ValueScope healthcare compliance experts understand programs such as HIPAA Privacy & Security Programs, Training, Auditing & Claims Review, Billing & Cash Flow Management, IT Networks, All Lines of Insurance, Accounting & Tax, Accreditation, Accreditation, Chronic Care Management, and more. ValueScope’s healthcare compliance experts have experience in testifying in front of the MAC and ALJ on claims denial cases as well as healthcare fraud and abuse coding defense.

A key component of an effective compliance program is ensuring accurate coding and billing, including proper training of responsible staff and regular auditing of coding practices.

Our healthcare coding and compliance experts provide healthcare audit and compliance services, including internal and external coding audits across all healthcare verticals. Our team works with Compliance Officers and Corporate Counsel to perform periodic, monthly, quarterly as well as focused services based upon client needs.

  • Our compliance experts have experience assisting with implementation and management of Corporate Integrity Agreements as well as responding to Centers for Medicare and Medicaid Services reviews associated with pre- and post-payment audits, Medical Reviews, Program Integrity/ZPIC audits, RAC audits, and quality reviews.
  • With our collective years of experience both in provider as well as payer settings, our team of professionals have expansive knowledge to address internal and external compliance risk areas and concerns. We have been invaluable in developing risk models and action plans based on specific issues and need to improve cash flow and reduce staff and external audit risks.  As part of that, we develop a flow chart and task assignment, so the project is completed timely and within specifications.  Previous Centers for Medicare and Medicaid Services contractor experience has been instrumental in assisting organizations in understanding Medicare Administrative Contractor requirements as well as developing strategic initiatives designed to respond to ongoing changes in a dynamic healthcare environment.
  • Our healthcare experts have extensive experience with third party commercial payer audits as well as Federal and State program compliance. We review third party determinations, appeal payment denials or other adverse actions.  We also assess why a provider may be experiencing slow payment by a payer through risk analysis.

Our healthcare experts have many years of experience educating co-workers, healthcare providers and staff, as well as all aspects of the appeals or litigation process because without education your points will not be made.  Education is key to having a successful business, compliance program or making a defense case.  We present defense and audit services as a thorough education of accusations, the policies associated with allegations and the solutions and or why those allegations cannot be true.  Educating staff on business processes is key to being efficient as well as ensuring compliance with state and federal regulations.  We provide training one on one or in group settings.  We have professionals that are trained in various coding methodologies from Evaluation and Management, MS-DRGs, APCs, CPT, ICD-10 CM and ICD-10 PCS.  We have professionals that are certified medical coders through PMIMD and certified healthcare compliance professional through HCCA.

Coding Services

Our overall process can include, but is not limited to and based on client needs, the following:

  • Provide an initial coding audit and documentation related to a selection of charts (single admit) the results of our audits will serve as the basis for our Baseline Audit Report.
  • Provide audits of denied claims and prepare written results report to outline process problems and other resolutions to reduce denials which will reduce audit risk
  • Each report will include our observations and recommendations related to:
  • Policies & procedures, if provided for review, processes, education, and protocols designed to eliminate the likelihood of future occurrences of billing errors;
  • Changes to billing practices that may be necessary or appropriate to comply with federal and state laws, rules, regulations and guidelines.

Such observations and recommendations will serve as our basis for providing quarterly audits and/or in-service/education training.

  • Meet state and federal requirements, national coding standards and other regulatory rules and payor contract terms. Wherever applicable, we will utilize guidelines and standards approved by the Centers for Medicare and Medicaid Services (CMS), which may include, without limitation, Medicare Manuals and Medicare’s National Correct Coding Initiative, fiscal intermediary program memoranda and bulletins, Local Medical Review Policies, and guidelines published by professional organizations.
  • Identify and document potential over- or underpayment (billing errors) and calculate/ extrapolate the potential error rates just as Federal payers would to demonstrate full risk
  • Utilize current codes, such as ICD-10-CM, CPT, HCPCS and any others whenever applicable.

Inpatient and Outpatient Line of Businesses

ValueScope’s healthcare compliance experts have compiled patient hospital bills for out of country claims and several hospital claim charge reviews on behalf of patients and injury attorneys, in the past. Since that time, ValueScope healthcare experts have completed the AAPC’s course on Certified Inpatient Coding.  We have tools we use to input claim data to provide possible errors based on the information provided.

  DRG (Diagnosis Related Groups) Validation

  • No matter what payer, any claims reviewed will include a comparison of clinical records to coding records to ensure the proper diagnosis, procedure, DRG, APC along with assigned co-morbidity which has been established to validate billing. We will compare as appropriate for that payer.
  • Clinical and procedure information will be reviewed against any edits and exclusion to ensure proper payment. At the same time our tools will provide us appropriate RVUs, base rate to ensure the appropriate amount was billed.
  • As part of the clinical review, we will track all diagnosis at admission and discharge to ensure proper indicators are noted for Present on Admission (POA) versus Hospital Acquired Condition (HAC) as these impact payments.
  • We will utilize, in a spreadsheet, claims that are coded much like a Medicare audit billed versus what we confirm the coding to be. This detailed spreadsheet will be scored, can track trends in coding and documentation.  If the information is provided in the claim data – we can track the coder as well.  This can be expanded to track many aspects of a business model.
  • To accurately compare DRG distribution to national rates, we will take the full claims data to compare totals per DRG to the national numbers.
  • Review clinical records for diagnoses and procedure codes to ensure compliance with appropriate assignment of the Medicare Severity Diagnosis Related Groups (“DRG”) for correct reimbursement.
  • Review Medicare inpatient claims in order to evaluate coding accuracy per industry standard coding guidelines and the validation of the principle diagnosis selection, secondary diagnoses, principle procedure and secondary procedures with an emphasis on the complications/co-morbid conditions (CCs) and major CCs.
  • Evaluate the accuracy of the coding for Present on Admission (POA) indicators as well as Hospital Acquired Conditions (HACs).
  • Utilize scorecards to trend coding errors by type and by coder in order to implement educational programs after completion of the audit.
  • For non-DRG third party payors, verify that the appropriate documentation is present in the medical record to support the charges and medical necessity, and that all procedures, tests and services have an appropriate order/documentation.
  • Compare DRG distribution to national rates.

  Medical Necessity

  • Review inpatient documentation to ensure that claims are based on complete medical records and that the medical records support the levels of service on claims submitted for payment.
  • Medical necessity is the backbone to all coding and must be documented and complete to support diagnosis, procedure, DRG, APC, labs, prescriptions, etc. This will be including in all claims review.  Medical necessity will be based on the payer’s coverage determination or Medicare guidelines, if payer guidelines are not available.

  Coding Validation

  • Validation of inpatient coding shall include, at a minimum, the validation of ICD-10-CM diagnosis and procedure codes, MS-DRG, DRG, and/or other mandated prospective payment group assignment, based on supporting medical record documentation. ValueScope will identify and document identified query opportunities. At a minimum, the below listed coding areas will be reviewed:
  • MS-DRG
  • Medical necessity
  • Review the facility/resource allocation and assignment of the Evaluation and Management (E/M) code selection.
  • Review claims to ensure documentation meets the Hospital’s defined criteria for assignment of code for outpatient departments, including the Emergency Department.

  Chart Documentation to Billing & Coding Audits

  • Our healthcare experts are familiar with Medicare and Medicaid payment systems. All outpatient department claims will be reviewed in the same format clinical documentation to support billing record from diagnosis and procedure to CPT codes.  Any audit includes notes on deficiencies, areas for improvement, and suggestions, if applicable.  By taking the detail of all claims, we can provide claims detail by code, payer, payments compared to your allowables noted in the data set.
  • Our healthcare experts will review samples of outpatient claims from various departments to determine if the services billed are adequately documented in the medical record. All audits will include a review of coding abstracts and remittance advices.
  • Our healthcare experts will verify that the charges and procedure codes as well as diagnosis codes reported on the claim form are consistent with documentation in the medical record.
  • Reviews will address claim form completion, coding detail, billing for covered services and billing accuracy.
  • Our healthcare experts can provide quarterly audits and reports detailing findings, financial impacts and reasons for any proposed changes in coding assignment.
  • Upon completion of the medical record review, our healthcare experts will calculate impact and reimbursement implications of any proposed changes.
  • Detailed knowledge of the Medicare Payment Methodologies, Texas Medicaid Payment System as well as clear understanding of Commercial plans as well as other Federal Payers. Reports will include follow-up from previous findings, analysis, trends, and comparison with state and national data.

Cash Flow Analysis

We will review various reports from your billing system to identify potential process improvement areas to improve collections and over all practice efficiencies.  With these reports, we can develop a risk assessment and areas for potential lost revenue.

 Common Problems:

  • Failure to properly verify insurance benefits
  • Failure to get or follow-up on renewal authorizations
  • Bad business processes, usually because staff don’t know or stopped the process because they didn’t see the point
  • Not working accounts receivable timely
  • One to two payers as main source of income
  • No benchmarking internally to know if business is performing well
  • Coding problems or payer focused audits

 Corporate Integrity Agreement Audits

Our healthcare experts assist healthcare providers in providing an independent review of their corporate integrity agreement.

OIG negotiates corporate integrity agreements (CIA) with health care providers and other entities as part of the settlement of Federal health care program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other Federal health care programs.

CIAs have many common elements, but each one addresses the specific facts at issue and often attempts to accommodate and recognize many of the elements of preexisting voluntary compliance programs.

A comprehensive CIA typically lasts 5 years and includes requirements to:

  • hire a compliance officer/appoint a compliance committee;
  • develop written standards and policies;
  • implement a comprehensive employee training program;
  • retain an independent review organization to conduct annual reviews;
  • establish a confidential disclosure program;
  • restrict employment of ineligible persons;
  • report overpayments, reportable events, and ongoing investigations/legal proceedings; and provide an implementation report and annual reports to OIG on the status of the entity’s compliance activities.
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