“The Audit Process by Sun Tsu”or

“Never, Never, Never Give Up”- Winston Churchill

Mark Owen, Jack Turner CDC Committee

Ed Gaines

Assumptions

• Basic understanding of the audit process and the different types of audits

• Recognition that payer audits will be an integral part of the payer revenue stream for the future

• Recognition that perfect processes will not prevent inquiry / demands for recoupment

• Understand that doing nothing is not an alternative

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Goals and Objectives

• Introduction to the audit process• Preparing for Audit

– Know yourself, your enemy, and your options.• Defending an Audit

– Describe specific audit defense strategies.• Questions and Answers

– Discussion, your experience and opinions are critical to our success and maybe our survival.

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The Cryptography of Audits

• Federal – ZPIC, Probe, CERT, RAC, MM935…• State – PERM, MIC, RAC…• Private – whatever

• Weakest link may be the person who opens your mail, or physician who tosses the letter into the trash– recognition is vital

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Definitions

• Improper payments.• Fraud.• Overpayments and Underpayments.• Prepayment review.• Post payment review.• Automated review.• Semi-automated review.• Complex review.

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The Art of Audit – Sun Tzu

• Threat Recognition• Response• Logistics and Support• Aftermath and Reassessment

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Threat Recognition

• Ongoing preparation• Know yourself : Know your opponent• Know your vulnerabilities• Maintain high alert• Its not just about government payers• Assess your resources• Gauge the motives of your opponent

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Threat Recognition

• Triggers – statistics, routine aggression, prior conflict, internal discord

• Know yourself – practice patterns, level mix, internal QA, policies, compliance

• Vulnerabilities – outliers, documentation, EHRs• Maintain high alert – audits come in many guises

and arrive through many doors

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Response

• Understand the terrain and weather• Toe to toe battle is the last resort• Is the battle winnable?• Will some sacrifice prevent loss?• Does the opponent fear harm• Tactics – attack from rear, seek allies• Defend or attack, but retreat strategically

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Logistics and Support

•Feed off the enemy•Shorten the engagement •Siege is only done as last resort•Reserves

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Aftermath

• Pyrrhic victory – was it a win?• Was it a loss?• What lessons were learned?• Prepare for next battle

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42 Reasons

You might not be an outlier – the theory

•An E/M Outlier is a Provider whose Level 4’s and 5’s are measurably higher than Peers.• If your peers under document you look too good to be true.

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42 Reasons

You might not be an outlier – the theory

•Was the comparison apples to apples; Did the study include MLP’s or just Drs?•Measuring Acuity by claims data alone is unfair and inaccurate, that is why payers do it.

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42 Reasons

• Look at Coding first, but no matter what you find don’t stop there…

• Run your numbers by Provider and run them every month;

• Adjust your numbers for accounts down-coded by the payer that you do not appeal or you lose on appeal.

• Remember, 42 is the answer to: Life, the Universe and Everything.

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42 Reasons - Favorites

• Number 7 – Patient Waiting Area; Shift Left.• Number 26 – EMS loves your facility; Shift Rt.• Number 3 – Age and Sex; Shift Right• Number 6 – Cookbook Medicine; Shift Right• Number 13 – I never work Fast Track; Shift Rt.• Number 30 – My 5’s are DOA; Shift Left• Number 22 – or Catch 22 moving more Level 4

cases to Obs. can increase ratio of 5’s.

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42 Reasons - Favorites

• Nbr. 29 – Provider Documentation Training• Nbr. 1 – Additional Work-up Planned• Nbr. 10 – Incentive Based Compensation• Nbr. 19 – NOPP; Setting your Coding Policies• Nbr. 18 – New Drs. and New Coders, oh my.• Nbr. 37 – Scribes can provide big ROI.• Nbr. 11 – Dx tests TAT and Admit Protocol

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42 Reasons – One More

• Changing ED practice → Changing Complexity and changing codes

• No longer admission for evaluation and treatment

• Now admission for treatment after evaluation completed in ED

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We Fixed The Problem – But

• For over 15 years all payers have been nagging emergency physicians and hospitals to re-direct lower acuity patients to more appropriate treatment settings. At the same time hospitals and physicians have expanded urgent care sites for this very reason. We have succeeded in our efforts to move these patients to more cost effective sites of service and our E.D. beds have been backfilled with higher acuity patients. Substituting high acuity patients for low acuity patients shifted our costs right yet they wonder why.

• By doing our job extremely well, shortening the time from door to bed for more high acuity cases thereby allowing our providers to see more sick patients per hour than ever before we have given the appearance that we are using technology to game the system. It is not that the patients are sicker, it is that we are now able to see more sick people than ever before.

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Appendix

• Defense strategies• Medicare appeal process• Numbers

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Top 10 Defense Strategies

1. The Marshfield Clinic Tool: if applicable, use it to help explain MDM and specifically how diagnostic and special studies impact the MDM;

2. Do not assume ED coding knowledge—use EMTALA to help explain medical necessity in the context of EM.

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Top 10 Defense Strategies

3. Differential diagnosis: explain why we code this way vs. the final diagnosis. http://www.gpo.gov/fdsys/pkg/FR-1994-03-04/html/94-4900.htm

4. Nature of Presenting Problem (NOPP): explain how NOPP impacts not only initial presentation but also comorbidities.

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Top 10 Defense Strategies

5. ED coders and billers: insist on providers being part of the audit defense process—use the audit as an opportunity to educate the auditor and the client;

6. And do the clinical case summaries with the clinicians—do narrative explanations of the patient presentation, differentials code choice rationale.

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Top 10 Defense Strategies

7. True, accurate and complete medical record documentation including signatures on E/M documentation, orders, supervisory notes re: NPPs and PATH documentation for residents.

8. Consult with counsel and/or outside experts where appropriate, e.g. where large amounts are at stake, extrapolation and/or extended pre-payment reviews.

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Top 10 Defense Strategies

9. Prepare prompt and thorough responses the first time—at the Redetermination or Reconsideration stages—prepare the case as if you are headed to SCOTUS.

10.Don’t argue for the sake of it—punt if you missed the coding—keep your powder dry for the tough cases—and maintain an expert, polite and professional demeanor

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Medicare Appeal Process

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The Numbers

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The Numbers

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Contacts

• Mark E. Owen

SVP, Nicka & Associates Ofc: 972-964-5330

mowen@Nicka-Associates.com

• John C. Turner, MD, PhD, CPC-ED, FACEP

Team Health Ofc: 865-293-5662

john_turner@teamhealth.com

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