“There’s another incredibly helpful resource that some might not be as familiar with: the list of services that Medicare Administrative Contractors (MACs) include in their Target, Probe and Educate (TPE) plan.”
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Compliance must build relationships with these healthcare functions – Legal, Internal Audit, Human Resources and Quality. Here are suggestions on how to effectively build relationships and collaborate with them to help achieve their goals.
Continue readingTelehealth is almost as old as the telephone itself. In 1879 – just three years after Bell patented the telephone – an article in Lancet described the concept and advocated its adoption.
A law that’s even older can trigger many telehealth audits today. The 1863 False Claims Act (FCA) was enacted to keep profiteering contractors from defrauding the Union army. It can trigger serious problems for hospitals that don’t take proactive steps to make sure their telehealth practices are audit-proof.
That’s because the 2010 Affordable Care Act updated the FCA to make healthcare providers liable for “retention of any overpayments” from Medicare and Medicaid. This even includes overpayments resulting from accident or error. Indexing penalties for inflation each year, a requirement added in 2015, increased hospital liabilities. This puts liabilities at three times the amount of the overpayment(s) plus $11,803 to $23,607 for each instance. (Some 29 states and the District of Columbia have additional False Claim laws.)
These laws’ implications and requirements touch every part of the hospital. Keeping the whole organization in compliance means that all departments have to work together.
Even before COVID, the government audited claims from what was then a smaller, rural telehealth system. Regulators found a trend of incorrect payments to doctors outside rural areas, who were therefore ineligible to receive them.
Telehealth is on the latest Office of the Inspector General (OIG) work plan, too. The OIG will be addressing remote patient monitoring by telehealth as an area of concern.
The public health emergency, with its series of 90-day waivers, made it possible for telehealth to grow so fast. Now, as the COVID emergency ebbs, Congress is considering making its current, expanded status permanent. (Two bills were introduced in May. One would enable audio-only telehealth services for Medicare enrollee. The other would expand telehealth for Medicaid and Children’s Health Insurance Programs.)
That’s good. But with laws come regulations covering acceptable types, locations and forms of delivery of telehealth services. And with regulations come scrutiny and audits. That can create challenges, especially with the specter of FCA liability in the background.
The best way to cope with audits is to prevent the need for them in the first place. Here are six steps to follow:
Patient demand for telehealth isn’t going away. Neither are the costs of noncompliance with telehealth regulations. As the public health emergency expires, fines from regulators and denial of claims from payers are sure to add up. The best way for your healthcare organization to solve these potentially massive financial problems is to work together to prevent them. Proactively partnering with colleagues in all relevant departments, your compliance team can lead the efforts to identify and fix issues before they become major problems. That way, you’ll be able to provide the telehealth services patients want in compliance with what the regulations demand.
It’s a big effort to keep your compliance champions connected and communicating. See how YouCompli can help you manage the rollout of new regulations and verify best efforts to regulators and your board. YouCompli is the only healthcare compliance software combining actionable regulatory analysis with a simple SaaS workflow.
Revised September 2022
Most healthcare providers, from large hospitals to solo practitioners, experience an external audit at some point. The scrutiny can unveil errors and violations, which can lead to hefty penalties.
The key to surviving an external audit, with the least amount of frustration, is to avoid these five common mistakes.
Your deadline to submit relevant documentation begins upon receiving that external audit request.
External audits may be requested by a commercial health insurance payer, or government agencies such as the Centers for Medicare and Medicaid Services (CMS) or Office for Civil Rights (OCR). While the origin of the audit request doesn’t matter, a timely response is essential.
Take all deadlines seriously. If an extension is needed, ask for one, immediately. Missing deadlines can result in hefty fines and penalties.
A common trigger for payer audits is improper or lack of necessary documentation. As a healthcare practitioner, you must prove the medical necessity of each test or procedure used to diagnose and treat your patients.
Here’s the tricky part. Sometimes payers and providers disagree on what tests or procedures are medically necessary. Additionally, medically necessary guidelines change frequently. CMS provides local coverage determinations (LCDs) and national coverage determinations (NCDs) to help with your documentation. Be sure you are aware of changes to these coverage determinations.
The best way to mitigate this problem is to educate your staff on what services the payer considers medically necessary, and what documentation is required to establish medical necessity.
Additionally, clearly document the need for a particular procedure to treat or diagnose a patient. Finally, when required, ensure that authorization is received from the payer before rendering services.
Incorrect billing and coding practices can raise suspicion of fraud, failed claims, or delayed reimbursement, and — you guessed it — external payer audits. Providers and patients overpay a whopping $68 billion annually due to incorrect billing.
Coding systems developed by the American Medical Association and the Centers for Medicare and Medicaid are designed to streamline the billing process. Every medical procedure and service from ambulance rides to chemotherapy drugs to doctor visits are contained within coding systems such as the ICD-10, CPT, and HCPCS.
Studies show 80 percent of medical bills in the U.S. contain errors. This percentage can decrease by ensuring appropriate staff stay current with billing and coding updates and communicate those changes to the right clinical and administrative staff to avoid old and outdated codes.
One way to prepare for payer audits is to perform regular self-audits within your facility. Internal audits are great for identifying and eliminating weak spots that can potentially lead to headaches down the road, like rejected claims and costly compliance failures.
One drawback is the strain on precious resources like time and personnel. You can get around this problem by hiring a third-party audit service. Make sure you have HIPAA-compliant Business Associate Agreements (BAA) so that you’re allowed to share your patient health information with third parties providing auditing services.
Another option is to use software provides 24/7 access to survey compliance data. Ideally, this software will provide automatic tracking of all documentation and decisions involved in the process of running your organization.
This ensures that compliance professionals can get immediate reporting on how well their team is doing, conducting audits more efficiently and effectively. It’s a time and cost-effective solution to hiring an outside third-party provider.
Having a healthcare attorney in your corner can mean the difference between a smooth audit experience and an audit nightmare.
Here’s how a healthcare legal team can benefit your health practice:
Again, software is a useful tool to support your attorney’s work. A system that stores all compliance information, including payment practices, and has search capability will provide your legal team with the information they need to fight payer audit discrepancies when the time arrives.
External payer audits don’t have to be a nightmare. By being adequately prepared and vigilant, your next audit experience can be more streamlined and less stress-inducing.
The best way to prepare for a payer audit is to carefully manage changes to regulatory changes and coverage determinations. YouCompli can help you establish a scalable, repeatable process so you don’t miss a relevant change and you can equip your clinical colleagues to respond to the change. Then, when the audit does happen, you’ll have an easy way to demonstrate your work to comply with the requirements. Find out more.
Jerry Shafran is the founder and CEO of YouCompli. He is a serial entrepreneur who builds on a solid foundation of information technology and network solutions. Jerry launches, manages, and sells software and content solutions that simplify complex work. His innovations enable professionals to focus on their core business priorities.
When it comes to hospitals providing best-in-class health care, stress comes with the territory. From stabilizing trauma victims, to accurately distributing medications, to physicians and nurses working long shifts, increased demands are everywhere — including operations not directly involved with patient care. One demand that can turn daily routines completely upside-down and compound stress is an audit. A GRC compliance audit can be conducted internally by various hospital committees or externally, often by government-approved contractors.
An internal audit seeks to determine if a hospital’s financial and operational controls, and their related policies and procedures, meet compliance and risk management demands.
Based on a hospital’s risk assessment, management develops and reviews the scope and goals of an audit. Running the audit is then delegated to a committee, with the most common committees focusing on:
An internal audit involves interviews and evaluating personnel or procedures. Upon the audit’s completion, a report of its findings is prepared by the appropriate committee and shared with management. Corrective recommendations of action to any areas of noncompliance are collaboratively developed, and a finalized report is presented to the hospital’s board of directors, chief compliance officer, and audit and compliance committee.
The ultimate goal of an internal audit is to improve patient care. Who in a hospital wouldn’t want to improve it, right? But the truth is that an audit can diminish quality of care while it’s in progress. That’s because committees are often comprised of physicians, nurses, and technologists who are pulled away from patient-care responsibilities to work on compliance administrative tasks.
According to a 2017 AHA report, four federal agencies — the Centers for Medicare & Medicaid Services, the Office of Inspector General, the Office of Civil Rights, and the Office of the National Coordinator for Health Information Technology — are the primary drivers of regulations and compliance costs across eight domains for hospitals:
The frequency and pace of regulatory changes implemented by multiple federal agencies are dizzying. Hospitals are often required to comply with regulations in very short timeframes, requiring a significant investment of staff time and finances. What’s more, responding to multiple external audits increases administrative costs, and funds could be tied up in lengthy appeals processes contesting an auditor’s inappropriate determination.
External audits are conservatively estimated at $100 per hour. For example, consider the total costs of a HIPAA audit:
If your hospital is like most others, it’s spending too much staff time and money dealing with a blizzard of regulations and an avalanche of red tape. Fortunately, there are solutions. youCompli GRC risk management software monitors, reads, and translates complicated regulations into plain English. Our solution enables you to fully understand which rules are pertinent to maintaining compliance, further simplifying the auditing process. And it tracks everything, from end to end, making audits much less painful.
Learn how youCompli regulatory compliance management software protects your hospital.