By Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Access to accurate information is vital to the successful management of a profitable healthcare organization. Physicians and other qualified healthcare professionals are educated with the most current information to diagnose disease, illness, and injuries and treat them with the most current approved methods. Because their education does not often include information technology (IT), health law, or business management as part of their curricula, they are often disadvantaged when faced with an audit.
Many provider organizations rely on the knowledge and skill set of certified coding and compliance staff to ensure proper reporting and reimbursement. From this perspective, it is easy to see that the business of medicine requires access to the right information.
In March of 2020, our nation was thrust into the COVID-19 pandemic, throwing the healthcare industry into a tailspin for a myriad of reasons, such as patient fear resulting in canceled appointments, varying federal and state laws identifying essential versus nonessential services, and the inability for many essential providers to implement a telemedicine program early on. For the first time in decades, hospitals, clinics, and other medical practices closed their doors or only allowed limited access due to the public health emergency (PHE).
Federal and individual state governments frequently published information on testing and treatment options, coding and reimbursement policies, and even made changes more than once in the same 24-hour period. In an environment such as this, we can surely agree that access to accurate information is vital to maintaining a viable medical practice.
Prior to the chaos of 2020, the OIG reported that in 2019, the estimated Medicare fee for service (FFS) improper payment rate was 7.25 percent, which represented $28.91 billion in improper payments to providers. Even though this is a decline of $32.71 billion from the previous year, this represents a significant number of dollars at risk of recoupment.
Medicare, commercial payers, and personal liability payers are busy trying to identify provider outliers responsible for improper payments and pursue legal options to recover them.
To accomplish this, payers request medical records, compare provider documentation to the codes reported, apply payer policies and guidelines to determine if an overpayment was made, and identify any funds to be recovered.
This is not a simple process and requires both the coder and auditor to possess a clear knowledge of the laws, regulations, code sets, guidelines, and the specific payer’s published policies. If this is not complicated enough, it is important to note that these code sets, guidelines, and policies often change annually, and during the PHE have sometimes changed daily. Can you imagine the frenzied atmosphere this has created in provider organizations with reduced staff due to the PHE?
The determination of an overpayment usually begins with software that tracks the claims submitted by healthcare providers to a specific payer. These programs use the provider’s taxonomy code, geographic location, and number/frequency of each code submitted on a claim, then compares them to other providers of the same type and location.
When a provider reports more of any specific service than the others, they are considered an “outlier” and an audit may be initiated with a sampling of claims submitted by that provider. Typically, if the result is a 5 percent error rate or more, the audit may be expanded or extrapolated across the universe of similar claims for a specific period to determine the final overpayment amount and a letter is sent to the provider/organization demanding a refund. When extrapolation is applied, the amount is often incredibly high, at times in the millions of dollars. Due to the expansion of data collection and monitoring (e.g., Medicare CERT program), all providers are subject to audit reviews.
To maintain a healthy practice and viable payer organization, access to an online database allows them to quickly and easily access essential information for correct coding and auditing decisions. Such a database should include all code sets (sorted by date), federal and commercial payer policies, and guidelines. This information must be easily accessible and organized in a way that the user can quickly locate everything they need in one place and reduce the burden of maintaining a library of printed materials that clutter desks and take too much time to navigate.
Find-A-Code is the informational expert in the field of healthcare coding and reimbursement information. We understand the need for instant access to the resources required for accurate coding, claims management, and audit review, accessible at the code level and at a price significantly less than printed materials. As we have learned, information is king and it’s important to have a partner with the information vital to creating a thriving healthcare organization.
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Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, is director of content for innoviHealth, the privately held, Utah-based, parent company of HCC Coder, Find-A-Code, ChiroCode, and Codapedia. The Founders have decades of experience in the medical billing and coding industry, and decades more experience in information technology. Every day, this unique blend of medical coding and information engineering skills are combined with on-going customer feedback to improve and simplify the process of medical coding, billing, and auditing for users.
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