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Quarterly Provider Documentation and Coding Reviews Wendy P. Wright, CHC, CHPC, CPC, CPMA, CEMC Manager, Corporate Responsibility CaroMont Health Gastonia, NC


About CaroMont Health •  We are a nationally recognized leader and valued partner in promoting individual health and vibrant communities. –  3800 employees –  452 medical staff –  268 volunteers •  CaroMont Regional Medical Center, 435 beds •  CaroMont Medical Group, a network of 45 primary & specialty physician offices in 5 counties and 2 states •  Courtland Terrace, 96 bed skilled nursing facility •  Gaston Hospice


Introduction •  Provider Engagement in Audits •  Auditing and Monitoring Plan •  Increased Audit Frequency •  Increased Awareness by Providing Timely Feedback •  Implementation of a Corrective Action Plan •  Development of a Compliance Incentive •  Quality Assurance Reviews


Audit Frequency •  175+ Multispecialty Providers –  Physicians and Non-Physician Practitioners

•  Baseline Reviews –  New Providers – 10 Cases Sampled

•  Quarterly Retrospective Reviews –  Routine Reviews – 5 Cases Sampled

•  Focused Reviews –  Aberrant Coding Patterns –  OIG Areas of Focus –  High Risk Areas


The Audit Process •  Emphasis Placed on Identifying Documentation and Coding Practices that do not meet Standards •  Case Selection –  Random Retrospective –  Top 25% Codes Billed –  CMS Normative Data

•  Case Audit –  Points Values Assigned to Errors –  Weighted Based on Error Significance –  Outcome Percentage Comprised of Point Errors –  CaroMont Target Standard 95%


Corrective Action Plan •  Baseline Established Following Two Audits •  3 Stages of Corrective Action –  CAP I –  CAP II –  CAP III

•  Written Notification Provided –  Corporate Responsibility Officer –  Chief Medical Officer –  VP Practice Operations –  Executive Compliance Committee


Corrective Action Plan (continued) •  CAP I – Scores below 90% for 2 consecutive audits –  Receive One on One Education within 30 days

•  CAP II – Scores below 90% for 3 consecutive audits –  Third Party Approved Education within 30 days –  Billing Suspension Recommendation –  Prospective Audit Performed

•  CAP III – Scores below 90% for 4 consecutive audits –  Termination of Employment

•  At any time, the ECC has right to invoke a CAP


Provider Education •  New Provider Education –  Documentation and Coding Guidelines –  Compliance Education –  Prospective Audit Conducted –  Feedback Following Audit

•  Provider Feedback Sessions –  Group Sessions –  Attendance is Mandatory –  Focuses on areas of Improvement –  Changes in Regulations


Reporting •  Provider Package –  Introduction Letter –  Provider Audit History –  Provider Finding Summary –  CPT-4 Coding Summary –  Provider Finding Detail –  Scoring Methodology –  E&M Bell Curve Report


Provider Finding Summary


E & M Bell Curve Report


Reporting •  Manager/Director Reports –  Provider Finding Summary –  Refund/Re-bill Summary –  Combined Provider Practice Summary


Refund/Re-bill Summary


Combined Provider Summary


Executive Level Reporting •  Dashboard Reviewed Quarterly •  Executive Compliance Committee •  Corporate Responsibility Committee of the Board –  Audit Outcomes –  Areas of Improvement –  Risk Areas


Physician Compliance Incentive •  Providers Who Score 95% and Above are Eligible for the Compliance Incentive –  Included in Physician Contracts

•  Compliance Incentive Contingent upon other Factors –  Completion of Mandatory Training –  Attendance at Mandatory Provider Feedback Sessions


Quality Assurance Reviews •  Continuous Quality Assurance Reviews –  Insures Rules are Consistently Applied –  Increases Auditor Accountability

•  Peer Reviews –  5% of all Cases Reviewed –  High Point Values Reviewed –  Provider Audit Outcome Reviewed

•  Management Reviews –  Auditor Accuracy Rate of 95% –  Performance Improvement Plan


Provider Engagement •  Asked for Physician Recommendations for Process Improvement –  Survey of Current Process and Auditor Performance

•  Provider Feedback Used in the Development Stage •  Corporate Responsibility Committee Approval –  Board Level –  Executive Level

•  Physician Council Buy-in –  Quality Committee

•  Education Provided to Providers Regarding Changes


Questions


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