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Auditing Management -Best Practice Case Study

Stephani E. Scott

Vice President Audit Services

Implement Precision

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Agenda:

• Audit Planning

• Audit Management & Productivity

• Knowing The Industry

• Staffing

• Educating The Provider

• Audit Case Study

Planning

Where should you begin?

Planning – Stephen Covey

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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

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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

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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

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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

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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 findings3. 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

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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

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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

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Knowing The Industry

Medical Specialty Correct Overcoded Undercoded

CPT

coded correct

CPT coded

incorrect

CPT codes

added

"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%

E/M coding results CPT coding results

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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

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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

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Staffing

Staffing Solutions

• Audit plan should reflect resource availability

• Hire a 3rd 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!

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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

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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

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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

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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

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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.

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Questions

Stephani Scott, AAPC

Healthicity Audit Services

866.200.4157

Stephani.Scott@healthicity.com