Audit for Reducing Medical Coding and Billing Errors. The Medicare Integrity Program also emphasizes the significance of avoiding payment errors. This has prompted the U. S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) to come down heavily on erring healthcare providers. The result: rejection of improper claims, financial penalties, initiation of in- depth investigations, and loss of revenue for physicians and medical practitioners. Hence, practitioners need to proactively design their coding and billing compliance policies in accordance with regulatory guidelines and industry standards. A key process that can be leveraged to ensure correct billing and coding is monitoring and auditing of medical claims. Claims audits improve and strengthen the overall coding and billing processes, by helping ensure that the right safeguards are in place to avoid errors. Common Errors in Coding and Billing. By ignoring coding and billing criteria, as well as documentation standards, and benefits requirements, healthcare providers face the risk of common coding and billing errors. These can pose substantial threats to physicians. Disease management is defined as 'a system of coordinated healthcare. Microsoft accomplishes this breadth of compliance. Role of the Audit &. A corporate information and reporting system exists, and 2. Problem areas include failing to attach the right codes to various diagnoses; not documenting the patient's chief complaint; wrongly coding an office visit as a referral, and not a consultation; unbundling, or billing each component of a multiple component service as a single service; manipulating billing by adding items and services; submitting unreasonable claims for equipment and medical supplies; upcoding the level of service provided, to enjoy better financial increments; and failing to properly document medical records. The OIG also stresses on the above risk areas, in its “Compliance Program Guidance for Individual and Small Group Physician Practices. If a “clean claims” report is sent, then payers pay the claims within 3. If the reviewer identifies overpayment or improper payments, the claim is denied. Office of the Chief Information Officer. Records Management Policy. Program managers and system developers should identify and. Standards and Requirements for Electronic Records Management. Guidance> Standards and Requirements for Electronic. The provider can appeal against the denied claim within 3. It may be upheld or overturned by the payer. If the payer upholds the denied claim, the provider does not receive payment. If the payer overturns the denied claim, it is paid within 3. Audit Process. Frequency of Audits - Claims audits are usually conducted annually, along with follow- up audits, which help establish high benchmarks for the process. Schedule of Audits - An ideal audit involves investigating five charts per provider, and rotating each provider every week. The Procedures - A claims audit involves a comprehensive review of medical records, documents, hospital records, provider contracts, billing histories, fee schedules, and medical claims, to thoroughly investigate coding and billing procedures. Documentation of Audit Findings - At the end of a claims audit, the claims auditor produces an audit results letter including a claims report documenting all findings. Corrective Action Plan - The audit results and insights must be leveraged by the medical practitioner to develop corrective action plans that improve medical coding and billing practices. Challenges in Auditing. Complex Data Analysis. Medical practitioners deal with an enormous number of medical claims in a year. The task of choosing sample claims to conduct an audit can be tedious and complex. Those claims with the highest probability for error have to be chosen as part of the audit sample population. A comprehensive study of the overall objectives of a claims audit has to be used to successfully conclude this process. Rigorous Review of Medical Record Documentation. If medical records documentation and selection of appropriate codes do not match medical bills, the medical claims are termed as false claims and might even be investigated under the False Claims Act. The medical records should be complete and legible. They must contain past and present diagnoses of patients, identify appropriate health risk factors, provide the rationale for ordering diagnostic and ancillary services, outline the patient's progress and response to treatment, reflect any revision in diagnoses, and detail any relevant patient history, physician examination findings, prior diagnostic test results, assessments, clinical impressions, diagnoses, plan of care, date of service, and legible identity of the observer. Investigating medical records documentation is a challenging task for auditors. Any loopholes in these can direct the auditor to irregularities in coding and billing. Hence, they have to be studied rigorously, so that auditors do not miss significant patterns of errors. Time- consuming Manual Documentation. Many healthcare providers follow a manual documentation system that is cumbersome and time consuming. Auditors have to conduct extensive reviews of billing forms and the application of diagnosis, service, and procedure codes. Computer logs also need to be checked periodically to detect discrepancies in coding and billing patterns. As many of these processes are done manually, there is a high probability of errors occurring. Isolated Internal Departments/ Functions. Since many healthcare companies function in silos, auditing medical coding and billing practices can be a tedious process. CGI is among the leading independent information technology and business process services firms in the world. Health and human services; State. Audit of local authorities. WorkSafe has produced an Occupational Health and Safety Management System Quiz to assist. SafetyMAP provides a set of audit. RISK MANAGEMENT POLICIES AND PROCEDURES. RISK MANAGEMENT PROGRAM Table of Contents. Benefits (i.e., health insurance, disability, group life. On the 26th day of September 2013 a Health and Safety Management System audit was. Managem ent) and who can. Tracking audits, records, and claims appeals can be demanding and laborious. It is difficult to generate relevant medical record requests, letters, and reports as required. Completing these processes within the designated timelines, and leaving sufficient time to make adjustments to claims can be delayed if there is no perfect coordination and cooperation between departments. Lack of Advanced Systems for Spotting Fraud and Abuse. Many healthcare providers lack foolproof methodologies for a comprehensive analysis of medical claims which is imperative to promptly identify fraudulent activities. They often do not use the right tools that alert healthcare providers to irregularities, provide a timely and accurate study of the medical claims, and help eliminate fraud, abuse and billing errors before and after the claims are paid. Limited Top- level Visibility. It is necessary to monitor the claims audits processes, and ensure that healthcare providers are up- to- date on requirements, targets achieved, documentation, timelines, and vulnerabilities within their system. However, often, executives and the management do not have sufficient top- level visibility into coding, billing, and audit activities. A high level of visibility is important to devise strategic measures to accurately assess, monitor, and manage the claims audit exercise in a smooth manner. Complex Appeals. Appeals for claims audits go through several stages with many stakeholders involved. It is demanding, resource- intensive, expensive, and requires thorough, clean documentation. Hence many health providers feel threatened by the appeals process even though they have a good chance of winning back their payments. A Progressive Audit Approach. Complete control over claims auditing maximizes the financial performance of any healthcare provider. A good claims auditing approach helps ensure that claims are paid accurately, and in compliance with regulatory requirements. Such an approach comprises certain key features: Is flexible to suit specific audit needs. Emphasizes annual audits and continuous monitoring. Gives priority to advanced fraud and waste algorithms and predictive modeling. Is driven by sophisticated data mining and business rules, and industry standards. Gives prominence to technology based auditing solutions. Incorporates a risk management strategy, for highly accurate analysis of coding and billing patterns, assessment of potential revenue loss, calculations of financial reserves to compensate unpaid claims, development of corrective action plans, and execution of quality oversight of documentation and coding. How Metric. Stream Audit Management Solution Can Help. Metric. Stream Audit Management Solution enables organizations to manage all aspects of a medical coding and billing practices on a single centralized platform. Its powerful capabilities include built- in status tracking and reporting, integrated document management, and remediation action management. These enable healthcare providers to implement industry best practices for accurate claims audits, and to ultimately sharpen their coding and billing practices. Organizations are empowered to stay ahead of all coding and billing requirements through a successful claims audit, thus ensuring their financial success. The Metric. Stream solution streamlines the whole array of activities under audits. Risk Assessment. Metric. Stream’s risk management tools and capabilities enable healthcare providers to reduce the number of denied claims. The solution offers a flexible data model that links risks with the organizational policies and objectives, industry standards, coding and billing guidelines, processes, controls, issues and remediation plans. It helps ensure that a healthcare provider’s operations consistently remain within its acceptable risk threshold, and also enables to carry out more focused audits. Managing the Audit. The Metric. Stream solution enables healthcare organizations to manage the different steps of reviewing the medical coding and billing practices, claims, and managing all appeals confidently. It provides centralized dashboards that offer complete visibility into the audit process, enabling managers to track the audit status easily. Important aspects of a claims audit, especially related to the diagnosis codes and medical billing, can be tracked using the solution’s trend analysis capabilities and graphical charts. Healthcare providers can also consistently track audit patterns. The solution enables audit management to be integrated across departments and healthcare locations through centralized, systematic, and work- flow driven processes.
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