MEASURING BILLING
MEASURING BILLING
ACCURACY THROUGH
PROBE AUDITS
ROY MASATANI, DIRECTOR,
COMPLIANCE AUDIT,
NATIONAL COMPLIANCE, ETHICS &
INTEGRITY OFFICE (NCO),
N G
O
C (NCO),
KAISER PERMANENTE
MARTINA HEASLEY BA RHIT CPC
MARTINA HEASLEY, BA, RHIT, CPC,
CCS, AHIMA APPROVED ICD-10-CM/
PCS TRAINER, NCO AUDIT
Measuring Billing Accuracy Through
Probe Audits
Discussion Topics
Probe Audits
About Kaiser Permanente
Discussion Topics
Target Risk Areas
Background & Purpose
Revenue Cycle Process
Audit Objectives
Clinical Review
Sampling Methodology
Logistics, Timeline, & Schedule Approach & Scope
Claims Audit
Scoring & Reporting Comments & Questions
About Kaiser Permanente
About Kaiser Permanente
Kaiser Foundation Health Plans.
Nonprofit, public benefit corporations that contract with individuals and groups for
prepaid, comprehensive health care services. The Health Plans contract exclusively with the Permanente Medical Groups and Kaiser Foundation Hospitals for medical and hospital services for members and patients.
Kaiser Foundation Hospitals.
Nonprofit, public benefit corporation that owns and operates community hospitals in California, Oregon, and Hawaii; owns outpatient facilities in several states; provides or arranges hospital services; and sponsors charitable, educational, and research activities.
P
t M di l G
Permanente Medical Groups.
Partnerships or professional corporations of physicians, represented nationally by The Permanente Federation, which contract exclusively with the Kaiser Foundation Health Plans to provide or arrange medical services for members and patients
About Kaiser Permanente
About Kaiser Permanente
Integrated health care delivery system
Integrated health care delivery system
Serving 9 states and the District of Columbia
More than 9 million members
533 medical offices
Over 15,800 physicians
36 hospitals and medical centers
Approximately 167,000 employees
44.2 billion annual revenues
Background
With increased federal a diting occ rring thro gh
g
With increased federal auditing occurring through
recovery audit contractors (RAC) and others, it is
important to be proactive in identifying, correcting, or
important to be proactive in identifying, correcting, or
preventing documentation, coding, and billing errors.
N
l C
l
h
&
Off
(NCO)
National Compliance Ethics & Integrity Office (NCO)
was requested by leadership to conduct billing
compliance probe audits for professional and hospital
compliance probe audits for professional and hospital
services to validate billing and reporting accuracy.
Purpose
p
To establish annual Programwide review in response to
To establish annual Programwide review in response to
government concerns and market pressures.
To provide base-line assessment of revenue cycle
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y
compliance performance across business units.
To present a standardized set of compliance metrics
across business units.
To evaluate potential high risk areas identified during
l i k
t
Revenue Cycle Process
A/R & Fi i l Pre‐Service programy
7 A/R & Financial Operations Financial Counseling Denial Management Focus on Patient Experience Registration & Check‐In C ll ti Payment Processing Ch D i ti p Collections Charge Description Master (CDM) & Provider Fee Schedule Billing Charge Capture Documentation & Coding g 7Audit Objectives
j
Report revenue cycle accuracy that is consistent and
Report revenue cycle accuracy that is consistent and
comparable across applicable locations/settings.
Provide actionable information for proactive
Provide actionable information for proactive
operational improvement (i.e. identification of missed
opportunities for revenue due to incomplete or
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p
inaccurate charge capture, inaccurate paper or
electronic claims, etc).
Support Sarbanes-Oxley (SOX) control requirements
Approach & Scope
Target and random claims audits will cover, at
Approach & Scope
Target and random claims audits will cover, at
minimum, the most recent four months and additional
months where available and as necessary.
Claims will be reviewed offsite (remotely) utilizing the
standards for 837P electronic forms for professional
billing and 837I for hospital billing, where available.
Approach & Scope (cont.)
Electronic claims will be obtained and utilized when
Approach & Scope (cont.)
Electronic claims will be obtained and utilized, when
available.
Patient statements and related billing information will
Patient statements and related billing information will
be made available or viewed electronically as needed.
If claims and/or patient statements are not available
If claims and/or patient statements are not available
in electronic formats, they will be audited utilizing hard
copy, paper-based information.
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Claims Audits
Claims Audits
Two Types
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AUDIT TYPE DESCRIPTION TARGET RISKS Focused audit included review of selected key claims field l t d li i l l t f ifi t t i k RISKS locators and clinical elements for specific target risk areas. Medicare FFS claim selections were based on target risks per OIG, RAC, and other sources. Audit included both professional and hospital services (inpatient and outpatient). Random audit included review of all high risk (as determined by Revenue Cycle) coding and clinical elements to support SOX requirement. RANDOM SAMPLES Claims were selected from all lines of business for professional and hospital services (inpatient and outpatient). l i d f l d li f Guarantor statements were also reviewed for selected lines of business (financial classes).Target Risk Areas – Professional
Billing (PB) Examples
Billing (PB) - Examples
New vs. Established Patient Visits.
V lid t th t ti t i it d t i d t ti t h h l d
• Validate that new patient visit codes were not assigned to patients who have already had a new patient visit with specialty within previous 3 years.
Modifier 25.
•
Validate accuracy of application of modifier 25 and ensure proper documentation. Validate accuracy of application of modifier 25 and ensure proper documentation. Improper use of modifier creates concern for claims which include E/M codes forservices that were not ordinarily identified as significant, separately identifiable, and above and beyond usual care associated with the procedure.
M difi 59
Modifier 59.
•
Validate accuracy of application of modifier 59 (distinct procedural services was performed). Anesthesia Billing
Anesthesia Billing.
•
Validate that anesthesia services rendered were adequately documented, units correctly reported, and required modifiers accurately applied.Target Risk Areas – Hospital Billing
(HB) Examples
(HB) - Examples
Short Stay.
V lid h d i i f 1 d 2 d d b di l d
• Validate that admission for 1 and 2 day stays were supported by medical record documentation.
3 Day Rule.
•
Validate that outpatient hospital diagnostic and non-diagnostic services provided Validate that outpatient hospital diagnostic and non diagnostic services provided within 3 days of an inpatient admission which are related to the admission were appropriately bundled and billed as part of the inpatient admission. High Risk DRGs (870-872)
•
Validate that the reported medical severity diagnosis-related group was documented and supported for accurate billing. Infusion Administration Codes.
• Validate that facility related infusion administration codes (related to physician • Validate that facility-related infusion administration codes (related to physician 96300-96425) codes are properly coded and documented including related medications
.
Clinical Review for Random or Target
Audits
Audits
Clinical staff (i.e. RNs) review claims to evaluate
Scored elements on selected PB samples.
Pl f C
(
)
medical record completeness.
• Plan of Care. • Authentication.
• Supervision Requirements.
• Orders
• Orders.
Scored elements on all HB samples.
• Orders for admission, discharge, treatment & medication.
Di h i hi 30 d f di h
• Discharge summary within 30 days of discharge.
• Authenticated entries with date, time, and signature, written
initials or unique computer logon.
Sampling Methodology
Sample Universe and Claims
Sampling Methodology
p
For TARGET - initial samples of ten claims for each selected
inherently high risk area to be expanded to 25 if errors are
found HB and PB risks were identified through
found. HB and PB risks were identified through:
•
Annual Joint Revenue Cycle, SOX & NCO risk assessment process.
•
Clinical Care Delivery toolkit assessments, prior internal and external audit
findings and CAPs, and analysis of denial rates for preventable and
targeted denials.
For RANDOM - sample of 60 PB claims across all applicable
p
pp
locations, 30 HB inpatient and outpatient claims across all
locations, most service types, plus guarantor statements.
Target Claims Count - SAMPLE
Target Claims Count SAMPLE
PROBE SAMPLES TARGET SAMPLE CLAIMS COUNT
(no Guarantor Statements)
DESCRIPTION BILLING TYPES HIGH RISK AREAS MIN MAX SAMPLES (no Guarantor Statements) A 10 25 This focused audit includes a review of key elements for target risk areas. the Medicare FFS claims Professional B 10 25 C 10 25 Medicare FFS claims selections were based on target risks per OIG, RAC, and other sources. This review
will include both D 10 25
A 10 25 B 10 25 A 10 25 will include both professional and hospital (inpatient and outpatient) services. Hospital ‐ Inpatient Hospital ‐
Random Claims Count - SAMPLE
Random Claims Count SAMPLE
RANDOM AUDIT TYPE RANDOM SAMPLES BY LOCATION LOCATION CLAIMS AUDIT AUDIT DESCRIPTION A B C D E F G H PB Random 60 60 30 60 60 60 60 60 LOCATION TYPE 1 LOCATION TYPE 2 The random audit will i l d i f di HB IP Random 30 30 30 30 include a review of coding and clinical elements to support the SOX Requirement. Claims will be selected HB OP Random 30 30 30 30 from all lines of business for professional and hospital (inpatient and outpatient) services. 120 120 90 120 60 60 60 60 GUARANTOR STATEMENTS (GS) HB Random GS ‐1/2 Inpt and ½ Outpt 30 30 30 30 GS will be reviewed for both professional and hospital services Total Sample Sizes PB Random GS 30 30 30 30 30 30 30 30 60 60 60 60 30 30 30 30 hospital services. Total Sample Sizes
Logistics
Logistics
Resources, Schedules
Obtain electronic access to patient statements, medical
records, and other billing information via partnership with
Resources, Schedules
,
g
p
p
location business units.
Observe PHI precautions
Schedule overlapping location audits based on availability of
Schedule overlapping location audits based on availability of
coding auditors.
Coding auditors perform as both auditors and quality
assurance for different location business units.
Utilize clinical reviewers judiciously.
Timeline - SAMPLE
Planning - research location-specific process flow,
Timeline SAMPLE
Planning research location specific process flow,
etc. – Week 1 through 8.
Kick off meeting with client partners – Week 2.
Entrance conference with client leadership – Week 9.
Plan
Conduct audit and QC results – Week 9 through 12.
Vet preliminary observations with client; share
preliminary scores – Week 13 through 16.
D t
Review, Evaluate, Test Controls
Exit conference and draft report to – Week 17
through 19.
Comments back from client – Week 22.
Fi l
t ith
CAP
t
l t W k 24
Communicate and
Document
Exceptions
Final report with CAP template – Week 24.
Completed CAP returned – Week 28.
Report
Resolve
Workforce Schedule - SAMPLE
Phase I ‐ PLAN & PREPARE: (1) Verify data received, prep tool, codify criteria, train staff, perform walk through or interview regional staff/populate prep questionairre, hold e Phase II ‐ EXECUTE: (2) Conduct audit, clinical review, and QA (for data accuracy and for individuals)
Phase III CONCLUDE: (3) Vet results with client update DB draft report and CAP prepare exit slides hold exit conference finalize report and CAP report to leadership
Phase III ‐ CONCLUDE: (3) Vet results with client, update DB, draft report and CAP, prepare exit slides, hold exit conference, finalize report and CAP, report to leadership
Q1 Q2 Q3 Q4
FEB
REG AUD QA B l f A di (3) REG AUD QA B l f A di (3)
SEP PB TARGET AUDIT PB RANDOM AUDIT OCT JUL AUG V VVV VV VVV V
JAN MAR APR JUN
V VVV VV VVV V MAY 2 Auditors & 2 QA
REG AUD QA 60 REG AUD QA 60
REG AUD QA REG AUD QA 120
REG 120REG AUD QA 120
Bal of Audit (3) Bal of Audit (3) HB TARGET AUDIT Bal of Audit (3) Bal of Audit (3) Balance of Audit (3) AUD QA V V VVV VV VV VV V 2 Auditors & V V VVV VV VV VV V HB RANDOM AUDIT Balance of Audit (3) REG AUD QA 120 REG AUD QA 120 REG AUD QA 120 REG AUD QA 120 Balance of Audit (3) HB TARGET AUDIT Bal of Audit (3) V VV VVV VV VVV V 2 QA V VV VVV VV VVV V HB RANDOM AUDIT Balance of Audit (3) Balance of Audit (3) REG AUD QA 120 MA (1) AUD QA 60 NCL AUD QA 60 Bal of Audit (3) Bal of Audit (3) V V VVV VV VVV V V GS & RA for PB & HB 2 Auditors & 2 QA V V VVV VV VVV V V Balance of Audit (3) (1) V VV V VV
Scoring
Random
Scoring
Overall location-specific score and results by category:
•
Coding information.
•
Service elements (for example, demographics).
•Financial elements.
•
Medical record completeness .
Heat MapColor
Description
Green - Meets 95% or above accuracy
Results by payor type, place of
Green MeetsExpectations
95% or above accuracy
Yellow – Needs Attention
80% to 94% accuracy
service, and type of service.
Guarantor Statement scoring by
element.
Attention
Red –Does not Meet E t ti
79% or below accuracy
Target
Overall location-specific score and
lt b
h i k
ExpectationsScoring – SAMPLE (PB)
Methodology
Scoring SAMPLE (PB)
Methodology
• Patient Name-FL2
• Patient Birthdate and Sex-FL3
R f i /O d i P id N d NPI FL 17 & 17b
Service Element Accuracy
• Referring/Ordering Provider Name and NPI - FL 17 & 17b • Rendering Provider NPI* - FL 24j
• Federal Tax Identification Number (TIN) - FL 25 • Patient Account Number - FL 26
• Provider Name, Credential and Date - FL 31 • Service Facility Location Information -FL32 • Service Facility Location NPI -FL32A
• Billing Provider Name, Address, ZIP, Phone, and NPI - FL 33-33a
Coding or Automated Charge
• Dx1 to Dx4-FL 21
• Pointer Dx Associated*- FL 24E • CPT Coding* - FL 24D
Scoring (cont )
Methodology (cont )
Scoring (cont.)
Methodology (cont.)
• Financial Class - FL 1
• Patient Medicare Health Insurance Claim (HIC) Number - FL 1a
Financial Accuracy
• Insured Policy Group or FECA Number - FL11 • Date of Illness, Injury or Pregnancy (LMP) - FL 14;
• Hospitalization Dates Related to Current Services (from/through) - FL18 • Anesthesia Time - FL19
• Date(s) of Service* - FL 24A • Place of Service* - FL 24B • Charge for Service* - FL 24F • Days/Units of Service* - FL 24G
Amount Collected from Patient FL 29
Medical Record
• Amount Collected from Patient - FL 29
• Plan of Care • Authentication Medical Record Completeness • Authentication • Supervision Requirements
Scoring (cont )
Scoring (cont.)
Methodology (cont )
Accuracy Rate per Attribute
Number of Accurate Lines/Claims Total Number of Applicable Lines/Claims
Methodology (cont.)
Attribute Total Number of Applicable Lines/Claims
Error Rate per Attribute
Number of Incorrect Lines/Claims Total Number of Applicable Lines/Claims
* attribute counted both on the line and claim level.
per Attribute Total Number of Applicable Lines/Claims
Some Field Locators (FL) exist at claim and line item level (e.g.
rendering provider NPI), others at claim level only (e.g. patient
g p
)
y ( g p
Reporting
Reporting
Daily Reporting
Daily Reporting.
•
Exception reports.
•
Accuracy reports.
Accuracy reports.
•
Completeness reports.
Summary Reporting.
y
p
g
Present draft findings to client.
Resolve disputes.
Resolve disputes.
Report - SAMPLE
Report - SAMPLE
RESULTS
Target Claims
Overall results demonstrated an accuracy rating greater than 95%.
Based on the results of the location review, it is our opinion that the billing
compliance controls for target Medicare FFS professional service claims tested
Met Expectations. The table below considers all errors. The overall accuracy rate
was greater than 95% at both the line and claim levels. % Line Item %Claim % Line Item %Claim % Line Item %Claim % Line Item %Claim % Line Item %Claim (88 li Location Overall Accuracy Rate Service Element Accuracy Coding Accuracy Medical Record Completeness Total Lines and Claims Financial AccuracyConclude Audit
Conclude Audit
Discuss Results with Clients
Draft and Final Reports.
•
Executive Summary.
•
B k
d
•
Background.
•
Scope & Objectives.
•
Opinion.
•
Summary of Results
•
Summary of Results.
Corrective Action Plan.
•
Control Objective.
C i
i
•
Criteria.
•
Deficiencies.
•
Potential Risks.
•
R t C
•
Root Cause.
•
Recommendation.
APPENDICES
Claim – Field Locations (PB)
Claim – Field Locators (HB)
Claim Field Locators (HB)
Audit Definitions
R f
& T l
Claim Type Field Locators (FL)
CMS 1500
yp
( )
30 Demographic
33 fields on CMS 1500.
Some fields report
Billi
p
demographics, others are
specific to coding & billing.
Required or conditional
BillingBilling Coding
Required or conditional.
Some pertain to the whole
claim.
Coding
Some pertain to a specific
UB-04 FL
Inpatient - 81 fields on the UB-04; some are the
same as CMS 1500 fields and some have no
equivalence:
Type of Bill.
Type of Admission/Visit.
Patient Status.
Condition Codes.
Occurrence
Occurrence
Codes/Spans/Dates.
Value Codes/Amounts.
Revenue Codes.
UB-04 FL (cont.)
(
)
Outpatient: Some fields on the same form are
used differently from Inpatient to Outpatient :
Inpatient claims show
revenue codes and
accommodation rates
accommodation rates.
Outpatient claims list line
items, e.g., ER, Lab,
Radiology services, each of
which may require HCPCS
codes.
Audit Definitions
Audit Definitions
Overall Conclusion Rating Definitions
Severity Level: Level of Difficulty:
Meets Expectations–when taken 4 — Critical Risk Related business or D — Challenging Resolution of exception may be complex
Meets Expectations –when taken
as a whole, business objective will likely beachieved, or one or more moderate/modest issues were identified.
4 — Critical Risk –Related business or control objective cannot be achieved
without resolution of issue;
D — Challenging –Resolution of exception may be complex
due to historical culture, significant changes to systems, and/or requires significant redesign of process, which will likely need a high degree of management attention or substantial commitment of resources;
Needs Attention -when taken as a
whole,business objective will likely not beachieved or one or more significant /modest issues were identified.
3 — Significant Risk – Remediation of issue would strongly support business or control objective;
C — Difficult - Resolution of exception may involve culture or
structural changes, buy-in from other functional areas and may impact on other processes;
Does not Meet Expectations
-when takenas a whole, business objective will notbe achieved, or one
or more critical /significant issues
2 — ModerateRisk – Issue presents
moderate risk such that related business objective may not be achieved;
B — Medium - Resolution of exception may require business
process changes or implementation of control activities and may require incremental resources;
g were identified.
1 — Modest Risk – Issue is considered a process deficiency or opportunity, not a key control, but if operating would reinforce or supplement other controls.
A — Fair – Resolution of exception is correctable in the
normal course of business.
The type of eachfinding is defined as follows:
33
reinforce or supplement other controls. The type of each finding is defined as follows:
Design – controls are not designed properly to meet business
objectives.
