A familiar adage about collecting data for healthcare insurance claims says, “If you don't need it to get paid, then it won't be saved.” In the age of healthcare reform, this adage is no longer true and has even become a risk.
Providers now need to save far more data beyond what is just required for a claim to be paid. Providers must collect-and have readily available-detailed information to assist supporting the paid claims in the case of an audit. Additionally, as more and more providers are completing their own internal audits, which sometimes result in self-disclosures, key data elements are critical for completeness of their audit findings and conclusions.
The processes for collecting data for claims to be paid are already in place. Equally important are the priorities for collecting other data to keep the payments received, if later reviewed by an auditor who demands supporting details.
AS CONTRACTORS WHO WORK IN TANDEM WITH THE MEDICARE ADMINISTRATIVE CONTRACTORS AND THE OFFICE OF THE INSPECTOR GENERAL BECOME MORE SOPHISTICATED, PROVIDERS WILL HAVE TO BE AT LEAST EQUALLY PREPARED.
A significant portion of health reform is focused on curtailing healthcare fraud. As such, the Centers for Medicare and Medicaid Services (CMS) has reinforced numerous components of its program focused on fraud and proactive audit activity. Three types of contractors play a key role in this regard:
Zone Program Integrity Contractors (ZPICs) audit claims data across all providers to determine if, for example, Medicare and Medicaid claims filed for dual-eligible beneficiaries are not being billed for the same services twice.
The Recovery Audit Contractors (RACs) review claims from any provider who was paid by Medicare, identifies net overpayments and recoups them on an automated or complex review basis.
Comprehensive Error Rate Testing (CERT) contractors analyze paid claims and calculate an error rate. They then can assess medical records and recoup overpayments.
As these contractors-who work in tandem with the Medicare Administrative Contractors and the Office of the Inspector General-become more sophisticated, providers will have to be at least equally prepared.
BEYOND OVERPAYMENT ISSUES
In addition to the “overpayment” police, health reform is placing health information demands and options on providers in a variety of areas. These include disease management, health information technology for care coordination and home telemedicine, quality of care measures, and quality of outcome measures. These trends and the continuing migration to electronic medical records contribute to the information challenge and questions of, “How much is too much?” and “What data elements should I start collecting and storing now?” Here are a few practical examples from some recent specific client experiences:
Pre-authorizations for medical necessity of an admission-Some state medical assistance programs require pre-authorizations for certain admissions. Even though a pre-authorization number is issued, it does not preclude the payer from reviewing the documentation supporting the admission at some point in the future. The documentation in the medical record must match the information reported to the state when obtaining the pre-authorization. The state is likely to ask such questions as: Is there a link between the reason noted in the request in the pre-auth system and the medical record documentation? Does it match? Is it captured electronically to allow for validation?
Last patient to get medicine for waste billing compliance-CMS has many payment policy requirements. One potentially difficult one to track is the billing of drug waste for a multi-dose vial. Providers need to consider such questions as, “Do I track and save the number of doses for a given drug provided on a given day?” “Is this matched to the number of milligrams contained in the number of vials billed on that same day?” “Can I capture the last Medicare patient to receive the drug to allow for proper billing of the waste as allowed by the regulations?” These types of data are critical to maintain to be able to monitor and accurately assess compliant billing of multi-dose drugs.
A HOSPITAL SHOULD BE ABLE TO IDENTIFY THESE CLAIMS IN THEIR DATA WAREHOUSE AND CONDUCT THEIR OWN ANALYSES ON THE DRIVERS FOR ANY OCCURRENCES APPEARING TO BE AN ‘OUTLIER’ STATISTIC.