Professional Risk Management Solution

Professional Services Risk Management Solution Gain the confidence that you are truly focused on driving down risk and meeting compliance goals. Panacea’s unique, holistic approach to auditing employs technology, expertise, and education to identify risk as well as business opportunities.

We help healthcare organizations improve their bottom line and strategic market position with front line expertise in revenue cycle management, smart software and enterprise-level educational solutions.

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Professional services have the largest set of codes in use today, so it’s no wonder there’s significant compliance risk.

Here are just a few examples • 15,000 individual procedure codes in the fee schedule • 300 modifiers, including HCPCS (CPT®) Level I and HCPCS Level II

A typical internal medicine practitioner uses: • 19 procedure codes for top 50% of cases • 77 procedure codes for the top 80% of cases

The Current Approach to Auditing In today’s compliance environment, most physician practices rely on retrospective baseline audits and subsequent annual audits to identify incidents and patterns of compliance risk within their professional services practitioner populations.

This audit methodology relies on the services of an experienced audit team (whether internal or external) to review randomly selected service encounters.

However, the random selection approach often falls short. The modern healthcare environment and the goals for compliance are just too complex.

Some organizations have addressed this by relying on utilization comparisons to the Medicare database instead. This method of risk analysis compares the utilization for a given practitioner against the utilization for the same specialty reported within the Medicare database.

The challenge with this approach is that utilization comparisons provide a false sense of security. By comparing to the limited Medicare specialty database, significant false positives can be created when subspecialties are added—which adds to rather than mitigates the cost of creating an audit plan.

In contrast, Panacea has developed a new holistic approach to auditing using technology, expertise, and education. Panacea’s overarching goal and objective with this new approach is to identify incidents and patterns of potential billing and coding risk as well as opportunities where under-coding of services may be taking place.

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Every member of our team has a minimum of 10 years of field experience as well as clinical experience in all professional fee specialties. Our consultants are certified in their abilities to:

A Holistic Approach: Identify Incidents and Patterns of Risk Panacea’s approach to annual reviews leverages our proprietary technology, predictive analytics, and the expertise of our auditing team in a proven four-step process. We identify patterns of risk, conduct a focused audit, prioritize cases for analysis, and develop and deliver long-term education for your team.

• Use our tools to process cases and identify those practitioners at risk • Ensure our audits are focused by understanding the risks involved • Complete the audit using our proprietary tools • Prioritize the reviews/cases using

Our Four-Step Process Through our work with hundreds of clients, we have developed a proven four-step process. This ensures every review audits based on risk and that we have identified incidents and patterns of potential billing and coding risk as well as opportunities where under-coding of services may be taking place.

the knowledge gained from the risk analysis • Establish plans to mitigate negative performance • Deliver the knowledge needed to educate your team

In each step, Panacea provides you with a valuable risk evaluation resource.

1. Deliver a risk profile and analysis Step one identifies which codes and modifiers pose the most risk to your practice. We do this by reviewing all your claims and comparing them against reference data of other practices. We then prioritize by risk, ensuring the audit is focused on the greatest risks to the practice.

2. Conduct baseline external documentation and coding audit Building on the results from step one, we work closely with you to design a focused data quality review with a recommended baseline review of 10 to 25 service encounters for each practitioner and coder. The audit concludes with the delivery of a report and plan.

3. Select cases to review, capture results, and report on Using the baseline reviews from step two, we find cases that have a high probability of matching the risk identified in step one through analytics that identify specific cases and the associated practitioners.

4. Deliver education on an ongoing basis Annual education for your team contributes to continuous improvement and is the last step in our holistic approach to meeting your compliance and risk goals.

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Step 1: Delivering a Risk Profile and Analysis Step one identifies which codes and modifiers pose the most risk to your practice.

We do this by reviewing all your claims and comparing them against reference data of other practices. We then prioritize by risk, ensuring the audit is focused on the greatest risks to the practice.

In this step, Panacea uses the Compliance Risk Analyzer (CRA), which is a proprietary web-based application that uses advanced statistics and predictive analytics to score coding and billing risk for every procedure code by practitioner.

Rather than reviewing an isolated number of procedure codes, CRA analyzes all billing activity for all practitioners and then uses proprietary mathematical and statistical modeling to produce a risk assessment for every code for every practitioner across five primary component areas. These primary component tareas are: 1. E/M utilization analysis 2. Procedure code utilization analysis 3. Modifier utilization analysis 4. Modifier violation analysis 5. Practitioner time analysis All comparisons within the risk assessment report are specialty specific and encompass practitioner specialties. The CRA assessment provides the data needed to prioritize the annual review by ranking practitioners in three levels of risk: high, moderate, and low.

As expected, the practitioners ranking as high risk will be reviewed first, practitioners ranking as low risk will be reviewed second (as there may be opportunities due to underreported services), and practitioners ranking as moderate risk will be reviewed last.

By identifying the CPTŽ codes and modifiers posing the greatest risk or opportunity, we ensure the best use of your time and resources. This thoroughly addresses your practice’s entire practitioner population and the overall intent of its compliance plan obligations.

In addition to the compliance risk analysis, the results of our study can also help identify business opportunities by pointing out inconsistent use of procedure codes, modifiers, Evaluation and Management (E/M) codes, and practitioner time/FTE comparisons. The compliance risk analysis identifies areas of potential over-utilization, while the business opportunity analysis identifies areas of under-utilization—making sure you are considering all areas of risk and opportunity.

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Step 2: Conducting Baseline External Documentation and Coding Audit Building on the results from step one, we work closely with you to design a focused data quality review.

We recommend a baseline review of 10 to 25 service encounters for each practitioner and coder, and the audit concludes with the delivery of a report and plan. Our remediation plan also includes education, which can be delivered online, by remote live instructors via webinar, on-site, or through a combination of methods.

The CRA assessment will drive the level of scrutiny for each practitioner in the baseline documentation and coding audit performed in this step, and the review outcomes should be discussed and further defined before performance criteria are established.

Based on the ongoing results of the baseline reviews, Panacea will help your practice create best practice coding and documentation policies. We will provide structure and input during the process; however, your practice must finalize, approve, and implement the final policies that will be adhered to moving forward by the practitioners, coders, and Panacea.

Throughout this process, we will continue to work closely with you as we apply and/ or evolve these agreed-upon scoring and performance measurement policies to avoid positively or negatively impacting individual practitioners.

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Secure Access

Step 3: Selecting Cases to Review, Capture Results, and Report On

Panacea’s integrated, web-based system uses Microsoft SQL and .net

Using the baseline reviews from step two, we are able to find cases that have a high

technology and operates in a secure

probability of matching the risk identified in step one. We use analytics to identify

SSAE-16 certified data center in

cases (and the associated practitioners) that are under-coded, over-coded, or non-

a HIPAA compliant environment.

Additionally, the system allows for

compliant. Our analytics identify additional cases at risk of having missing or lost

different levels of user privileges,

charges, over charges, or quality issues. All this information ensures we target the

and health systems may see results

appropriate cases.

for individual practitioners or a specific specialty or across multiple

Summary reports are produced showing the cases selected, and patient-level

practitioners or specialties.

worksheets are created for reviewers to use during their account and chart reviews to write notes and feedback on during the validation process.

Detailed bill-level data is summarized on a customizable, on-screen dashboard as well as in Excel reports. You can also design your own reports and dashboards with Panacea’s integrated web-based reporting system.

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Step 4: Deliver Education on an Ongoing Basis Annual education for your team contributes to continuous improvement and is the last step in our holistic approach to meeting your compliance and risk goals.

This ongoing education does not exceed 12 hours annually, and it covers these topic areas: • General medical record documentation principles (including requirements for scribes) • E/M training (multiple modules, 3-4 hours total) • Preventive care services • Modifiers • Incident to and split/shared services • Teaching practitioners and medical students • CPT® and ICD-10 coding updates

Annual tutorials include competencies and CMEs for MDs, DOs, PAs, ANPs, and LCSWs. Panacea’s education system provides online access to all tutorials, allowing practitioners to study from computers, tablets, or smartphones. Individuals each have their own login and password; however, your organization’s leadership and administration can easily view reports of completed competencies and scores and track delinquent training.

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A Holistic Approach to Addressing Compliance Risk With the continued need for complete and accurate practictioner documentation and the limited impact of traditional audits, healthcare organizations are searching for a better solution.

Panacea’s unique approach to auditing offers the opportunity to be completely confident that you are focusing on driving down risk and meeting your compliance goals. Every member of our team has a minimum of 10 years of field experience as well as clinical experience in all professional fee specialties. Our consultants are certified in their abilities to: • Use our tools to process cases and identify those practitioners at risk • Ensure our audits are focused by understanding the risks involved • Complete the audit using our proprietary tools • Prioritize the reviews/cases using the knowledge gained from the risk analysis • Establish plans to mitigate negative performance • Deliver the knowledge needed to educate your team

Is your organization interested in learning more? Contact us to schedule a review, A Career Step Company

We help healthcare organizations improve their bottom line and strategic market position with front line expertise in revenue cycle management, smart software and enterprise-level educational solutions.

at 1-866-926-5933 or visit us online at panaceainc.com.