Quarterly Provider Documentation and Coding Reviews Wendy P. Wright, CHC, CHPC, CPC, CPMA, CEMC Manager, Corporate Responsibility CaroMont Health Gastonia, NC
About CaroMont Health • We are a nationally recognized leader and valued partner in promoting individual health and vibrant communities. – 3800 employees – 452 medical staff – 268 volunteers • CaroMont Regional Medical Center, 435 beds • CaroMont Medical Group, a network of 45 primary & specialty physician offices in 5 counties and 2 states • Courtland Terrace, 96 bed skilled nursing facility • Gaston Hospice
Introduction • Provider Engagement in Audits • Auditing and Monitoring Plan • Increased Audit Frequency • Increased Awareness by Providing Timely Feedback • Implementation of a Corrective Action Plan • Development of a Compliance Incentive • Quality Assurance Reviews
Audit Frequency • 175+ Multispecialty Providers – Physicians and Non-Physician Practitioners
• Baseline Reviews – New Providers – 10 Cases Sampled
• Quarterly Retrospective Reviews – Routine Reviews – 5 Cases Sampled
• Focused Reviews – Aberrant Coding Patterns – OIG Areas of Focus – High Risk Areas
The Audit Process • Emphasis Placed on Identifying Documentation and Coding Practices that do not meet Standards • Case Selection – Random Retrospective – Top 25% Codes Billed – CMS Normative Data
• Case Audit – Points Values Assigned to Errors – Weighted Based on Error Significance – Outcome Percentage Comprised of Point Errors – CaroMont Target Standard 95%
Corrective Action Plan • Baseline Established Following Two Audits • 3 Stages of Corrective Action – CAP I – CAP II – CAP III
• Written Notification Provided – Corporate Responsibility Officer – Chief Medical Officer – VP Practice Operations – Executive Compliance Committee
Corrective Action Plan (continued) • CAP I – Scores below 90% for 2 consecutive audits – Receive One on One Education within 30 days
• CAP II – Scores below 90% for 3 consecutive audits – Third Party Approved Education within 30 days – Billing Suspension Recommendation – Prospective Audit Performed
• CAP III – Scores below 90% for 4 consecutive audits – Termination of Employment
• At any time, the ECC has right to invoke a CAP
Provider Education • New Provider Education – Documentation and Coding Guidelines – Compliance Education – Prospective Audit Conducted – Feedback Following Audit
• Provider Feedback Sessions – Group Sessions – Attendance is Mandatory – Focuses on areas of Improvement – Changes in Regulations
Reporting • Provider Package – Introduction Letter – Provider Audit History – Provider Finding Summary – CPT-4 Coding Summary – Provider Finding Detail – Scoring Methodology – E&M Bell Curve Report
Provider Finding Summary
E & M Bell Curve Report
Reporting • Manager/Director Reports – Provider Finding Summary – Refund/Re-bill Summary – Combined Provider Practice Summary
Refund/Re-bill Summary
Combined Provider Summary
Executive Level Reporting • Dashboard Reviewed Quarterly • Executive Compliance Committee • Corporate Responsibility Committee of the Board – Audit Outcomes – Areas of Improvement – Risk Areas
Physician Compliance Incentive • Providers Who Score 95% and Above are Eligible for the Compliance Incentive – Included in Physician Contracts
• Compliance Incentive Contingent upon other Factors – Completion of Mandatory Training – Attendance at Mandatory Provider Feedback Sessions
Quality Assurance Reviews • Continuous Quality Assurance Reviews – Insures Rules are Consistently Applied – Increases Auditor Accountability
• Peer Reviews – 5% of all Cases Reviewed – High Point Values Reviewed – Provider Audit Outcome Reviewed
• Management Reviews – Auditor Accuracy Rate of 95% – Performance Improvement Plan
Provider Engagement • Asked for Physician Recommendations for Process Improvement – Survey of Current Process and Auditor Performance
• Provider Feedback Used in the Development Stage • Corporate Responsibility Committee Approval – Board Level – Executive Level
• Physician Council Buy-in – Quality Committee
• Education Provided to Providers Regarding Changes
Questions