COMPLIANCE AUDIT SERVICES

With the development and initiation of Medicare's Targeted Probe and Education (TPE) program, Comprehensive Error Rate Testing (CERT) and pre and postpayment reviews, as well as increased scrutiny by several regulatory bodies [e.g., Office of Inspector General (OIG)], both Healthcare Facilities (Hospitals) and Providers (Physicians / NPPs / QHPs) have been forced to implement action plans for verifying compliance with Medicare documentation and billing rules. In addition, the recent audits of the Hyperbaric Oxygen Therapy (HBOT) indication, Diabetic Wounds of the Lower Extremity, by Noridian (the Medicare Supplemental Medical Review Contractor, or SMRC) and skin substitute applications by Unified Program Integrity Contractors (UPICs) make medical record reviews even more critical!

“An ongoing evaluation process is critical to a successful compliance program. The OIG believes that an effective program should incorporate thorough monitoring of its implementation and regular reporting to senior hospital or corporate officers. Compliance reports created by this ongoing monitoring, including reports of suspected noncompliance, should be maintained by the compliance officer and shared with the hospital’s senior management and the compliance committee.”

Many organizations that desire or attempt to conduct internal audits often struggle with having sufficient resources to meet the ongoing auditing burden - - and even if they do have their own internal audit team, the likelihood is they may have priorities in other areas. C+ Consulting is pleased to offer auditing services with a focus on compliance with those key areas and requirements identified by the CMS and OIG.

RAC / SMRC / UPIC AUDIT ASSISTANCE package:

The principle focus of this package is to assist outpatient wound management programs with preparation of a response to an Additional Documentation Request (ADR) from the designated Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and/or Unified Program Integrity Contractor (UPIC) .

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rac / SMRC / UPIC AUDIT ASSISTANCE PACKAGE INCORPORATES AND PROVIDES:

Single retrospective review (chart audit) of ten (10), or more, designated patient accounts and accompanying dates of service focused on the presence (or absence) of supporting medical record documentation for the wound management or HBOT services under review by the RAC, SMRC or UPIC. This review is conducted remotely using reasonable safeguards (as outlined by HIPAA) when accessing and/or transmitting electronic Patient Health Information (PHI).
Written report detailing the audit findings with recommendations of documentation to be included in the packets sent to the RAC, SMRC or UPIC for review. These recommendations include a final review of the packets prior to submission.
Presence on the Discussion and Education (D&E) session (call) with the SMRC or other type of call with either the RAC or UPIC to better understand the rationale used for the denied dates of service and which documentation might be missing for subsequent submission and re-review.
Followup includes responses to any telephonic/electronic queries related to the audit findings, for a period of ninety (90) days after the audit completion date.
Price and completion time is dependent upon the number of additional patient accounts selected for review, as well as any other services requested (such as preparation/review of the additional documentation to be sent for re-review).

Documentation-only Audit package:

The principal focus of this package is to determine whether Wound Management Center (WMC) personnel are compliant with documentation requirements that support all billing and coding aspects for wound care-related services. An excellent way to quickly identify any potential areas of exposure to liability and/or non-compliance with documentation requirements (as identified in relevant Medicare policies, also known as Local Coverage Determinations or LCDs).

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This package is recommended for clients who have serious concerns about the lack of supporting documentation for wound managment services - - and are confident there are no major issues with the current coding, billing and collection processes utilized for these services.

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Documentation-Only package incorporates and provides:

Single retrospective review (chart audit) of twenty (20), or more, designated patient accounts and dates of service focused on the presence (or absence) of supporting medical record documentation for the services provided by WMC personnel. This includes matching the supporting documentation to charges submitted for those dates of service, but does not include a review of billed services (claims), payments (collections) and/or any denials. This review is conducted remotely using using reasonable safeguards (as outlined by HIPAA requirements) when accessing and/or transmitting electronic Patient Health Information (PHI).
Written report detailing the audit findings with recommendations for improvement.
Virtual education of WMC personnel (including Providers, if available) as well as any Hospital or Clinic Billing, Coding or other personnel. Education is focused on issues identified by the audit as well as a review of required documentation practices and/or requirements currently accepted by most payors.
Followup includes responses to any telephonic/electronic queries related to the audit findings, for a period of ninety (90) days after the audit completion date.
Price and completion time is dependent upon number of additional charts selected for review as well as any other services requested.

Onsite visit (two business days) and education of WMC staff (including Providers, if available) as well as Hospital Billing, Coding or other personnel, can be added for an additional cost.

Revenue Cycle / Documentation Audit package:

Action plans for determining compliance should also focus on auditing billed charges and actual monies collected from both payors and the patient, if appropriate, to determine fiscal accountability for the services provided. This package provides an excellent way to quickly identify any potential areas of exposure to liability and/or non-compliance with established revenue cycle practices.

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This package is recommended for clients who require validation of the coding, billing and payment (collections) processes utilized by the Hospital and Wound Management Center (WMC) personnel. It confirms that documentation supports billed services.

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Revenue cycle/Documentation package incorporates / provides:

Single retrospective review (chart audit) of twenty (20), or more, designated patient accounts and dates of service that encompass a review of billed charges (claim), payments (collections) and any denial efforts (if appropriate) along with a review of supporting medical documentation for the services provided by WMC personnel. This review is conducted remotely using using reasonable safeguards (as outlined by HIPAA requirements) when accessing and/or transmitting electronic Patient Health Information (PHI).
Written report detailing the audit findings with recommendations for improvement.
Virtual education of WMC personnel (including Providers, if available) as well as any Hospital or Clinic Billing, Coding or other personnel. Education is focused on issues identified by the audit as well as a review of required billing and documentation practices and/or requirements currently accepted by most payors.
Followup includes responses to any telephonic/electronic queries related to the audit findings, for a period of ninety (90) days after the audit completion date.
Price and completion time is dependent upon number of additional charts selected for review and if a chargemaster review or other services are requested.

Ongoing Monitoring package:

Regulatory oversight and targeted audits of the wound management industry are rapidly increasing and constantly evolving, which means that ongoing audits are necessary. Organizations need to establish monitoring and continuing surveillance processes that will allow them to identify, analyze and mitigate potential compliance violations. This package provides an excellent way to increase the comfort level of a Hospital or independent Provider Clinic with the presence of supporting documentation for billed Wound Management Center (WMC) services.

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This package is recommended for clients whose WMC has recently failed a RAC, TPE or other audit type, or who are under a Corrective Action Plan (CAP) that requires regular internal audits. It can also be effective if/when an ADR is required. Of course, it can also be utilized by organizations that are not under scrutiny and/or a CAP.