Unit 4 Assignment 1 Draft CAPSTONE POWERPOINT-Management Affiliation
jmjewett
NCHAuditEvaluationSummaryDocument.docxIntroduction
This report has been put together to give an understanding of areas that can use improvement and can be used to create plans and protocols for future use. It is not the intent to use this report to place blame but more over to review, educate and create avenues of teachable moments for the benefit of all who are involved in the overall process.
Summary of Findings
In order to determine areas of concern we came up with a strategy to audit 10 Accounts for 6 of the licensed Clinical Practitioners and 10 Accounts for 6 for the Medical Providers this was a total of 120 accounts that were evaluated over the last 90 days.
Documentation
This most consistent area that needs improvement would be in the documentation of Time within the body of the Actual Note. Upon inquiry. It was noted that the time stamp found in the Note Header does not transmit to the printed copy of a note. This is needed for a few reasons, based on how BH is billed and paid Time is the predominant factor. In some cases, not having time listed changes the way the visit can be billed, and the change is normally for a lesser charge. This could create a loss in revenue due to missed opportunities to capture an increased dollar value not just in the charge but the amount allowable for payout as well.
Medication Management is another item that needs evaluation there are many providers capturing a basic level E&M when there is a specific code to be captured for a Medication Management Level being able to assess when it can be used, and which insurance will allow it to be used. It is helpful to develop a protocol for all providers and Medical billing staff to create a work flow that will produce a greater outcome in reimbursement
Billing
Insurance Validation is a deficiency that can be fixed with the creation of a protocol. We recommend that the Insurance be validated before each visit, this will allow the billing staff to be aware of any pre AUTH’s, or any other required permissions that are needed in advance. This will also create the understanding for the requirements when billing. There are some insurance carriers that require documentation with each bill submission, there are other carriers that require a renewal of the authorizations every 90 to 120 days all this information would be available when performing a validation and verification of insurance.
Medicare specific issues stem from ABN that are not found in the scanned portion of the patient file and this is problematic when attempting to collect on debt not payable by Medicare. I found rarely any ABN ‘s on file. This is a issue that can be corrected with consistent and thorough use of the system. The Tier software allows for the programming of reminders for expired plans, ABN’s missing there are alerts that could be establish with the thorough use of the system. Especially in the financial section. We found missing scan Ins and ID cards which prevent insurance fraud and create proper billing by having current ins card information and updated Demographics.
There are still many unpaid DOS and those need further evaluation because it is unclear why they have not been paid to date. We also found write offs that need revaluation to determine it the write off can be reversed. Some patients are listed as self-pay although they have valid insurance.
In reviewing the Tiers system, it is felt that if there were to be a more thorough and consistent use of the System there may be fewer errors and higher evidence of reimbursement.
Contract Obligations
This is another area that can be address for further improvement. It has been reviewed that some insurance carriers are paying different rates for the same service with different patients this is an issue that would warrant the review of the contracts that are in place to determine if any recent changes have occurred, or If renegotiations are necessary.
Charge master
CPT and ICD 10 CM is updated every October of every year. Because of this there will be a need to make changes within the Chargemaster, I am not sure of the current process, but it is felt that there Is a need for assistance in this area because there have been codes that were found to be discontinued that have been billed.
Finally, there needs to be a system put in place to retroactively review accts for unpaid secondary claims and unpaid claims in general. It is very easy to lose sight of retro billing when new claims are coming in every day. Out of the 120 Patient accts reviewed 29 of them had out standing balances not paid or partially paid that were at least 30 days old.
Coming up with a systematic approach will greatly decrease the outstanding balances and create positive cash flow in reporting.
In Conclusion: This audit is no worse than any other audits for any other facilities. The only way to improve an area is knowing that improvement is needed. We feel that there are items that can be addressed, and once they have been addressed it will create a satisfactory increase in work flow and revenue. We are willing and available to assist in creating the protocols and providing education that will create a smoother process for all involved. We look forward to being of service to you in any capacity that will be of help.
