3/17/2016. Unleashing the Power of Data Analytics Presented to: 2016 Compliance Institute. Today s Agenda. What Makes CHAN Healthcare Unique

Transcription

1 Unleashing the Power of Data Analytics Presented to: 2016 Compliance Institute 2016 CHAN Healthcare 1 Today s Agenda What Makes CHAN Unique Adding Value through Data Analytics Using Data Analytics in the Audit Process Examples of High Value Data Analytics 2016 CHAN Healthcare 2 What Makes CHAN Healthcare Unique The only U.S. provider of internal audit, risk consulting and cybersecurity services dedicated solely to healthcare organizations Our dedication to healthcare gives us deep industry knowledge, insight, and intense focus that are unmatched by any other firm We help approximately 600 provider care entities across the country effectively manage risk and meet their compliance obligations We provide more than 5,000 action plans annually to improve controls and processes CHAN identifies millions in revenue enhancements and costs savings for clients each year We apply our deep industry knowledge and expertise to develop sound methodology and advanced technology tools As a subsidiary of Crowe Horwath LLP, CHAN has access to additional subject matter experts and advanced technological innovation 2016 CHAN Healthcare 3 1

2 Data Analytics Definition Process of identifying, gathering, validating, analyzing and interpreting various forms of data using computerized tools to provide meaningful intelligence CHAN Healthcare 4 Benefits of Data Analytics Risk Value Risk Value Risk Value Cost Cost Cost More risk focused More efficient Higher value 2016 CHAN Healthcare 5 Why Data Analytics? Why Now? Increasingly complex business landscape Fast paced business environment Increasing expectations of stakeholders Limitations inherent in traditional audit techniques Need to move towards an environment of more sophisticated risk analysis and monitoring Availability of powerful data analytics tools Explosion of data 2016 CHAN Healthcare 6 2

3 Emerging Risks in Healthcare 2016 CHAN Healthcare 7 Traditional Method No Data Analytics Next Generation With Data Analytics Benefits Investment Benefits Investment 2016 CHAN Healthcare 8 Overview of the Internal Audit Process Risk Assessment and Audit Plan Development Audit Planning Fieldwork Follow Up Continuous Auditing/Monitoring 2016 CHAN Healthcare 9 3

4 Data Analytics in Healthcare Video 2016 CHAN Healthcare 10 Risk Assessment and Audit Plan Development 11 Data Analytics in Risk Assessment and Audit Plan Development Provides knowledge and insight into operations Facilitates and encourages conversations Adds auditor confidence in uncomfortable areas Offers a quantified risk assessment 2016 CHAN Healthcare 12 4

5 Examples of Data Analytics Risk Assessment Charge capture analysis Healthcare compliance analysis Financial analysis Trending and Benchmarking Other routines such as patient access, denials, LOS, CDM and E&M analysis 2016 CHAN Healthcare 13 Example of Data Analytics Risk Assessment - Financial Analysis Summarize Trial Balance By revenue and expenses By company Compare current year to prior year 2016 CHAN Healthcare 14 Example of Data Analytics Risk Assessment - Benchmarking 2016 CHAN Healthcare 15 5

6 Example of Data Analytics Risk Assessment - Trending Regulatory Findings Audit Action Plans 2016 CHAN Healthcare 16 Audit Planning 17 Data Analytics in Audit Planning Focuses audit resources on high risk areas Facilitates audit efficiency Provides insight into operations 2016 CHAN Healthcare 18 6

7 Example of Data Analytics Audit Planning Managed Care Managed care contract reimbursement risk identified Management uncertainty of the payors/contracts most at risk Data analytics identifies high risk payors/contracts of focus 2016 CHAN Healthcare 19 Example of Data Analytics Audit Planning Charge Capture Perform to target specific department(s) or areas Use to focus audit resources to high risk areas 2016 CHAN Healthcare 20 Example of Data Analytics Audit Planning Evaluation & Management Codes 2016 CHAN Healthcare 21 7

8 Example of Data Analytics Audit Planning Evaluation & Management Codes 2016 CHAN Healthcare 22 Fieldwork 23 Data Analytics in Fieldwork Uses scarce audit resources effectively Increases audit efficiency Allows for analysis of 100% of a population Provides quantified results Expedites fraud detection AUDIT 2016 CHAN Healthcare 24 8

9 Example of Data Analytics Fieldwork Managed Care Audited managed care contract reimbursement Fieldwork results suggested that the payor was compliant Gaps were found between charges and contracted rates 2016 CHAN Healthcare 25 Example of Data Analytics Fieldwork System Access Identify terminated employees with access to critical systems No process to communicate terminated employees 2016 CHAN Healthcare 26 Example of Data Analytics Fieldwork Payroll Fraud Engaged to quantify the impact of a PTO fraud scheme PTO diversion enabled by inappropriate access Media pressure created urgency in resolution Supported management in addressing issues 2016 CHAN Healthcare 27 9

10 Example of Data Analytics Fieldwork CDM Comparisons CDM pricing compared to contracts and competitors Revealed charges below contracted rates Identified charges above or below market pricing Success led management to request additional projects 2016 CHAN Healthcare 28 Example of Data Analytics Fieldwork Drug Diversion Analyzed drug dispensing records and identified: Late or incomplete drug administration records Dispensing of drugs from unexpected stations Excessive waste and witness nurse combinations Exceptional override, waste and witness transactions 2016 CHAN Healthcare 29 Example of Data Analytics Fieldwork Pyxis Analysis Audited Emergency Department drug dispensations Identified dispensations not traceable to a patient log Success led to ongoing monthly continuous monitoring 2016 CHAN Healthcare 30 10

11 Example of Data Analytics Fieldwork 340B Mixed Use 340B mixed use pharmacy audits identified: Lost savings due to missed 340B accumulations Ineligible accumulations Inappropriate inclusion/exclusion of Medicaid activity Inappropriate monitoring of Orphan drugs Drug purchases in excess of eligible dispensing records 2016 CHAN Healthcare 31 Example of Data Analytics Fieldwork 340B Contracted 340B contract pharmacy audits identified: Ineligible accumulations Credit transactions not being processed Inappropriate inclusion/exclusion of Medicaid activity Ineligible carveout drugs Drug purchases in excess of eligible dispensing records 2016 CHAN Healthcare 32 Follow Up 33 11

12 Data Analytics in Follow Up Very efficient use of resources Simplified data access More efficient data validation Leveraged programming syntax Straightforward and efficient exception testing Identification of patterns, outliers and trends 2016 CHAN Healthcare 34 Example of Data Analytics Follow Up Examples of data analytics in Follow Up are as limitless, some examples include: 340B Drug Discount Charge Capture Payroll and Paid-Time-Off AR Valuation (Hindsight) 2016 CHAN Healthcare 35 Continuous Auditing 36 12

13 Data Analytics in Continuous Auditing Traditional auditing Broadens audit coverage Uses scarce resources more efficiently Best Practice INVOICE 2016 CHAN Healthcare 37 Example of Data Analytics Continuous Monitoring AR Valuation 2016 CHAN Healthcare 38 Example of Data Analytics Continuous Auditing Three Day Rule TEST DESCRIPTION POPULATION EXCEPTIONS % Number of Clinic patients meeting 3 day rule requirement SSN % Number of Clinic patients meeting 3 day rule requirement - Name % 2016 CHAN Healthcare 39 13

14 Example of Data Analytics - Continuous Auditing Duplicate Payments 2016 CHAN Healthcare 40 Key Takeaways 41 Key Takeaways Rapidly changing industry Next Generation Internal Audit Specialized resources Deeper risk coverage Innovative thinking Knowledge growth for Auditors 2016 CHAN Healthcare 42 14

15 43 The Sky is the Limit 30 Day Readmissions Analysis 340B Drug Discount Program Review Accountable Care Organization Accounts Payable Review Accounts Receivable Valuation / Hindsight Analysis Anesthesia/CRNA Contract Analysis Balance Sheet Review Cardiac Catheterization and Electrophysiology Lab Charge Capture Charge Description Master (CDM) Review Data Profiling and Outlier Testing Denials Analysis Diagnostic Radiology Charge Capture Drug Diversion Detection Due Diligence Support Emergency Department Charge Capture Employee Expense Reimbursement Analysis Evaluation and Management Coding Analysis Excluded / Sanctioned Provider Analysis Fraud Detection Gastrointestinal (GI) Lab Charge Capture Hospital Acquired Condition (HAC)/Present On Admission (POA) Analysis Hospital NCCI Edit Analysis Interventional Radiology (IR) Charge Capture Invalid Social Security Number Testing and Deathmaster Comparison Journal Entry and Trial Balance Analysis Laboratory Charge Capture Late Charge Analysis Lawson Security / Segregation of Duties Testing Length of Stay Analysis Managed Care Contract / Reimbursement Modeling Maternity Charge Capture Medicaid Managed Care Contract / Reimbursement Modeling 2016 CHAN Healthcare Medicare Managed Care Contract / Reimbursement Modeling Medication Administration Observation Charge Capture Oncology Charge Capture One Day Inpatient Stays Review Paid Time Off (PTO) Fraud Detection Pain Management Charge Capture Patient Access / Admitting and Registration Review Patient Credit Balances Payment Processing Payor Incurred But Not Billed (IBNR) Analysis Payroll Review Pharmacy Charge Capture Physician Charge Description Master (CDM) Review Physician Contract Analysis Physician Practice Managed Care Contract / Reimbursement Modeling Post System Conversion Review Purchasing Cards Analysis Relative Value Units (RVU) Analysis Respiratory Therapy Charge Capture Risk Assessment Dashboard Risk Assessment Support Same Day Readmissions Analysis Scheduling vs. Billing Analysis Statistical Sampling Support Sterilization / Ethical and Religious Directives (ERD) Analysis Supply Chain / Procurement Review Surgery Charge Capture System Interface Testing Three Day Rule Analysis Transfer in Lieu of Discharge Analysis Two Midnight Rule Review Wage and Hour Analysis Wound Care Charge Capture Value through Data Analytics Data analytics can help internal auditors meet their audit objectives. By analyzing data within key organizational processes, internal audit is able to detect changes or vulnerabilities in organizational processes that could expose the organization to undue or unplanned risk. This enables internal audit to identify changes in organizational processes and ensure that it is auditing today s risks not yesterday s CHAN Healthcare 44 THANK YOU for your time today

16 We appreciate the opportunity to tell you about CHAN Healthcare and the value we can bring to your organization CHAN Healthcare 46 For more information, please contact: Terri Allen Data Analytics Audit Director Direct: In accordance with applicable professional standards, some firm services may not be available to attest clients. This material is for informational purposes only and should not be construed as financial or legal advice. Please seek guidance specific to your organization from qualified advisers in your jurisdiction Crowe Horwath LLP, an independent member of Crowe Horwath International crowehorwath.com/disclosure 2016 CHAN Healthcare 47 16