Provider Billing Compliance a Risk Management Model

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Provider Billing Compliance a Risk Management
Model

• Martha R. Weiner
• Senior Director, Office of Billing Quality
  Assurance
• The Johns Hopkins University School of Medicine
• Baltimore, Maryland
• The Fifth Conference for Effective Compliance
  Systems in Higher Education
• The University of Texas System
• June 4, 2007

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Outline

• Johns Hopkins University School of Medicine and
  Clinical Practice Association Snapshot
• Office of Billing Quality Assurance Overview
• Original Audit Model
• Risk-based Audit Model
• Effectiveness Measures and Controls
• Additional Areas of Responsibility
• Q A

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Johns Hopkins University and School of Medicine

• Johns Hopkins largest private employer in
  Maryland
• Leader in academics, research and patient care
• Johns Hopkins University and Johns Hopkins Health
  System separate legal, corporate entities with
  separate Compliance Offices
• Integrally function as Johns Hopkins Medicine
• FY 06 68,532 admissions (Johns Hopkins Hospital
  and Bayview Medical Center) and
  over 800,000 outpatient pro fee visits

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FY 2006 Clinical Practice Snapshot

• 20 clinical departments
• 1800 physicians and other clinical providers
• 845.0 million in pro fee charges
• 310.4 million in fee-for-service revenue
• 78.5 million of revenue from federal programs
• 2.7 million billing transactions
• 40 payer contracts

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Background and Overview

• 1996 Billing Compliance Program started
• Each Department appoints a physician and
  administrative compliance liaison
• 1997 Moved into the Clinical Practice
  Association
• November 1996 - February 2003 PATH Audit
• January 2002 Increased leadership and financial
  commitment supported transformation from
  compliance cops to compliance colleagues
• June 2003 Revised Program and individual
  Departmental Compliance Action Plans approved,
  plus new name - Office of Billing Quality
  Assurance

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Billing Quality Assurance Objectives

• Protect the clinical revenue and reputation of
  the School of Medicine and its faculty through
• Commitment and oversight
• Goals and principles
• Individual department clinical responsibility
• Education
• Internal review and monitoring
• Communication of standards and procedures

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Scope of Activities

• Training
• Documentation reviews
• Internal resources for coding and billing advice
• Revenue opportunities

• Resolve operational issues
• Special projects
• Investigations
• Coordination with JHHS Compliance and various
  JHH, JHBMC and SOM Committees

Staffing 14 FTEs Budget 1.5 million (00.5
of clinical revenue) funded by clinical
departments
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Johns Hopkins University School of
MedicineClinical Practice AssociationOffice of
Billing Quality Assurance
Executive Director / Compliance Officer
Director, Clinical Research Billing Quality
Assurance (CRBQA)
Administrative Coordinator
Senior Director Billing Quality Assurance
Admin. Coordinator
Director of Operations
17 FTEs by FY 2008
Secretary
Secretary
Lead Compliance Specialist / Trainer
Lead Compliance Specialist / Trainer
Compliance Auditor
Compliance Auditor
Compliance Specialist / Trainer
Compliance Specialist/Trainer
Compliance Specialist / Trainer
Compliance Specialist / Trainer
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Johns Hopkins University School of
MedicineClinical Practice AssociationOffice of
Billing Quality Assurance
JHUSOM Dean / CEO - JHM
Clinical Practice Association Vice Dean, Clinical
Practice
Board of Governors
Compliance Committee
Executive Director / Assistant Dean Compliance
Officer
Senior Director, Revenue
Senior Director, Contract Services
Administrator, Ambulatory Practice
Senior Director, Billing Quality
Assurance and Clinical Research BQA
Senior Director, Finance
Senior Director, Info Technology
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Original Audit Model

• Annual review for everyone
• 5 services
• Nearly impossible to accomplish with 4
  Specialists
• Departmental statistics, but no individual or
  aggregate benchmarks

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Introduction of Scoring Methodology FY 2001

• Physicians asked for a comparative measurement
• Competitive nature
• Data driven
• Adaptation of Georgetowns point system

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Provider Scoring
? Aim for a low score just like golf ! ? A
single audit case is capped at 12 points even
though more points may have been assessed for
that service.
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Administrative Scoring
When a Department has an average score of 6 or
more administrative points, or when a systemic
pattern has been identified, a meeting with the
Office of Billing Quality Assurance (OBQA) staff
is required. The OBQA staff assists in the
development of an action plan and recommendations
as to how to resolve the identified issue(s).
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Preparing for the Risk-Based Audit Model

• Reviewed 5 services for everyone in less than a
  one year period
• Established baseline score for individuals and
  departments
• Slotted individuals into quarterly audit cycles
• In parallel, selected and implemented new audit
  software tool - MDaudit

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Risk-Based Provider Audit Matrixas of July, 2003
Some Departments have asked that all providers be
reviewed annually, even if score qualifies for a
bi-annual review.
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Documentation Review Process

• Documentation Review Guidelines published prior
  to each FY audit cycle
• 10 services selected from prior quarters billing
• Scope of documentation reviews
• Adequate support for code(s) billed
• Most appropriate code(s) selected
• Teaching Physician rules met
• Mid-level Practitioner rules met
• All services provided were billed (missed
  revenue)
• Administrative vs. provider errors

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Reporting the Audit Results to the Provider

• Provider audit score and detailed summary
• Key errors highlighted using color
• Cover letter customized to audit score
• Auditors worksheet and copy of the clinical note
  for any points assigned
• Meeting required if score is 12 or more points
• Provider and/or Department meeting based on
  type(s) of errors.

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Results Reporting and Corrective Action

• Quarterly meeting with each Department Chair,
  Administrator and Compliance Liaisons
• Report package high level data down to
  individual provider detail by department,
  division and campus
• Trends, issues, and corrective actions discussed
• Chairs are actively engaged personally
  follow-up with faculty

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Results Reporting and Corrective Action

• Quarterly meeting with the Dean, Vice-Dean for
  Clinical Practice, Executive Director/ Compliance
  Officer, General Counsel and Senior Director
• Dean follows-up with Department Chairs, as needed
• Quarterly meeting with Revenue Operations
  management to address Administrative errors
  stemming from pro fee billing offices
• Annual presentation to University Trustees

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Quarterly and FY Score Cards

• By Department - reviewed, with 12 or more
  points, average score and letter grade
• Presented to the Dean, to the Compliance
  Committee and CPA Board of Governors
• Competitive nature continues
• How are we doing compared to ?
• What did Department X do to improve so much ?
• Volume of reviews
• FY 04 reviewed 11,526 CPT codes for 809
  providers
• FY 05 reviewed 13,409 codes for 954 providers
• FY 06 reviewed 12,850 codes for 861 providers

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Handling the Outliers

• Pre-Billing Review Process Effective 7/1/2004
• If two consecutive failures, all charges are held
  and coded by Office of Billing Quality Assurance
• Intensive training and weekly meetings with the
  provider
• Must pass post-training review or pre-bill status
  continues
• Physician is responsible for cost of the reviews
• After passing, reviewed again in 30 days
• If passing score is sustained, placed in regular
  audit cycle
• If failing score, returned to pre-billing review
• Entire process managed in MDaudit

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Impact of the Pre-billing Review Process

• First failure is taken very seriously
• Providers and departments are more actively
  engaged
• Number of first failures that pass the next
  review has grown significantly

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Evaluating the Effectiveness of the Risk-based
Audit Model

• Resources are devoted to the providers or issues
  where help is most needed
• Risk areas are more quickly addressed
• The quarterly review and meeting cycles keep this
  program front and center
• This model, coupled with strong support from the
  Dean and Board of Governors, has given the
  Billing Quality Assurance Program even greater
  credibility
• Sophisticated audit tool is essential to our
  success
• 
  

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Evaluating the Effectiveness of the Risk-Based
Audit Model
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Evaluating the Effectiveness of the Risk-Based
Audit Model
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Key Policies and/or Resources

• Policies
• Single Standard of Documentation
• Discounts and Professional Courtesy
• Refunds and Corrected Claims
• Professional Fee Billing Privileges
• Resources
• Documentation Guidelines (self-developed)
• The Guardian (newsletter)
• Web-based training (self-developed)
• Intranet Website
• Coding Pro e-mail

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Additional Areas of Responsibility

• Billing Approval for Moonlighting
  Residents/Fellows
• Clinical Personnel Leases
• Annual Medical License Renewal
• Computer-Assisted Coding Applications
• Place of Service Audits

• Part-time Faculty Appointment Letter Audits
• Federal and Military Employment
• Clinical Systems Reviews (when documentation is a
  component)
• Clinical Research Billing for professional fee
  and hospitals

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Questions ?