4/26/2016. Auditing Management - Best Practice Case Study. Implement Precision. Stephani E. Scott Vice President Audit Services

Transcription

1 Auditing Management - Best Practice Case Study Stephani E. Scott Vice President Audit Services Implement Precision 1

2 Agenda: Audit Planning Audit Management & Productivity Knowing The Industry Staffing Educating The Provider Audit Case Study Planning Where should you begin? Planning Stephen Covey 2

3 Planning Have A Direction 3 Major aspects of Management Leadership - What you want to accomplish? Management - How can you accomplish it? Productivity Now do it. Planning Leadership Develop department mission statement Include everyone in the process Affirm and visualize mission Planning Leadership Identify your audit goals What you want to accomplish Audit focus - baseline, compliance, risk areas Number of audits to be performed Set realistic time lines Set accuracy thresholds may be different for specific audits 3

4 Planning Leadership Identify the center of your audit program Create a solid foundation policies & procedures, audit guidelines, post audit education Develop life support auditors / support staff / upper management Engage in successful relationships Identify specific achievements Ensure financial security Hire great people Leadership - Case Study Leadership Hire Great People Marcus Buckingham s Story of Manjit who won a contest of selling 1,600 Gillette deodorants Recognize talent and build your team Channel each employee s talents in to performance The greatest leader is not necessarily the one who does the greatest things. He [she] is the one that gets the people to do the greatest things. Ronald Reagan 4

5 Planning Keeping the Revenue Flowing Be proactive Identify strategies to ensure claims processing is not impacted Determine if audits should be prospective audits vs. retrospective Off set audit time lines around monthly, quarterly, annual financial reporting periods Target high risk / high dollar / high utilized CPT codes Planning Keeping the Revenue Flowing Include financial impact in audit results Assess revenue impact by provider, by practice Trend revenue impact Utilize data analytic software / resources Consider incentives for providers Management Efficiencies & Effectiveness Analyze, Implement, & Reassess Processes Eliminate duplication Non valued processes Identify that s how we have always done it processes Automate processes Think outside the box - innovate 5

6 Management Efficiencies & Effectiveness Keeping Deadlines Understand what timelines are not negotiable Time lines should be reasonable Develop tracking method automate if possible Frequent monitoring & reporting or status Ensure adequate resources on project Management Efficiencies & Effectiveness Keeping Deadlines Create synergy among auditor team Synergy is defined as: The interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects. Management Efficiencies & Effectiveness Quality Initiative Program Institute a Quality Audit Committee Develop audit quality standards, guidelines and corrective actions Educate auditors Conduct regular quality reviews Report & Re-educate 6

7 Management QI Case Study Importance of Having a QI Program Pre Implementation audit scores = 68% Most notable errors: 1. Inconsistent application of guidelines 2. Lack of documenting findings 3. Typographical / grammar 4. Miss calculation of scores 5. Coding Management QI Case Study Importance of Having a QI Program Developed Written Audit Guidelines Defined the Grey Areas of E/M coding HPI (chief), Exam (95 detailed), MDM (Rx management) Developed predefined Audit Finding statements Utilized better audit software Performed monthly quality reviews Enforced corrective action Management QI Case Study 7

8 Productivity Productivity Set productivity standards Time study One size does not fit all Monitor & Re-evaluate Utilize audit software Regular team meetings Identify urgent vs. non urgent projects Productivity - Case Study Productivity Audit Services Difficultly in meeting deadlines Utilized coding books Technical challenges with accessing audit software System was slow during high utilization periods Auditors became frustrated Productivity - Case Study Productivity Audit Services Poor utilized software auditor completed on paper then entered into system Software lacked: Flexibility Different E/M calculations & scoring methodologies Standardized comments Ability to audit procedures and other elements Resulted in poor quality of audits 8

9 Productivity - Case Study Productivity Audit Services Leveraged technology Implemented better audit software On-line coding books List of approved references Improved productivity by 30% Cost savings over a team of 3 auditors = 1 FTE Auditor satisfaction improved Knowing The Industry Know your MAC carrier and guidelines Review website often & attend trainings Knowing The Industry Know your at risk population mix 9

10 Knowing The Industry E/M coding results CPT coding results CPT CPT coded CPT codes added Medical Specialty Correct Overcoded Undercoded coded correct incorrect "Anesthesiology" 84% 12% 5% 89.5% 6.1% 4.3% "Cardiology" 74% 19% 7% 72.1% 25.3% 2.6% "Critical Care" 87% 7% 7% 60.0% 40.0% 0.0% "Dermatology" 79% 13% 8% 83.5% 11.4% 5.1% "Emergency Medicine" 74% 21% 5% 86.7% 5.6% 7.7% "Family Medicine" 77% 17% 5% 70.2% 25.0% 4.8% "Otorhinolaryngology (ENT)" 77% 19% 5% 61.8% 30.3% 7.8% "Gastroenterology" 63% 32% 5% 91.1% 5.7% 3.3% "Internal Medicine" 78% 15% 6% 67.9% 26.6% 5.5% "Obstetrics and Gynecology" 77% 17% 5% 68.7% 26.0% 5.3% "Orthopedic" 76% 20% 4% 79.9% 16.6% 3.5% "Pediatrics" 79% 17% 4% 68.4% 24.8% 6.8% "Surgery, General" 69% 25% 7% 76.9% 17.7% 5.3% Averages 73% 21% 6% 79% 16% 5% 10

11 Knowing The Industry OIG Work Plan 2016 Carryover Audits Anesthesia & Pain Management services Sleep Disorder Clinics high utilization Imaging Services practice expenses Incident To Services Knowing The Industry OIG Work Plan 2016 Physician Audits Referring/ordering of Medicare services / supplies Home Visits Prolonged Services Knowing The Industry Case Study Pain Management Physician SC Medicaid ID physician as an outlier Performed audit, requested $78,500 for none covered services: Consultations E/M services for specific Dx Drug Injections on same day as E/M Prolonged E/Ms Nerve conduction studies 11

12 Knowing The Industry Case Study Pain Management Physician Consultation down coded to New or Established E/M E/M services all supported Prolonged Services not supported Drug Injections all supported Nerve conduction studies all supported Staffing Common Staffing Issues Performance peak and valleys Low productivity / quality High volume of work - burn out Keeping auditors motivated Turn over Under staffed to meet audit plan Staffing Common Staffing Issues In consistent results among the auditing team Auditors lacking specialty skill set and/or credentials Always working to catch up not working head No contingency plan for staff shortages 12

13 Staffing Staffing Solutions Audit plan should reflect resource availability Hire a 3 rd party vendor to assist with short falls Allow for flexible schedules Targets - daily vs. weekly vs. monthly Work at home Understand your auditor s performance thresholds Staffing Staffing Solutions Offer incentives Team approach build bridges between staff, management, & providers Communication daily stand ups Celebrate Successes Together! 13

14 Educating The Provider How to Gain Provider s Trust Providers are the the clinical experts learn from them Personalize their audit findings / results Apply consistent methodologies / education 14

15 Educating The Provider How to Gain Provider s Trust Provide trending data and comparisons Practice Specialty National Educating The Provider How to Gain Provider s Trust Utilize credible references AAPC AMA / Specialty associations CMS / LCDs / commercial Educating The Provider Approach to training Be an advocate to the provider Meaningful Reports organized easy to draw conclusions Be prepared know / understand the audit results Identify key opportunities do not overwhelm 15

16 Educating The Provider Approach to training Tailor education to provider s needs One / One Group Shadowing Report only Allow for rebuttals Celebrate success! Educating Provider Case Study Disinterested Provider Feisty provider Did not acknowledge audit results No improvement in behavior Educating Provider Case Study Disinterested Provider Outcome: Understand why the disinterest Find common ground Agree to a resolution Schedule future audit plan 16

17 Auditing Management Coding & Documentation Audits Benefits to outsourcing your audits Assess internal operations Reveal strengths Uncover weaknesses Perform the heavy lifting Supplement your team Auditing Management - Case Study Auditing Management Case Study Client Challenges Under staffed & auditors with the wrong skill set Failure to utilized technology Limited audit standards Poorly structured audit reports Failure to perform post audit education Internal challenges with Revenue vs. Compliance 17

18 Auditing Management - Case Study Auditing Management Case Study What they did to improve Outsource their prospective audits Formalized audit plan / timelines & audit standards Improved internal auditor skill sets Utilized audit software Revised audit reports Implemented training and post audit education Implement Precision with Managing your Audits. 18

19 Questions Stephani Scott, AAPC Healthicity Audit Services