing, making sure that you're staying compliant. What types of audits can you get? Well, we've got OIG, and they have kind of, again, they have a list of areas that they focus on. So they're an objective oversight that promotes economy, efficiency, and effectiveness in the programs and operation of the health and human services. OIG's program integrity and oversight activities are shaped by legislature, okay? OIG carries out its missions to protect the integrity of HHS programs and the health and welfare of the people served by those programs through a nationwide network of audits, investigations, and evaluations conducted by the following operating components with assistance from the OIG. The task list applies to hospitals, home health, physicians, chiropractors, ambulance, lab, DME. Basically any entity that accepts federal money is subject to a review, okay? Incident two and split shared. Remember, I just talked about this, and they say more than 85% of claims reviewed for these types of services were incorrect. That's not going away. And now that we're getting a little bit stricter on the shared guidelines, probably going to be some more issues there. Modifier 25, okay, that's another thing that they look at. So modifier 25 means I performed a significantly separate visit on the same day as a procedure or other service. So we have to make sure that it's not, oh, I stuck my head in the door, and I'm going to write a sentence, and I'm going to bill for a visit. It's I evaluated the patient. I made recommendations other than what they're being seen for today, or like the procedure that's being performed today or the infusion that's being done today, anything like that. Billing your higher levels, those will also be reviewed, 214s, 215s, 233s. Providers must understand the components to support those levels. 99233, I'm just going to make a comment about this. That is the highest follow-up subsequent visit in the hospital. 99233 is comparable to a 215 in the office, okay? So think about that. Sometimes I think providers have a misunderstanding of the hospital follow-up visits. There's only three levels. There's a level one, two, and three. So they think level three, and they kind of think, oh, that's probably like a level three in the office, but it's not. Okay, so just make sure you're aware of that. New versus established patient. So know when to bill. When can you bill a new patient versus established? It's the three-year rule, okay? Even if the patient has a colonoscopy from Dr. A two years ago, and you're seeing the patient, new patient, as a Dr. B or the nurse practitioner or whatever, follow-up, it's a follow-up visit. So you have to know the guidelines there. Modifier 59. Okay, so we can't just put a modifier 59 on everything and hope it gets paid. No, you have to follow CCI policy, CCI edits, and making sure your documentation supports the separate site, separate lesion, et cetera. Medicare 60-day rule. It says if you become aware of an overpayment, you are compelled by Medicare law to refund the money within 60 days of the identified overpayment. Failure to do so may result in false claims and civil monetary penalties. That just is scary, okay? So if you become aware, you have 60 days as soon as you identify it. Cloned records. I'm going to talk about this. I think it's my last talk today. Make sure you customize your notes. Auditors are being trained and educated on the quality, not the quantity, okay? They will request two, three, four visits in a row and make sure they're customized, okay? Change your notes. They shouldn't all look the same. Place of service errors. They look at that. You know, obviously, we get paid more if we own it in the office than if we go over to the facility and do something. So you have to make sure that your place of service is correct. Observation versus inpatient. Making sure you're holding those observation charges for a couple days just in case the patient switched to inpatient because what happens? Oh, I got to get the bill out the door. So you bill it as observation. And then the patient switches to inpatient and Medicare will convert that entire stay to inpatient. And they're going to deny your claim for a place of service error. Guess what? It is your error. You have to match the hospital's designation, okay? Those are just a few. I mean, I could talk about the types of audits and what they're looking at all day long, but those are just some of the top for GI. So what's a RAC review? Recovery Audit Contractors. They are contracted by Medicare to find your claim deficiencies, okay? Improper payments, things like that. So they're definitely not going away. You should know who your RAC is, okay, because you will get letters from them requesting records. All right, I live in Missouri. I'm Region 2 cotivity. I can get on their website. I can email them. I can call them. So utilize their websites. Reach out to them if you have questions. Assert, that's another type of review. Certified Error Rate Testing. Established by CMS to monitor the accuracy of claim payment in the Medicare fee for service program. The intent of the CERT program is to protect the Medicare trust fund by identifying errors and assessing error rates on both the national and regional level. Findings from the CERT programs are used to identify trends that are driving the errors, such as errors by a specific provider, type or service, and assist with allocation of future program integrity resources. So claims are randomly selected for a CERT review. The provider will receive a letter via fax or U.S. mail from CMS requesting documentation to be submitted for review. To ensure your letter is a valid CERT request, the first page contains the CMS logo, a barcode, and has been signed by the CMS CERT government task leader, okay? CERT errors are typically not because the services were not necessary. Rather, they indicate either failure to submit documentation or a lack of documentation to support medical necessity, things like that. There was an update, too, and I wanted to include this slide because I wanted to talk about your signature, your signature on your medical records. And this was a good update from the CERT in regards to one area of scrutiny concerns the amendments and corrections made to your medical record, okay? So they are finding significant errors in amended records. So this is not just Medicare issue. This is a commercial payer. This is anybody. Medical record is a medical legal document. You have to sign it correctly. And this is from Noridian, which is a Medicare contractor, and they have good information concerning proper corrections to the medical record. And here are some of the excerpts from this document. It says, late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum, or a correction to the medical record bears the current date of that entry and is signed by the person making the addition or change, okay? So a late entry supplies additional information that was omitted from the original entry. It bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry. So here is an example. A late entry following treatment of multiple trauma might add abdomen soft with no masses or organomegaly and sign. You know, we understand that there are, you know, we're going to make mistakes. We're all human. We might accidentally click a template wrong and leave off the physical exam. I've seen that done before. If you have total recall, you can add an addendum for late entry and include that information. However, you know, if it's six months later, I have a feeling you're probably not going to have total recall. An addendum is used to provide information that was not available during the original entry. So you're adding that information. So it could say, so maybe you ordered a CT scan and you want to include that finding, okay? So then you can put that finding in an addendum. A correction, what happens if you're like, uh-oh? So someone addressed a contradiction or a misspelling or something like that. It says when making a correction to the medical record, never write over or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible, sign or initial, and date the deletion stating the reason for the correction above or in the margin and document the correction. Okay, now, I'm thinking of this. When I first read this, I'm like, oh, my gosh, this is like it takes me back to when we didn't have electronic medical records and we had handwritten notes, and it was easy to make a correction. The physician, you know, drew a line through it and then wrote on the side, you know, what the correction was. Now, I mean, we can still, you know, mark a line through it, but in that addendum, enter that correct information, but don't write over it, don't delete it, things like that. It says correction of electronic medical records should follow the same principles of tracking both the original entry and the correction with the current date, time, and reason for the change and your initials. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected records submitted must make clear the specific change, the date, and the identity of that person. Okay. Here's falsified documentation. Providers are reminding that deliberate falsification of a medical record is a felony offense and is viewed seriously when encountered. So here are some examples. Oh, and this is just a big no-no, creating a record when records are requested. Oh, gosh. Okay. You shouldn't be billing for anything you don't have documentation of. Backdating, postdating, predating, writing over, or adding to existing documentation unless it's in the form of those that we just went over. All right. And, you know, we've done lots of reviews. We've done lots of training, and we have heard some scary stuff, but it's out there. It's like, oh, yeah, I can just unlock my note and change everything and sign it again. It's like, no, once you sign it, it should be locked. Any additional information you need to add should be added in an amendment. That's correct documentation. All right. Then we've got individual payer reviews. Okay. And sometimes those individual payer reviews are worse than RACs and CERTs and OIG. Okay. We've been into practices doing training, and they've got stacks of medical record requests from a commercial payer. So it's not just Medicare. Then you've got your ZPICs. All right. ZPICs, these are the guys that you never want to come see you. They're called the Zone Program Integrity Contractors. This is to investigate suspected fraud, waste, and abuse. So this means they've identified a clear issue of fraud, waste, and abuse. Okay. They are in a timely manner. They take immediate action to ensure that Medicare trust fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the Medicare contractor. Okay. So actions that take to detect fraud, waste, abuse, Medicare program include investigating potential fraud and abuse for CMS administrative action or referral to law enforcement, conducting investigations in accordance with the priorities established by CPI's fraud prevention system, performing medical record reviews as appropriate. Okay. Identify the need for administrative actions, payment suspensions, prepayment reviews, referring cases to law enforcement, often work with the FBI. These are not a random review. It's like a raid. Okay. So if you have them all knocking on your door, they can tell you to leave, and they'll look at your computers, your everything. So, yeah, this is more of a raid. Never want those guys knocking on your door. All right, how do you respond to an audit? Routine audits, those that do not involve some suspicious suspicion of false billings or fraudulent activities should nevertheless be treated extremely serious. Okay. If the letter or audit notice is from the ZPICs, like I said, it usually comes in the form of a subpoena. If any FBI agent or OIG special agent is involved, it's extremely serious. Retain a healthcare attorney immediately. Even on a routine audit, given the possible consequences, we recommend you retain an experienced healthcare attorney. Okay. All correspondence from Medicare or Medicare contractors should be taken seriously. So all of it is. If a payer is requesting information from you, you've got to respond to it. Read the letter. What are they asking for? So read the letter carefully and provide all information requested. Include anything that helps defend what you billed. Okay. Don't just say, oh, here, have the whole entire patient's medical record, anything you want. Just give them what they're requesting. So if it's a progress note for 5-1, send them the progress note for 5-1. However, I always say this, too, you know, if you build an endoscopy and they're requesting records on the endoscopy, and let's say you bill based on pathology findings, I would send the endoscopy report and the pathology report because that helps also to support what you billed. Okay. So you have to look, send the correct information. Make sure that the records you send back to them are legible, good copies. All right. You also should give the provider a copy of the letter. They should know who is requesting their medical records. Never alter the records after notice of an audit. However, if there are consults, orders, tests, et cetera, that have not been filed into the chart, you can scan those and upload those into the chart. Altering a medical record can be basis for fraud claim, including criminal penalties. So don't change anything. Just give them what you have. Copy each page. Make sure they're legible. Again, good copies. Make color copies if you can. Include a brief summary of the care that you provided. Okay. So anything that helps defend what you billed. Include an explanatory note and any supporting literature. So clinical practice guidelines, LCDs, medical journals, anything else to support what you're billing. Again, keep copies of everything that you send to them. And again, pay attention to the date and how long you have to respond to that audit. Consult an attorney again and be prepared to test the results of audits. Never accept findings at face value. Sometimes it may even take your director and the medical director at the payer side to get something paid or defend what you're doing. And that's okay. The thing is, is, you know, any kind of denial you get, you write it off, nobody knows about it. That's what the payer wants. They kind of want you to, you know, they want to keep their money. We want to be a thorn in their side. So if you really believe that you billed correctly, go up the chain. Never accept that at face value.

auditing best practices

healthcare industry

benchmarking

internal audits

payer audits

responding to payer audits