Today's healthcare providers face a dizzying array of new regulations
and increased enforcement actions designed to combat fraud and abuse.
As federal and state authorities multiply their efforts to scrutinize
payments and recoup money, it has never been more important for
providers to identify areas of compliance weakness and develop solutions
before these problems multiply. To prevent and address compliance
issues Provider Consulting Solutions offers the following services:
Put PCS' experts to work for you:
- Review medical records, coding, billing and Medicaid Rate Code Compliance
- Identify and quantify exposure
- Audit support with Independent Review Organization for Corporate Integrity Agreements and Recovery Audit Contractors (RAC) Response Services
- SentinelTM Compliance Report Series
PCS has vast experience assisting providers in all aspects of
compliance related services, working with large academic medical
centers, hospital systems, physician groups, nursing home chains
and other providers, as well as significant experience in working
with the OIG and the DOJ.
As an Independent Review Organization (IRO), PCS offers an interactive
approach. Given the nature of the engagement, it is critical that
the IRO be involved during the earliest planning phase of the work
and we recommend establishing open communications with a representative
from the Office of Inspector General (OIG) to address issues that
may arise during the planning and audit process. PCS will keep the
client's Compliance Officer fully informed of any issues that arise
during the review process and apprised of all communications with
the OIG representatives.
The Claims Review must be performed annually for each one-year
period of the Corporate Integrity Agreement (CIA), beginning with
the effective date of the CIA. Year two of the IRO consists of reviewing
the adequacy of billing, coding practices and compliance obligations,
based on documentation available at the Hospital pursuant to the
specific requirements of the CIA and applicable regulations and
guidance under the general requirements of Federal health care programs.
The review involves a "Discovery" sample of 50 paid claims, randomly
selected by the IRO. If the Error Rate in the Discovery Sample is
less than 5%, no additional sampling is required, nor is the Systems
Review required. If the Discovery Sample has an Error Rate of 5%
or greater, we perform a Full Sample and a Systems Review. The Full
Sample will be designed to 1) estimate actual Overpayments in the
population with a 90% confidence level and with a maximum relative
precision of 25% of the point estimate, and 2) conform to the Centers
for Medicare and Medicaid Services ("CMS") statistical sampling
for overpayment estimation guidelines. As permitted by the CIA,
the Discovery Sample may serve as the probe sample and Discovery
Sample findings may be included as part of the Full Sample.
The Systems Review (if required-depending on the results of the
Discovery Sample) requires that for each claim in the Discovery
and Full Sample that resulted in an Overpayment, the IRO will perform
a "walk through" of the system (s) and process (es) that generated
the claim to identify any problems or weaknesses that may have resulted
in any identified overpayments. The focus will be on what circumstances
might exist which could give rise to a billing error and not being
detected by the system.
The objectives and scope of work involved in the Systems Review
cannot be determined until the Discovery and Full Claims Review
have been completed, but may include the following elements:
- Review order entry systems/ encounter forms and Charge Description
Master for Behavioral Health.
- Preparation of a Flowchart of registration, order entry,
billing, claims submission, payment posting and verification
for Behavioral Health services to identify problems or weakness
in the accuracy/integrity of information and the internal control
- Evaluation of the knowledge of Behavioral Health clinical
staff and administrative support (registration, billing) staff
relative to documentation, coverage, coding and billing requirements
- Develop observations and recommendations to improve the
systems and processes involved in coding and billing.
PCS will prepare a report based on findings of the Discovery
Sample, Full Sample and Systems Reviews, as applicable. The information
included in the report will be based on the requirements listed
in Appendix A of the CIA.