Navigating the audit gauntlet
in CMS billing is getting more challenging by the week and recently, it seems, by
the day. Two things are becoming abundantly clear. First, and no matter how
well intentioned and honest, the old methods of claims preparation and submissions
no longer work. Second, and more than ever, you must avoid submitting what you
can’t defend.
The first line of the gauntlet
is firmly in place.
MACs – Medicaid Administrative Contractors
RACs – Recovery Audit
Contractors
ZPICs - Zone Program Integrity Contractors
Each of the above
hired, licensed, paid and deployed throughout the country to oversee, review,
process and question each and every claim you submit.
As challenging as understanding,
complying and staying current with the medical and health care aspects of providing
home care is and the proper ‘care coding’ and claims submission documentation
is, the challenge of navigating and avoiding the deepening scrutiny of these multiple
audit weapons that CMS has operational to oversee fraud, waste and abuse (FWA)
is equally challenging. The ROI for CMS is provably simple. CMS spent $450
million on FWA programs and re-gained $42 billion. Without a blink they just announced
a $11 billion charge back to hospitals for past over payments. So don’t expect the
pressure to lessen any time soon. The authorities granted these contractors
extends to being able to refer home care agencies to the DOJ or OIG for investigation
and potential prosecution.
Quality assessment and
control (QA) over claims documentation has now become a mandatory staffing and
skill set requirement for home care services.
As Michael McGowan an experienced
auditor now leading OPERACARE stated, “Poor documentation that doesn't show
necessity, skill, or documentation to standards of CoP can all down grade a
visit. Or, visits are easily deemed non billable due to no orders to
support the claim or even improper supervision. So it is no longer a
matter of RAP vs reality of how many, but so many other factors can down grade
your therapy counts. Even a whole chart with MUE can negate all therapy
visits before they occur. Only proper OASIS scrutiny in real time at SOC
to plan for necessity and efficient treatment followed up by rock solid documentation
can help you get the payment you think you are going to get.”
With the new pre authorization
claim review, and with MACs, RACs and ZPICs and all the other audit teams out
there, it is best to be sure of what you are doing and why, and make sure it
all follows through.
So what can be done to
lessen audit risk? To prevent being audited into bankruptcy? Use software that
lets you see what CMS sees before they see it and don’t submit what you can’t
defend.
The best I have seen
is OPERACARE. But don’t only take my word for it.
Ben Galin of Galin Consulting
after reviewing OPERACARE said “It is the only tool I have seen that automates
some of these first steps to let you see your chart from a macro and micro and
agency macro view simultaneously, in seconds, where it can take an entire QA
team to do this in hours.”
The true bottom line
is this: It is a new world, a new age and a new era for home care, one where your
bank accounts now have large exit doors. It is time to step up to these new
challenges with advanced weaponry of your own, show your worth and lessen your
worries about MACs, RACs and ZPICs knocking at your door. OPERACARE can help
you do that.
