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AUDITING EPIC CHARGESCHARGESAMY LEE SMITH, CIA, CRMA, CPC CPC H CPMACPC, CPC-H, CPMASENIOR MANAGER, INTERNAL AUDITAUDITBON SECOURS HEALTH SYSTEM, INC.
AHIA 32nd Annual Conference – August 25-28, 2013 – Chicago, Illinois
www.ahia.org
Objectivesj
Brief overview of Revenue Cycle
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Brief overview of Revenue Cycle Introduction to charge capture audits Present EPIC charge methodologies Present EPIC charge methodologies Review items to watch during EPIC implementations
related to charge integrityrelated to charge integrity Share actual revenue cycle risks experienced with
EPICEPIC Discuss audit ideas for hot spots in EPIC charge
capturecapture
R C l O iRevenue Cycle Overview3
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d Ch C A dIntroduction to Charge Capture Audits6
Charge Capture Workflow and Risks
Revenue-Producing departments are responsible for complete and accurate charging, including charge entry and charge reconciliation
Risks include: Risks include: Entering charges on wrong patient encounter Incomplete documentation to support charges Incomplete and/or inaccurate charge capture Interface issues causing charges not to post Lack of reconciliation processes Incorrect codes in chargemaster
Introduction to charge capture auditingg p g
Since the False Claims Act was passed which created phuge penalties for submitting inaccurate claims, auditing claims/charges has become commonplace.
Charge reviews attempt to verify compliance with documentation, coding, billing, reimbursement and other requirements other requirements.
Auditing charges is NOT easy due to the complexity of billing guidelines and regulations. of billing guidelines and regulations.
Why are charge capture audits important?
Facility reimbursement depends on completeness & accuracy of documentation and coding/billing
Evaluate compliance with CMS & third party payorregulations – before the government identifies non-compliance!
Review compliance with internal policies & procedures Provide assurance that documentation supports charges
billed Avoid lost revenue due to missed charges
EPIC Charge Capture MethodologiesEPIC Charge Capture Methodologies10
Common Charge Methods in EPICg
Flowsheet rows
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Flowsheet rows Preference lists / Charge Navigators Charge Router Charge Entry Charge Router Charge Entry Batch Processing
Ch l i Charge on completion Charge on dispense/administration (meds) Interfaces
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EPIC I l i
I l i Ri k
EPIC Implementations16
Implementation RisksRecommended Mitigation Strategies(Open Discussion)
Implementation Risks with EPICp
Various build errors – assigning incorrect charge codes 17
to documentation or charge navigators; general ledger Build/design decisions on charge methodology – auto-
charging based on documentation vs. charge navigator charging based on documentation vs. charge navigator or charge router charge entry
Security access to charge entry, reconciliation reporting, workqueuesworkqueues
Training effectiveness – charge entry, workqueues, charge correction, charge reconciliation
Test system differs from Production Key is MONITORING (ADR, reconciliations, dashboards,
etc )etc.)
Recommended mitigation strategiesg g
IA involvement from design through implementation & 18
g g pbeyond Observe design sessions, attendance/participation,
decisions evaluate controlsdecisions; evaluate controls Validate testing completeness & accuracy Charge posting (all the way to the claim) Reporting & resolution of defects noted GL readiness Interfaces – charge posting, etc.g p g,
Validate/monitor training completion; assess quality of training classes and department readiness
Validate CDM EAP build completeness and accuracy Validate CDM-EAP build completeness and accuracy
Go-Live Risk Mitigation – Keys to Successg y
Build teams meet with each department; review 19
p ;charge tickets/lists from legacy system
Average Daily Revenue prepared and monitored Revenue Watch reports for high-risk charges Log-in days; DTAR days to confirm security access
prior to go-live Revenue Cycle Hub includes “help desk” and nurse
di 100% bill diauditors – 100% pre-bill audits Multi-disciplinary rounding teams daily with daily
reporting/huddlesreporting/huddles
R C l Ri k i h EPICRevenue Cycle Risks with EPIC20
Revenue Cycle Risks with EPICy
Duplicate charges / Charge Router rules21
Duplicate charges / Charge Router rules Manual charges may remain
W k ( l k h f) Workqueue activity (or lack thereof) Logical security (users and project
team/administrator access) Charge entry design decisions/effect on g y g /
workflows & revenue Charge table/map/method set-up (Willow) Charge table/map/method set up (Willow)
More Revenue Cycle Risksy
EAP/Fee Schedule mapping errors22
EAP/Fee Schedule mapping errors Radiant verify orders errors
P d f l Procedure master file setup errors Log-in department determines revenue posting Medication to charge record mapping errors Must select “HC” charges for hospital charging Must select HC charges for hospital charging Encounters not closed/orders not completed
P i l EPIC A diPost Implementation Charge Integrity Audit Ideas
Potential EPIC Audits23
Post-Implementation Charge Integrity Audit Ideas (Open Discussion)
Other Post-Implementation Concerns
Ideas for EPIC Charge Capture Auditsg p
Review # of items in charge workqueues & date last 24
g qaccessed
Review claims for duplicate charges (esp. for departments which interface charges)
Review areas where charges are not based on d i (i d h h documentation (i.e., departments where charge navigators/preference lists are used) to look for missing chargesmissing charges
Validate charge reconciliation processes Validate mark-up policy vs. process (pharmacy and Validate mark up policy vs. process (pharmacy and
supplies)
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Other Post-Implementation Concernsp
Security access to Charge Router/Charge 29
Security access to Charge Router/Charge Entry
/ Project team/Administrator security accessAudit trailsEAP/Fee Schedule updatesEAP/Fee Schedule updates
CPT annual updates
Need more information?
EPIC’s website – request an account using your 30
q g ybusiness e-mail address Online Learning (UserWeb’s weLearning); recommend
“Life of a Charge” courseLife of a Charge course User Forums Documents
/ Ask your build team members/trainers Talk to end users about their concerns! Discuss issues with Revenue Integrity and Business Discuss issues with Revenue Integrity and Business
Office Contact me with general questions!
Save the DateS b 2 2 2September 21-24, 2014
33rd Annual Conference Austin, Texas
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