Agenda / Overview. Trinity Health: Unified Enterprise Ministry

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1 Don t Take Those Old Records off the Shelf: Change Your Tune Using Real-Time Monitors to Focus on Risks Identified by OIG, CMS and Other Regulators Andrei M. Costantino, MHA, CFE, CHC Director, Organizational Integrity & Audit Services Health Care Compliance Association April 23, 2012 National Harbor, MD Agenda / Overview Overview of Trinity Health Current Regulatory Environment Audit / Monitoring Approach Benchmarking / Data Analysis Tools of the Trade Developing Real-Time Monitors Next Steps Questions and Answers 2 Trinity Health: Unified Enterprise Ministry Serving Ten States Nationwide One of the largest Catholic health systems in the United States (based on Operating Revenue) 53,400 full-time equivalent employees More than 9,000 active staff physicians (over 3,200 employed) 20 Ministry Organizations, encompassing 47 hospitals 35 owned, 12 managed 401 outpatient centers Revenues of $9 billion Over $455 million in Community Benefit Ministry Copyright 2011 Trinity Health Novi, Michigan 3 1

2 Who s Who in Health Care Enforcement Recovery Audit Contractors (RACs) Medicare and Medicaid Medicaid Integrity Contractors (MICs) Medicare Administrative Contractors (MACs) Responsible for both Part A and Part B claims Accountable by CMS for reducing payment errors to providers on front-end Zone Program Integrity Contractors (ZPICs) Data mining and analytics Health Care Fraud Prevention and Enforcement Action Team ( HEAT ) Medicare Fraud Strike Teams HHS - Office of Inspector General (OIG) Hospital Audits Department of Justice (DOJ) $8 to $1 return 4 5 Audit/Monitoring Approach Trinity Health is re-evaluating our approach to auditing and monitoring in consideration of: Impact of proposed 60-day repayment rule and 10-year look back period Challenges in handling of voluntary repayments with various CMS contractors Increasing volume of audits performed by CMS contractors (RACs, MACs, ZPICs, MICs, QIO and CERT) Unified Revenue Organization increasingly performing auditing and monitoring activities of hospital claims Copyright 2011 Trinity Health - Novi, Michigan 6 2

3 Audit/Monitoring Approach Develop additional continuous monitoring, predictive modeling and data analytic capabilities Goal to mirror CMS predictive modeling objective Leverage data available in internal systems Use available industry data (e.g. PEPPER, CMS) for benchmarking Real Time focus on risks identified by OIG, CMS and other regulators Limit performance of retrospective claim audits Copyright 2011 Trinity Health - Novi, Michigan Audit/Monitoring Approach Resources will be needed to increasingly respond to CMS audit contractor activity Action plans, follow-up and monitoring of CMS contractor audit issues Trinity CMS Copyright 2011 Trinity Health - Novi, Michigan Department of Pure Speculation Department of Data Analysis 3

4 Benchmarking / Data Analysis Use of Benchmark Data Analyze data Establish goals/targets Prioritize for auditing and monitoring Make your case for additional resources Develop audit plans Identify Outliers / Target risk areas Develop compliance scoring system Acquisition Due Diligence 10 Tools of the Trade 11 CMS s data sets PEPPER Reports MGMA Internal provider data Third party vendors Data Resources 12 4

5 YOU NEED A DATA GUY!!!!!!!!!!!!!!!!!! Basic comprehension of stats Structured Query Language (SQL) experience (or other database experience) Programing experience Industry knowledge is a huge plus but not necessary Standard Deviation OIG Tool of Choice Normal Operations Operational Issue Billing/Coding Concerns They re Coming!!!!! Standard Deviation shows how much variation or dispersion exists from the average (mean, expected value). Coding/Billing Validation 15 5

6 Disclaimer Disclaimer is very important: The analyses are for benchmarking purposes only and to assist in prioritizing areas for further review by hospital management Coding and billing is dependent upon the services rendered by the hospital as determined to be medically necessary and appropriate based on the patient s presenting medical condition No conclusions regarding the accuracy of coding and billing, nor compliance with government and third-party payer rules and regulations can be made without further review of the provider s underlying medical records documentation. 16 What To Do With The Data Develop real time monitoring that includes the following: Modifier -25 Modifier -59 Reimbursement > charges Unit problems MS-DRG coding and medical necessity Physician Data Analysis Analyzing data for audit purposes Develop a dashboard/scorecard reporting tool 17 Modifier -25 Distribution 18 6

7 Modifier -25 Example 19 Modifier -59 Monitor Trend the use of modifier -59 across each facility Running monthly average Identifies top 10 codes reported with -59 appended Contact to individual facility when spike occurs Monthly, quarterly or annual summary report Can dive deeper into data to identify specific code sets when data indicates anomaly Need to exclude certain HCPCS codes so that the denominator is not diluted e.g. evaluation and management services 20 Sample: Modifier -59 Report 21 7

8 OIG Inspired Monitors Lesson learned from current OIG hospital audits Inpatient and Outpatient reimbursement greater than charges Inpatient Payments greater than $150,000 Outpatient Payments greater than $25,000 Outpatient Surgery Units greater than 1 22 Examples of OIG Inspired Monitoring Reports IP or OP Payment > $1K over charges IP Payment > $150K OP Payment > $25K 23 OP Surgery Units of Service >

9 PEPPER Example Select the PEPPER target area you want to track internally Recreate the national 80 th and 20 th percentile data and hospital specific data Extend the national percentile data Average the 12 previous quarters and use the average as the monthly or quarterly data point Use real-time internal hospital data Two choices for reporting: Enter internal data monthly (wide variances) Enter internal data quarterly (evens out the monthly variation) 25 Example: PEPPER Focused Inquiry/ Review Copyright 2011 Trinity Health - Novi, Michigan Physician Benchmarking / Data Analysis Develop Physician Snapshot that includes the following: E/M level coding distribution peer analysis Visit per day analysis Modifier use Work RVU analysis Revenue Analysis 27 9

10 Using Internal Data to Define Scope Identify highest reimbursement; highest volume services within the organization Sort and analyze data to determine top 5 departments in facility 29 Dashboards / Scorecards Physician Inpatient Outpatient 30 10

11 Spike in Data..Next Steps Reach out Ask questions; New hire, software, new service line, operational issue? Do a deeper data dive Pull records validate Sampling? Potential payback? Follow-up data analysis 31 Current Issues / Challenges 32 Reality 33 11

12 Questions/Discussion Thank-You for Your Attendance and Participation! Follow-up questions can be directed to: Andrei M. Costantino, MHA, CFE, CHC, CPC-H, CPC Director, Organizational Integrity Trinity Health (248)