The Coming Audit Storm
- Tue, 8/14/12 - 2:00pm
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Those of us on the Gulf Coast know that even on an otherwise beautiful, sunny day, complacency about the weather can be dangerous. With that, anyone who runs a business or owns a home near the coast is encouraged to have a “disaster-preparedness plan” in place in the event of an emergency. In developing such a plan, people are instructed to identify potential hazards, assess possible vulnerabilities that exist, and analyze the potential impacts of an emergency and the state of one’s business and/or home. Specific preparations are then expected to be enacted. This article intends to apply these concepts to the wound care clinician’s responsibility to have a preparedness plan in place in the event of an audit to safeguard against any financial and/or legal “disasters.”
Prepaing for ‘Disaster’
We often speak figuratively of “storm clouds gathering” when we see problems developing within an industry. The various recoupment programs currently underway by Medicare through the Affordable Care Act (ACA) are an example of such a storm for the wound care industry. It will be very big, very protracted, and potentially very devastating for those who are unprepared. So, how do you get prepared for the impending storm of audits on the horizon? When a hurricane develops, some of the most valuable information is obtained from satellite images that allow us to track the trajectory of a storm in order to predict where it will make landfall. That “30,000-foot view” is critical to disaster preparedness. But how do you use that information to get your wound center, your private practice, or your hospital prepared for an audit?
As a compliance auditor, I am often asked to evaluate wound centers and physician’s practices to assess their risk for recoupment, should they be audited. Given the fact that the recoupment programs put into place by the ACA are vital to Medicare’s solvency, the question is not “If?” but “When?” will a wound center’s program be audited. Hospital and physician practices simply cannot afford to be unprepared. Most hospitals have formed Recovery Audit Contractor (RAC) committees to proactively seek out the areas in which they are at most risk for loss. Understandably, hospitals tend to focus attention on the services that have the highest collection ratio, and since many hospital administrators believe wound centers generate little revenue, they incorrectly perceive the risk of an audit occurring within these programs as “low.” Many wound centers do have unrealized revenue potential. However, the pitfalls that make billing wound care services properly so challenging are the very issues that could make a RAC audit more likely.
Remember, when you create a RAC audit plan, you are asking not just how you get paid but how you stay paid. This may be a shift in mindset for some clinicians who believe (for example) that if “Mr. Jones” needed his dressing changed twice per week, there was no reason not to see Mr. Jones twice per week as long as the services were coded properly and the claim was paid. However, the payer’s perspective is not the same as the clinician’s. Unless the documentation in Mr. Jones’ chart justifies the medical necessity of his frequent visits, those charges may not stand up to a RAC audit.
“Necessity & Staying Paid
Failure to document medical necessity is likely to deal a serious blow to wound and hyperbaric oxygen therapy (HBOT) programs around the country as more complex reviews unfold. Hospitals performing internal audits often review documentation only to ensure that the correct billing codes are reported on a claim. Administrators often overlook the lack of supporting information that is equally necessary to justify medical necessity. Hospital auditing practices should mirror payers’ auditing practices when it comes to establishing medical necessity.
As an industry, wound care and HBOT medicine are made more vulnerable by the lack of well-written, nationally recognized standards of practice. We are thus more often at the mercy of regional Medicare intermediaries or private payer policy guidelines that are subject to frequent and seemingly random changes. The absence of clear national standards gives individual auditors even more discretion in how they interpret medical necessity. This is particularly true in HBOT. Electronic health records (EHRs) can help in establishing medical necessity because they can standardize certain documentation. Some physicians believe that “pasting” excerpts from practice guidelines (for example) will completely satisfy medical necessity requirements (eg, statements such as “hyperbaric oxygen therapy is beneficial in the management of failing flaps because of its ability to mitigate ischemic reperfusion injury”). However, what an auditor is looking for is why an intervention such as HBOT is warranted for the patient at that particular point in time. Pasting “cookie cutter” phrases into your EHR from practice guidelines may be a very useful tool, but will not provide sufficient substantiation unless the comments are linked to the details of this particular patient. As you evaluate potential vulnerabilities within your wound care center, ask yourself whether or not your HBOT charts sufficiently make the case for the medical necessity of the HBOT treatments that have been provided to each patient. Do your charts contain the supporting documentation that is needed (eg, bone scan results, operative reports, laboratory studies) and reflect the clinician has reviewed them?
Another area of potential vulnerability is debridement.