Kusserow’s Corner: Billing, Auditing, and Monitoring Effectively—Measure to Manage Risk!

One of the most important elements of a compliance program for health care organizations is adhering to accurate claims processing. This entails proper documentation of medical records, accurate application of diagnosis and billing codes, and proper charging of payers for services rendered. Today, health care systems face increasing scrutiny of their coding and billing by regulatory agencies and their recovery audit contractors. The Medicare Integrity Program also emphasizes the significance of avoiding payment errors. HHS, with CMS and the Office of Inspector General (OIG), is coming down heavily on inappropriate billings and payments to health care providers. The result: denials of improper claims, recovery audits based surveillance, financial penalties and refunds, initiation of in-depth investigations, and loss of revenue for physicians and medical practitioners, including litigation cost in some cases.

Proactive effective internal monitoring of billing, while a must, can still be very challenging. The massive availability of consolidated claims data to government contractors for mining and surveillance is a real threat to revenue, if not billed correctly. Today, health care organizations must know how to appropriately bill and assess billing accuracy pre- and post-billing. They need to know:

  1. How to better manage claims data using measures.
  2. How to get ahead of the game and think like contractors.
  3. How to use data to manage and measure risk proactively.
  4. How to keep it simple while still being sophisticated.

Billing Auditing and Monitoring (A&M) has always been a core component of an effective compliance program and a critical success factor to revenue integrity. However, a sea change of how claims data is being used by regulators and contractors can represent a real problem, if you have not kept up to date. Dr. Cornelia Dorfschmid, a leading expert on the subject, states “If you have not advanced your sophistication in how data can be assessed, measured, and used proactively; you are at increased risk of being targeted and caught and required to refund with potentially huge penalties.” She basically makes the point that if you want to manage your risk, you need to have an effective and advanced auditing and monitoring program. She sums up her point by stating “If you want to retain what has been billed, you must be able to verify revenue integrity through metrics and measure results. Revenue integrity cannot be managed well without being able to measure what you are doing.” Sophisticated data analysis and contractors empowered with tools and recovery successes can only be met successfully with the same sophistication and vigor. She points out that “Without well-defined metrics, routine versus non-routine approaches, and sophisticated risk and data analyses as part of a billing auditing and monitoring programs, an organization is at risk.”

Dr. Dorfschmid has a wealth of experience in this area and has published widely on the subject. She is presenting a free webinar to address this subject on June 5, 2014, in some detail and will discuss how providers can meet the challenge. The program features:

  1. Effective Billing Auditing and Monitoring in an era of data analysis/mining and contractor reform.
  2. How to use metrics, sampling, and phasing to monitor billing effectively.
  3. How A&M and use of metrics can assist enormously in preventing demand letters/surveillance and establish that compliance oversight works.

I recommend this program to anyone who is involved in meeting the compliance challenge of accurate and reliable data to support their claims processing system.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow’s Corner Newsletter

Copyright © 2014 Strategic Management Services, LLC. Published with permission.