Customer Profile
Multispecialty group with 1,200 physicians and 250 midlevel providers across 40 specialties
Location: Mid-Atlantic Region
Affiliation: Major university medical school involved in cutting-edge research and trials
Activity: 1 million patient visits annually and revenues of nearly $200 million
The Challenge: Analyzing Data in Real Time
In this multispecialty physician group, 19 practice groups are supported by a small compliance team that manages all professional fee auditing including Medicare Part B billing. The department includes three documentation auditors, each of whom supports about 500 providers. According to the supervisor of coding, billing and compliance, the team may be small, but it is “amazing [and] always trying to be mindful of using time wisely by not auditing something without informed purpose and reason. As such, we’ve been shifting away from doing larger scheduled audits and focusing more on potential risk areas.”
Like most compliance departments, the group’s team creates an annual work plan based in part on what the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) will focus on for the coming year and what is carried over from the previous year. For example, targeted probe-and-educate (TPE) audits by Medicare Administrative Contractors (MACs) and Recovery Audit Contractor (RAC) audit topics remain priorities.
To elevate its strategy, the compliance team also wanted to leverage its internal data to plan risk-based audits based on the potential risks that are unique to an academic group practice, such as new provider audits and under/over-coding. The challenge, however, was that being limited to routine audits made it difficult to identify the trends necessary to effectively address these types of issues. And, once a trend was identified, manual reports would have to be created using specific parameters to ensure the right data was compiled—which meant if the compliance team wasn’t sure exactly what they were looking for, it was never going to be found.
Further complicating the process was another common scenario: dependence on IT resources to run reports and the inability to leverage real-time data for those reports. The compliance team would also need to ensure it was requesting reports monthly or quarterly so identified issues would be tracked over time, which took auditors away from their greater responsibilities of auditing additional risk areas and looking at new issues as they are identified.
As a result, while they were effectively auditing, educating, and training, as well as taking corrective action on a small scale, the monitoring component was missing. This meant the team wasn’t able to fully demonstrate to the Board of Directors and compliance committee the tangible results of its activities.
Providing a comprehensive view required an enterprise solution that would allow the compliance team to tap real-time claims data to identify and monitor trends and issues without relying on other departments for reports. For that, they turned to MDaudit Enterprise from Hayes.
The Solution: Real-Time Data Analysis and Monitoring
MDaudit Enterprise is a cloud based (SaaS) healthcare billing compliance and revenue integrity platform that enables healthcare organizations to audit physicians, hospitals, and coders to mitigate billing compliance and revenue risks. The platform brings together billing compliance and revenue cycle departments within the system’s healthcare organizations—two critical areas that have traditionally operated in silos, creating a fragmented approach to revenue integrity.
Now, auditing can be addressed in a more holistic manner. Compliance professionals leverage the platform to audit entities and perform corrective actions to mitigate compliance risks, while revenue cycle professionals leverage the analytics modules to identify revenue risks and take action to capture revenue. Workflow engines and analytics are tightly integrated to empower organizations to act on the insights in a collaborative manner that produces better outcomes.
When we transitioned to MDaudit Enterprise, the compliance team was able to see claims data in real time so we could monitor things in-house rather than constantly requesting and waiting for reports. With fresh data, we can look at reports just to see if anything is bubbling up or get high- or low-value alerts. So instead of uncovering trends through multiple audits, they are being served up to us on the dashboard, which is my favorite part of MDaudit Enterprise.
The Results: Real-time Metrics Reveal the Big Picture
The first metric the compliance team identified to monitor with MDaudit Enterprise was denial of claims for Evaluation & Management (E&M) services. By leveraging just one of the many of curated metrics available as metric cards on the platform’s dashboard, the team was able to identify one practice that was an outlier when compared to the others.
By drilling down into the metric, “we saw that the issue lined up with a risk area that had been the subject of ongoing eduction. But now we could drill down into the data to find out what the claims had in common, which gave us a better picture of the issue,” said the supervisor. “We were able to identify the specific location and group of providers that was the source of the issue, which enabled us to add an edit into the billing system and alert the practice that we would continue monitoring the situation. It let us hold the practice accountable and gave us an easy representation of the issue over time, so that we could share it with our board.”
She adds: “That is really helpful to have if you’re trying to demonstrate the effectiveness of your compliance program, for example using the seven elements of compliance,” which are standards and procedures; oversight; education and training; monitoring and auditing; reporting; enforcement and discipline; and response and prevention.
Ultimately, the team saw a real-time drop in the percentage of times the group was incorrectly using a modifier 25 on their established patient visit coding, down from approximately 30% to under 10%. And while the uptick in telehealth has lessened both E&M and procedure coding, the compliance team continues monitoring the situation to ensure the percentages do not creep back up. This saves time and eliminates the need to conduct additional audits of dozens of similar cases just to ensure the modifier’s use is reasonable.
MDaudit Enterprise also enables the creation of custom metrics cards to monitor areas where the compliance team may need to target coding education, such as with services provided during the COVID-19 pandemic. By setting up three key metrics around specific ICD-10 codes—U07.1 (COVID) in the secondary position, B34.2 (coronavirus infection, unspecified), and B97.29 (other coronavirus as the cause of diseases classified elsewhere) for dates of service after April 1, 2020—auditors are alerted to review claims using any of those ICD-10 codes before they are submitted to the payer.
The Conclusion: The Power of Real-Time Metrics and Monitoring
The group’s compliance team has slowly expanded the scope of its monitoring to target additional error-prone areas, such as the use of a modifier 59 and creating custom metrics. Strategies were also refined to just focus on alerts that were triggering as high value, then KPI metrics in the E&M sub-category.
“Doing so filtered all the metric cards down to a much more digestible, manageable list of things to watch,” said the supervisor.
By optimizing MDaudit Enterprise to address risk areas that are unique to the organization, this large physician group is reaping the rewards of proactive intervention based on real-time monitoring and risk-based auditing—which allows the compliance team to find issues before they can negatively impact the organization’s bottom line.
