Our Audit and Assurance Practice provides specialized healthcare audits. Our team is comprised of nurse reviewers who are experienced in analysis of ICD-9 and CPT-4 coding as it impacts hospital billing audit. Our practice team also has more than 10 years experience in healthcare management and billings. We provide the following Specialized Health Care Services:
APC Validation Audits
Many factors can affect the correct assignment of APCs. APC audits include a thorough review and recoding of the medical records ensuring coding accuracy and the reasonableness of services rendered. There can be multiple APCs on a single claim and many factors could affect the correct assignment of APCs.
CCI violations, correct usage of modifiers and current knowledge and expertise with all of the rules pertaining to pass-through items can also be an assignment of the APCs. Further, the service must be deemed appropriate for the treatment of the diagnosis, which is determined by Local Coverage Determinations (LCDs) and Local Medical Review Policies (LMRPs).
DRG Validation Audits
The audit process consists of a thorough review and recoding of the medical record in order to validate the procedures and diagnoses coded that resulted in the DRG billed by the provider and reimbursed by the payer. Subsequently, through the use of nationally accepted technology, we recode and re-price the claim based upon the audit results, thereby providing clients with accurate payment validation information for each claim.
Through the continuous tracking and trending of its state of the art database, we are able to optimize its audit process and results by focusing on historically abusive facilities or incorrectly coded/abused DRG codes.
RUG Validation Audits
The billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay is confered on the SNF per the consolidated billing requirement. Consolidated billing also provides coverage for the physical, occupational and speech therapy services received during a non-covered stay. A RUG (Resource Utilization Group) score is determined by the completion of the Minimum Data Set (MDS) which calculates the RUG score.
We conduct a comprehensive review of all claims where the costs are based on a RUG score. A detailed review of the complete medical record and associated MDS allows our team to determine if the billed RUG score is valid. In the event the review determines that an incorrect RUG score was billed, our team will report the valid score and report the reason the change was necessary.
Inappropriate Admission Review (IAR)
There are times when hospitals admit patients on an inpatient basis as opposed to providing an alternative and more appropriate level of care in observation or the outpatient department. This costs Medicare and commercial payers hundreds of millions of dollars. Our team identifies and reviews specific claims that have a high potential for overpayment based on the level of care, severity of illness, and intensity of service provided.
We present payers with an opportunity to identify savings for inappropriate admissions on inpatient claims: ability to reconcile overpayments based on inappropriate level of care; targeted review of admissions with high potential for inappropriate level of care; and effective post-payment cost control for inpatient large facility bills with minimum repercussions.
Medical Chart/Hospital Bill Audits
A medical chart audit validates proper payment of hospital bills for payers by conducting a line-by-line comparison of the itemized bill to the corresponding medical records to verify that all goods and services that were billed were both prescribed and administered in the specific levels and quantities specified. The audits aimed at claims reaching certain charge or catastrophic thresholds. Payers also may identify hospitals that have shown an increase in charge base or when contractual changes have resulted in more carve-outs or pass-through charges.
Despite computer-assisted charting and charge functions, there still is great potential for identification of billing errors due to lack of appropriate crediting, missing physician orders and internal hospital protocols that are not documented or ordered by the physician. Our audit programs are specifically designed to closely scrutinize and assist in the control of these costly errors.