Beyond Benchmarking: Integrating Audit Analytics into Day-to-Day Compliance Operations. Jared Krawczyk, Mathematician - Fi-Med Management Inc.

Transcription

1 1 Beyond Benchmarking: Integrating Audit Analytics into Day-to-Day Compliance Operations Presented by: Jared Krawczyk, Mathematician - Fi-Med Management Inc. Curtis Udell, CPC, CPAR, CMPA Director of Compliance Center for Vein Restoration 2 Session Agenda Introduction Speakers / Audience Compliance Imperatives & Benchmarking Challenges Benchmarking at the Statistical Level Identify your Statistically-Hot Code Issues and Providers Importance of Understanding Peer Group Data Explore Benchmarking Techniques to Simplify Profiling Process Integrate Monthly Analytics into Compliance Ops Q&A HCCA 2013 National Conference 1

2 3 Your Compliance Imperatives Never-ending Compliance Mission Monitor / Prevent / Detect / Investigate / Remediate Maintain an Effective Compliance Program Look at all risk areas and we know them all, right? Can t manage what isn t measured We need to support effectiveness through metrics Problems identified and detected Providers audited and problem(s) fully vetted Structured remediation efforts ROI Revenue (impact) and Cost reduction (savings) averted audits, overpayments, fines or penalties 4 Your Compliance Reality HCCA Surveys: Stress & Economy (Jan/Feb 2012) Job Stress and Position Challenge: 50-70% report stagnant or declining Staff & Budgets Stress of the Position / Responsibility: 60% report Losing Sleep or Considering Leaving Job Greatest Cause of Stress: >60% associated with Prevention / Detection / Investigation and Remediation >40% have fears of missing something HCCA 2013 National Conference 2

3 5 Common Benchmarking Challenges Restricted Resources: Staff / Budgets / Data / IT and Applications Data Issues: Comparative Benchmark Data Source Reliability, Specificity and Relevance Scope Only E/M vs all CPT, modifiers, RVU and Time Internal Provider Data: Timeliness of billing and production data Provider Scope 100% or need to divide and conquer Reliance on other depts. for data (Billing / IT / Practice) Managing the volume of data (Input and Output) 6 Common Benchmarking Challenges Analysis: Biggest Issue = Resources, Time and Effort Manual vs Automation (learning to love Excel!) Data Interpretation: Busy Tables + Color graphs = Data Overload Meaning behind the numbers? STATISTICAL RELEVANCE? Work-Plan: Can data & results assist the work-plan path? Consolidate results & impact into meaningful action Define priorities by Code, Dept, Location & Provider Operationalize Assignment / Audits / Remediation HCCA 2013 National Conference 3

4 7 Importance of Benchmarking Value of outside looking in : Meet compliance imperatives, mission & objectives Compliance Dept = Revenue Assurance Applications: Current providers (Cycle & Focused Audits) New provider due diligence reviews Consolidate functions across health system Facility / Practice / Provider New ACO Requirements Risk Mgmt / Compensation / Performance Reviews Revenue Cycle / Cost Mgmt / Initiatives (PCMH / PQRI) The New View - Statistical Benchmarking Proof Positive: Analyze statistical variance at 95% CI Identify statistically-hot coding issues and/or providers know where to focus limited resources Move from manual needle in haystack review to automated assessment of 100% of provider billing Detect and identify help to refocus work-plan path Monitor track and trend data over time measure change, remediation efforts (ensure behavioral change) Validate genuine reasons for outlier issues (ie, patient population, subspecialty, teaching, etc.) Data control Staff accountability Integration 8 HCCA 2013 National Conference 4

5 9 Entire Spectrum of Compliance Benchmarking Evaluation and Management Coding Audit Risk Revenue Potential Cross-Category Behavioral Trends Procedural or Non-E/M Coding Surgical / Imaging Drugs / Injections Modifiers OIG identified high risk modifiers CMS CERT Study OIG Time Study 10 Comparative Data Notes Benchmarking data is always wrong and is to be only used as a reference point Need to understand two concepts before conducting a benchmarking analysis: The goal of the analysis The bias that are in the comparative data Common bias to be aware of: Volume of data (Total / Specialty / Locality) Sub-specialty data Pay mix HCCA 2013 National Conference 5

6 11 Example #1: University Neurosurgery University University 12 Example #2 : CMS CBR Report HCCA 2013 National Conference 6

7 13 Example #2 Cont. : CMS Data 14 E/M Benchmarking Two Basic Types of Benchmarking Intra Category Distribution Analysis Specific High Risk E/M Code Analysis How to simplify the process: Get analysis results down to a single number Calculate category distribution variance Determine risk by accounting for volume Hypothetical charge adjustment/differential Redistribute frequencies and apply fee schedule HCCA 2013 National Conference 7

8 15 E/M Intra Category Variance Quantify over/under utilization potential per provider with an objective differential Use the RBRVS database to calculate average weighted RVU per E/M category Assumptions: RVU value per E/M service increases, so does complexity of the service The higher the RVU value within a category, distribution shifts towards higher utilized services 16 How to Calculate Provider s weighted average RVU SUM (Utilization % for each code in E/M category X its respective RVU value) Compare the provider s average RVU by category to the national average for the same category and specialty Resulting ratio determines the variance HCCA 2013 National Conference 8

9 17 E/M Variance Example 18 Risk More Than Just Variance Account for the volume of each particular category/service performed Biggest bang for the buck Quick E/M risk formula: (E/M Category Variance) X (E/M Category Volume) = Risk Score HCCA 2013 National Conference 9

10 19 Risk Score Example 20 E/M Audit Risk HCCA 2013 National Conference 10

11 E/M Revenue Potential 21 E/M High Risk Code Analysis 22 HCCA 2013 National Conference 11

12 23 Calculate Charge Adjustment Redistribute the provider s frequency total to match the national peer group expected coding distribution Apply fee schedule to the provider s per code frequency totals Sum all E/M CPT charge totals to determine the category redistributed charges Charge differential: Original charge amount minus redistributed charge amount 24 Charge Differential Example HCCA 2013 National Conference 12

13 25 High Risk Modifier Analysis Top OIG Modifier Targets Modifier 24 Modifier 25 Modifier 59 How to properly calculate utilization: Modifier usage as a percentage of how it is properly billed 26 High Risk Modifier Analysis HCCA 2013 National Conference 13

14 27 Top 25 Procedural Analysis See 100% of a provider s billing compared to peer Benchmarks the following: Surgical procedures Imaging procedures DME Drug and Injections E/M services How to properly calculate: Usage of each service as a percentage of total billing frequency 27 Top 25 Procedures 28 HCCA 2013 National Conference 14

15 Top 25 Procedures Monthly Benchmarking Benefits Benchmark monthly to trend track coding behavioral change over time Measure impact of educational plans Conduct analytic audits to minimize need for documentation reviews Respond proactively & timely to potential issues HCCA 2013 National Conference 15

16 Trend Tracking Example # Trend Tracking Example # 2 HCCA 2013 National Conference 16

17 33 Thank You Feel free to contact us with any questions. Jared Krawczyk (414) Curtis Udell, CPC, CPAR, CMPA (703) Application: HCCA 2013 National Conference 17