Signs of an Impending Audit: Are You Waving Red Flags?
- Tue, 8/14/12 - 2:02pm
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Editor’s note: The introduction to this article was contributed by Des Bell, DPM, CWS. For information on further internal audit topics and the documentation found during an audit, see “Business Briefs” on page 6.
The “business of medicine” may sound like an oxymoron, but unless one’s bills are paid each month, even the most talented clinicians cannot provide their services. As anyone in a private or solo practice knows, being a steward of the organization’s finances is critical on several levels. Like any other business, an appreciation of the value of each dollar spent and earned develops over time.
My “appreciation” began when, after launching the mobile aspect of my wound practice (Wound Care on Wheels) in 2008, I came under audit by the Centers for Medicare & Medicaid Services (CMS). I wasn’t prepared for the critical eye the government would develop regarding my business and finances as I broadened my horizons in an attempt to meet the continuing needs of others in my community. Before long, I was involved in an ongoing pre-payment review that lasted more than a year, and it took its toll on me not just emotionally but physically and financially — ultimately leading to the restructuring of my organization and the discontinuation of home wound care services.
Several issues were raised by CMS regarding my practice (which I share with my wife De Anna, a nurse practitioner and fellow wound specialist) from the start of my mobile expansion, the primary concerns being why we were providing wound care in patients’ homes and the level of service provided during hospital rounds. Additionally, working as a mobile provider automatically put me outside the “bell curve” when CMS compared my business to my colleagues and other wound care-providing organizations, meaning that I was reporting services either more or less frequently than what is statistically the norm for similar providers.
My favorite question I fielded from my case manager at the time was, “Do you perform a lot of wound care?” Imagine trying to convince CMS officials that, like them, I was the steward of an organization’s money. I wasn’t convincing enough to ward off inspection, but I was able to correct the main issue, which, according to CMS, was level of service provided to hospital patients. Upon adopting an electronic health record (EHR), I discovered that we were inadvertently under-billing for our services and not being credited for all the work we were doing. The other eye-opener came from the power of seeing our healing rates and further validation that our model was and could be successful beyond doubt.
After auditing ended, we decided the emotional stress of the experience, combined with the continued financial hardships we faced, were not worth continuing the venture. Having to wait several weeks beyond what is typically expected to receive Medicare reimbursements as our documentation went under formal review created lengthy gaps and disruptions in our payments. We decided to discontinue home visits after little more than one year. Today, we’re proof that going through any type of audit can certainly be a career-changing event. Though miserable and taxing, my auditing experience proved to be valuable in the sense that the knowledge gained made me stronger and wiser, professionally and personally. Being proactive and diligent with documentation is the best advice I can offer fellow providers, and the best way to be proactive, in my opinion, is by utilizing a reputable EHR that’s wound care-specific.
Hypothetical Clinical Case Files
Physician Supervision of Hospital-Based Outpatients
Typical Scenario: Regional Medical Center’s busy hospital outpatient wound care department (HOPD) is open five days per week, has seven treatment rooms, and generally maintains a full schedule.
The Problem: Dr. Doeslittle, an internist/gastroenterologist and the HOPD medical director, works in the HOPD every day except Thursday mornings (when he performs endoscopy procedures) and Friday afternoons (when he does consults in his office, which is about seven miles away). Dr. Toe, a podiatrist, works in the HOPD on Thursday mornings. The HOPD nurses perform “nurse only visits” on Friday afternoons. Dr. Doeslittle still covers the hyperbaric patients on Thursday mornings and Friday afternoons, with the staff calling him for any issues.
What Should Happen? First, the HOPD program director and medical director should carefully review the hyperbaric oxygen therapy (HBOT) supervision requirements set forth by the Centers for Medicare & Medicaid Services, the Medicare contractor that processes their claims, and Undersea and Hyperbaric Medical Society guidelines. Then, all should verify whether or not the regulations, as well as the hospital bylaws and Dr. Toe’s hospital privileges, permit Dr. Toe to supervise HBOT therapy. If “yes,” all need to ensure Dr. Toe’s Thursday morning schedule includes time for him to be in the HBOT unit at the appropriate times. If “no,” all need to staff another physician to provide the appropriate HBOT unit supervision on Thursday mornings. A physician must be scheduled to work on the HBOT unit on Friday afternoons. Supervising an HBOT unit from miles away will not meet any stakeholders’ regulations and guidelines.
Serial Billing vs. Episodic Billing (Billing Frequency)
Typical Scenario: Mr. Jones is receiving care in the hospital-based outpatient wound and hyperbaric department (HOPD) for a Wagner grade-III diabetic foot ulcer. During the month of April, he undergoes 17 hyperbaric oxygen therapy (HBOT) treatments as well as the application of Apligraf® and two MIST Therapy® therapy sessions.