The best defense is a good offense. Handling documentation proactively will protect your organization from future audit problems.
[Editor’s Note: This article was contributed by Jayne Warwick, RN, HBScN is the director of Industry Insight, PointClickCare.]
The Medicare/Medicaid claim sets the stage for reimbursement. It is the documentation behind the scenes, however, that will determine the outcome of an audit. Right now, the Centers for Medicare and Medicaid Services (CMS) audit just 0.3% of claims, but the agency has signaled that it will increase that number in the coming years by expanding the Medicare Modernization Act’s systematic three-year look-back on provider claims via recovery audit contractors (RACs). These teams, comprising certified coders, nurses, therapists and a physician, are responsible for finding overpayments as well as underpayments.
Do long-term care and skilled nursing facilities document care well enough to stand up to federal recovery audit program scrutiny? There’s a good way to find out: Self-auditing.
In order to ensure complete and accurate claims documentation that will stand up to an audit, it is essential to establish internal processes to monitor compliance, review clinical documentation, and track claim issues. As a best practice, an internal project manager should carry out ongoing monitoring of claims, and the documentation to justify them, and a third party should perform an audit to maintain objectivity. Compliance officers should not be directly involved with ongoing monitoring, but rather track that appropriate follow-up was made in response to the issues.
An audit can be an effective way for a long-term care organization to ascertain what, if any, problem areas exist and identify the risks associated with those areas. Monitoring is the ongoing, day-to-day course that ensures you’re completing tasks correctly and on time. If you have multiple facilities, be sure your audit letters are being delivered to all of them.
An organization can conduct internal audits post-payment. The sample should be 10% of the claims value. This should be the total charge to chart audit to support all service items on a claim and the appropriate coding. You’ll be looking at certifications, validating long-term care medical data sets (MDS) to the claim, that the resource utilization group (RUG) levels and assessment reference dates (ARD) are appropriate. All of this leads to justifying the diagnosis coding meets the standards.
While creating such a self-auditing program might seem like a big task, it can be broken down into smaller tasks, abbreviated with the mnemonic “SCREaM,” which stands for:
“Set, Compare, Reflect, Evaluation and Measure.”
Set new standards
Providers should start by setting new standards – look at what’s being done now where improvements can be made. Before submitting Medicare claims, they must be sure there is an objective in-house review. Then, they should use a checklist on each claim – be scientific. The business office should manage the process and complete it before sending out the bills.
It will be important to adopt strong monitoring techniques to remain in compliance with federal and state policies, and be sure internal controls operate effectively. Monitoring also allows for early identification and correction before an issue worsens.
A provider should also consider implementing a strong triple-check system to review claims prior to submission. This can prevent Medicare billing errors by ensuring medical necessity for claims are warranted and documented. It can also confirm that activities of daily living, an area of risk for long-term care organizations, are properly documented and coded.
Compare current results
CMS looks at claims with high utilization scores and asks if the providers are doing the minimum amount of services to make those RUG categories. Look at current documentation practices through the lens of new standards to determine problem areas.
Engage with the healthcare community to prevent erroneous claims or payments. High RUG utilization will be the auditors’ focus area, and should be the lowest-hanging fruit of a self-auditing practice. Focus on documentation to make sure those RUG scores are reflected in the details.
Reflect, plan, implement
When auditing documentation, reviewers need to step back, remove themselves from the process and think like an auditor. They should be objective, look at each claim from the lens of auditor and be sure to meet all necessary guidelines.
Providers should make sure everyone involved knows what the guidelines are and understands the compliance regulations, and make changes based on where there needs to be improvement.
An organization can’t improve what it can’t evaluate, so it must determine triggers for improvement and set metrics that can determine progress. After making changes, the provider should evaluate and determine where it has seen improvement and where it needs to do more work.
It is important to track outcomes to see where to redirect. With the right foundation, an organization can focus on education and quality assurance to ensure consistency and continuous improvement on outcomes.
It’s worth the investment
While all this auditing, monitoring, and compliance can seem overwhelming, chances are some of this is already being done. A provider simply needs to install a framework for organizing and formalizing at least some existing documentation processes.
The National Recovery Audit program has recouped $9.5 billion in overpayments since its inception in the 1990s, and more than $2.5 billion in 2014, showing that CMS is still ramping up from demonstration programs into permanent implementation. This includes hospitals, skilled nursing and home health.
The best defense is a good offense. Those who handle documentation in a proactive way will protect themselves and their organizations from audit problems down the road. Patient need, rather than payment system incentives, is what is driving the provision of services.
Note: Adapted from “Audits, ADRs and Documentation,” a webinar sponsored by PointClickCare that included Maureen Hedrick and Jennifer Leatherbarrow, RN, BSN, RAC-CT of Richter Healthcare services. Full archive available here.