Beyond Benchmarking. My Background. Session Roadmap 3/5/ My Background Purposes of Benchmarking. 3. Benchmarking Challenges

Transcription

1 Beyond Benchmarking Integrating Audit Analytics into Day-to-Day Compliance Operations Jared Krawczyk Mathematician REVEAL/md Session Roadmap 1. My Background 2. 3 Purposes of Benchmarking 3. Benchmarking Challenges 4. How to Begin Benchmarking in Your Organization 5. Building Documentation Review Plans Around Benchmarking My Background 1

2 3 Purposes of Benchmarking Reduce Your Workload Allow You to Plan and Allocate Resources 2

3 Create Transparency Throughout Health System Benchmarking Challenges Restricted FTE and Tech Resources Data Issues Understanding of Analysis Fear How to Get Started Determine Analysis Areas Understand Comparative Data Needed Determine How to Calculate Analysis Prioritize and Organize Results Create Documentation Review Plan 3

4 Determine Analysis Areas Common Sources for Areas OIG Work plan OIG Audit Reports Past Audit Requests Internal Knowledge / Sources CMS Resources News Sources Information form Educational Events Word on the Street Common Analysis Areas These are a few common areas that every compliance department should be focusing on with benchmarking. Evaluation and Management Audit Risk Revenue Potential Cross-Category Behavioral Trends Procedures Surgical and Imaging Drugs and Injections High Dollar Services Mod 24 Mod 25 Mod 59 Modifiers Others CMS CERT Study OIG Time Study OIG Identified Services in Reports Understanding Comparative Data You need to Determine 1. The Goal of Analysis 2. Bias to Take into Account Common Bias Volume of Data (Total / Specialty / Locality) Sub-Specialty Data Payer Mix Type of Health Systems 4

5 Comparative Data Examples Mismatching Goals and Bias Goal: Determine Audit Risk from Government Payers Comparing data from a University Exclusive Database to the CMS Database. Aligning Goals and Bias Goal: Determine Audit Risk from Government Payers Comparing Data from a CMS CBR and Data from REVEAL/md (created out of a CMS Database) CMS CBR Utilization of = 42.27% REVEAL/md Utilization of = 42.49% 5

6 Determine how to calculate metrics For the purpose of this session we will focus of E/M benchmarking. Two Step Approach 1. Intra-Category Analysis 2. Single High Risk Service Utilization Analysis Start with Intra-Category Goal is to get results down to a single metric that can be sorted and prioritized. The 30,000 ft view. Three important metrics will be calculated: Distribution Variance Risk Metric Adjusted Charge Differential Distribution Variance Goal: Quantify over/under utilization potential per provider with a single objective differential Analytical Technique Utilize the RBRVS database to calculate a weighted RVU average per provider per E/M category. Weighted Average RVU = 2.56 Assumptions As the RVU value per E/M service increases, so does the complexity of the service The higher the RVU value within a category the distribution shifts towards higher utilized services Weighted Average RVU = 2.89 Distribution Variance How to calculate the E/M category weighted average RVU for a provider Step 1 CPT RVUwrk Provider Total RVU Count Step 2 Provider Weighted Avg RVUwrk = / 478 Provider Weighted Avg RVUwrk =

7 Distribution Variance How to calculate the E/M category Distribution Variance Step 1 Distribution Variance = Provider Avg RVU / Peer Group Avg RVU Distribution Variance = / Distribution Variance = Step 2 Distribution Variance = Distribution Variance = Step 3 Distribution Variance = * 100 Distribution Variance = 5.9% Distribution Variance The End Result E/M Category Risk Metric Audit Risk is More than Just Being a Utilization Outlier Assumptions about Auditors They want to recoup the maximum amount of money in the most efficient manner. Two Influencers for Audit Risk Utilization Outlier Volume of Performed Services How to calculate the E/M category Risk Metric Risk Metric = E/M Category Distribution Variance * E/M Category Volume Risk Metric = * 478 Risk Metric =

8 E/M Category Risk The End Result E/M Category Risk Comparing Distribution Variance to the Risk Metric Distribution Variance Risk Metric When looking only at the Distribution Variance Provider 4 seems to present the biggest risk for audit. When volume performed is included with the Risk Metric Provider 3 is actually where compliance efforts should be focused. Adjusted Charge Differential Goal: Quantify the potential dollar amount impact from over / under utilization of E/M billing Analytical Technique Calculate the difference between a providers actual E/M category charges and hypothetical charges based on redistributing the providers E/M billing within a category to match the peer group. What does this mean? If a provider billed exactly like the peer group, what would the difference in their charge amounts be. Word of Warning These dollar amounts are ENTIRELY hypothetical and should be only used as a method of prioritizing providers for review. These are not actual overpayment amounts. 8

9 Adjusted Charge Differential How to Calculate Adjusted Charge Differential Step 1: Gross Charges = Annual Frequency * Current Fee Step 2: ReDist Frequency = Tot Annual Frequency * Peer Dist. Step 3: ReDist Gross Charges = ReDist Frequency * Current Fee Step 4: Charge Differential = ReDist Gross Charges Gross Charges Adjusted Charge Differential The End Result What Does This Lead Us To? 9

10 Identified Provider Audit Risk Identified Provider Revenue Potential Single High Risk Service Goal: To determine if a provider exhibits similar coding behavior across numerous E/M categories Analytical Technique Compare the utilization of high level E/M services across all categories to determine if trends exist. 10

11 Create Documentation Review Plan Three Basic Plans Needed 1. Cycle Audits 2. Early Warning Audits 3. Due Diligence Audits What will be accomplished: Methodically reduce audit risk currently within health system Proactively identify and review signs of audit risk prior to it compounding over time Prevent practice acquisition from increasing entire health systems risk profile Cycle Audits Goal: To efficiently reduce the Health Systems audit profile by reviewing the exact services that would be targeted by audit entities. Old Way Review 10 charts in random for every provider. This process is conducted every 12, 18, or 24 months. New Way Prioritize providers based on risk exposure metric and review only areas that are causing the exposure. Benefits Instantly making the greatest impact with your documentation reviews because you are directly targeting high risk areas Allows for strategic planning (resource management) and monitoring based on statistical evidence. Possibly reduce cost by only reviewing providers that are at audit risk. Typically every health system has between 15%-30% of their providers at audit risk. Cycle Audits The Process Step 1 Step 2 Step 3 The provider that has been identified as having the greatest hypothetical over charges and only is an outlier for Five s will be reviewed by the staff. 11

12 Cycle Audits After the Review and Education Process Incorporating benchmarking following the initial risk identification, documentation review, and provider education processes will allow you to instantly determine if the provider is coding differently. This is a cost savings alternative to completely reviewing the provider again. Example 1 Example 2 Early Warning & Due Diligence Plans Goal: Proactively identify and remediate potential audit risk concerns prior to them compounding and/or entering your health system. Early Warning Identified Audit Concerns Conduct the benchmarking analysis on a month-to-month basis. This will allow to identify potential problems immediately instead of letting them compound over a significant period of time. Due Diligence Conduct the benchmarking analysis on prospective physicians that the health system is considering purchasing. This will allow you to identify and make leadership aware of any potential risk concerns that would accompany the acquisition of those physicians. Transparency Throughout Health System 12

13 Thank You Feel free to contact me with any questions. Jared Krawczyk (414) Screen Shots and Data Examples from: 13