Identifying the best practices and deficiencies in the multi-discliplinary group within a healthcare organization's Revenue Cycle - Patient Access/Registration, Patient Accounting/Business Office, Health Information Management & Charge Capture Staff, Charge Description Manager (CDM) & more.
ICD-10 Readiness Assessments, Action Plans, and Implementation - including Training & Process Redesign
Providing cross-functional assessments with Compliance to minimize claim submission risks.
Workflow analysis
Billing audits (chart-to-bill audits for inpatient, outpatient & physician services)
CDM & Charge Capture Reviews - High Risk IP/OP services and Specialty Physician Practices
CDM Maintenance & Charge Capture Reviews to assess and improve workflows - especially related to meeting State and Federal compliance regulations!
CLINICAL AUDITS - Evaluation of medical records for clarification of documentation, comparison to Local or National coverage determinations (Medicare, Medicaid, and Other Third Party Payers), and assessment of Level of Care (inpatient versus outpatient).
Coding Compliance & Medical Necessity educational programs for both clinicians and non-clinician staff
Data Mining & Risk Area Analysis
Use claims data to identify specific “weak points” for Inpatient, Outpatient, & Physician service areas
Review medical records from all risk areas to evaluate “translation” of documentation of services to codes and charge capture processes plus review medical necessity through specific screening criteria
Differentiate technical (software, CDM, etc.) issues from clinical documentation or coding issues
Provide focused reports on trends - by MSDRG, by coder, by physician, by service area, etc.
Collaborate with healthcare provider to assist them with reproducing these risk area analyses for ongoing internal improvement initiatives
Comprehensive Chart to Bill Audits
Data mining to select high risk or targeted cases
Evaluate documentation submission process
Confirm documentation for technical and physician/clinical services matches services billed on claim
Confirm reimbursement is correct for the claim and the financial impact of coding or charge capture recommendations for change
Comprehensive reporting with detailed action plan and recommendations for compliance
Post audit exit conference and education session
Post audit follow up interviews to evaluate action plan improvement implementations
Inpatient Audits
MSDRG validation
POA validation
HAC risk area review
RAC risk area review
Coder competency
Clinical documentation assessment
Level of Care (medical necessity criteria) evaluation
Short-Stay risk area review
PEPPER risk area review
Outpatient Audits
CPT/HCPCS validation - hard coded/CDM
High risk area charge capture reviews (Wound Care, Infusion Therapy, Emergency Department, etc.)
CPT/HCPCS validation - HIM coded, high risk area reviews (AmbSurg, Wound Care, Endo, etc.)
RAC risk area reviews
Outpatient Clinic Audits - Article 28, Article 31, Article 16, Article 822 - especially with the implementation of NYS APGs!
CERT, PSC, RAC peer review analysis
Physician Services Audits
Physician comprehensive documentation and charge capture reviews
Physician Practice Revenue Cycle & Operational Assessments with education, policy development, and implementation
Specialty physician service audits - Psychiatry, Physiatry, Wound Care, Emergency Medicine, Critical Care, Internal Medicine, Obstetrics & Gynecology, Hospitalists, Pain Management
Identification of missed revenue opportunities - "Charge for what you are actually doing!" - Prolonged services coding, consultations, concurrent care scenarios, etc.
CERT and Provider Peer Review reviews
Medicaid APG analysis
Operational Assessments
Outpatient Services (Clinics, Hospital OPD) Charge Capture Reviews - From initial patient contact through to claim submission and reimbursement, we evaluate and report on best practices, deficiencies, effectiveness of staffing, effectiveness of technology, missed revenue opportunities, compliance issues, and overall charge capture improvements.
Inpatient Services (HIM, Revenue Cycle, Patient Access, Case Management, CDI) Data Capture Reviews - From initial patient contract through to medical necessity criteria to documentation improvement activities, coding and claims submission, we evaluate and report on best practices, deficiences, effectiveness of staff, effectiveness of technology, missed revenue opportunities, compliance issues, and overall workflow improvements.
ICD-10 Operational Reviews - From coding accuracy and workflow through to necessary training, staff skill sets, we analyze current processes throughout the organization (HIM-IP and OP, Physician Coding, Revenue Cycle, Case Management, CDI) and develop realistic action plans to successfully migrate from ICD-9 coding to ICD-10 for your organization, regardless of size or resources.
Physician Practice Charge Capture Reviews - From initial patient contact through to claim submission and reimbursement, we evaluate and report on best practices, deficiencies, effectiveness of staffing, effectiveness of technology, missed revenue opportunities, compliance issues, and overall charge capture improvements.
Staff Productivity Analysis - Interview, observe and track staff productivity to identify deficiencies in time management, operational processes, and compliance with best practices for departmental or physician practice efficiencies.
Targeted Revenue Cycle Reviews - Evaluate claims processing procedures, technology, auditing/monitoring activities, denial management activities, and appeals capabilities. Focus on both Medicare and Managed Care workflows.
Engaging the Healthcare Community Across the Country
Providing quality management improvement training
Collaboration & Education
Articles
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Upcoming Courses
ICD-10 Hands On Workshop through the NYMAC AAPC Local Chapter - December 2011 - Jamaica, New York
