Targeted probe and educate audits coming to a provider near you

“When Medicare claims are submitted correctly, everyone benefits.” That’s what CMS says verbatim on its website about the newly-launched targeted probe and educate audits that are designed to reduce denials and appeals through one-on-one education.

During an AAPC chapter meeting on February 13 in Providence, Rhode Island, Lori Langevin, education consultant at National Government Services (NGS), walked attendees through the process. NGS is the Medicare Administrative Contractor (MAC) for jurisdictions 6 and K.

“It’s all about lessening the burden on providers,” she said.

Here’s how it works: MACs use data analysis to identify providers/suppliers with high error rates or unusual billing practices. Common claim errors include an omitted physician signature, lack of medical necessity, or incomplete certification. The initial probe includes a review of 20-40 claims. Practices have 45 days to respond to the request for documentation, though Langevin says 30 days is best practice. A lack of response equates to an error, she added.

After the review, providers receive a letter detailing the results. They’ll also have an option to receive one-on-one education via teleconference or webinar. During these sessions, providers will have the opportunity to ask questions and learn about the specific CMS policies that apply to each claim.

Langevin was unable to provide a concrete definition of what constitutes a high error rate, though she did say that she anticipates E/M codes and prolonged services will be targeted due to the high error typically associated with these services. Other targets will likely include topics that have surfaced during CERT and RAC audits, she added.

The overarching goal of these audits is to reduce the administrative burden on providers and MACs, said Langevin. Not only is it costly for providers to appeal denials, but it’s also costly for MACs to review the appeals and potentially overturn the denials. The probe and educate audits will hopefully drive process improvement, she said.

To learn more about targeted probe and educate audits, view this FAQ.

 

 

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Can HIM and technology be friends?

Let’s face it. Technology changes every industry. This is especially true in HIM as it continues to revolutionize the way in which providers release health information, document in the medical record, assign codes, and more. How can HIM professionals keep up, and what must they do to stay current? These are two of the many questions that arose during the recent RIHIMA meeting on February 9 in Warwick. Approximately 50 people attended the event.

The future of HIM

Now that the hurdle of ICD-10 implementation has passed, AHIMA has set its sights on data analytics and information governance, both of which require a new level of training at the master’s or doctorate levels, said Donna Corbani, CCS. Corbani attended the 2017 AHIMA House of Delegates meeting in October and reported on several AHIMA initiatives. “We have to embrace technology to be relevant,” she added. “Automation is coming.”

Specific EHR certifications are helpful, said Corbani. “You’re golden when you have this and a background in HIM,” she added.

HIM must convey to executives that no technology is 100% accurate and that coders must validate coded data, said Corbani. One attendee voiced concerns about computer-assisted coding, stating that HIM must educate senior leaders about its limitations and flaws. Another attendee said HIM needs to be at the table as EMRs are developed and implemented because they can shed light on the flaws inherent in many products, preventing executives from having false hope that the technology will be a panacea.

HIM and IT also need to work together to develop best practices for EHR use and maintenance. Requiring users to ‘open a help ticket’ isn’t efficient in a rapidly-changing patient care environment, said one attendee.

Managing health information for transgender patients

Angela Carr, partner at Barton Gilman, LLP, provided an informative session on how healthcare providers can manage electronic health information most effectively for transgender patients by developing a policy for release of information, name changes, and more.

“The more we learn and talk about it, the better we’re going to be at providing care. The ultimate goal is to provide better care for this population,” said Carr. HIM can help by developing a policy to address the following:

*Data capture — Help providers explain to patients why they collect information about gender identity and preferred pronouns (e.g., for continuity of care, preventive care, etc.).

*HIPAA authorizations — Explain how and why providers may share information about gender identity and sexual orientation when it relates to treatment. This requires an explanation of uses and disclosures for treatment, payment, and healthcare operations, said Carr. Patient education must happen long before records are completed. This would help avoid conflict when sensitive information in the discharge summary is auto-faxed to the patient’s primary care physician, she added.

*Names/name changes —  Explain how the provider handles patient name and any subsequent name changes. For example, the medical record includes the individual’s legal name as it appears on their insurance card, but the provider uses an ‘aka’ when communicating directly with the patient.

Carr suggested conducting focus groups with transgender patients to see what they want and need. “The best way to learn is to talk to the people you’re trying to protect,” she said. “Be honest, and have a dialogue with people.” She also directed attendees to the World Professional Association for Transgender Health.

Reducing cancer in Rhode Island

David Rousseau, chair of the Partnership to Reduce Cancer in Rhode Island, talked about the importance of data in cancer research. Approximately 6,700 people in Rhode Island are diagnosed with cancer annually, and approximately 43,000 residents are living with cancer already.

Rousseau’s team is at the forefront of prevention. His team examined more than 500 people at various skin cancer screening events throughout 2017, helping individuals who couldn’t get a timely appointment with a dermatologist. This year, Rousseau said the partnership will be looking more closely at the large number of individuals who have insurance but don’t undergo preventive colonoscopies. Approximately 650 Rhode Islanders are diagnosed with colon and rectal cancers annually.

What’s at the heart of this research? Coded data.