Since Medicare Audits began they have primarily been used as information gathering. However with the passing of the Tax Relief and Health Care Act of 2006, which made recovery audit contractors extension into all 50 states mandatory by 2010, and adding the passage of PPACA and the effects of HITECH, audits are coming from all directions. More importantly they are being used to recover over-payments and possibly with penalties. What do we do as ED physicians?
Look for physicians with outlying data. Check your standard deviations for over performing E&M levels, critical care and procedures. If you find outliers, then prepare a document that substantiates why they are outliers and/or identifies what the physician(s) is doing wrong, document education and follow up that they have corrected the issues. Not only can you do this with over performers but also under performers to improve charge capture. In my experience, for every over performer, there are three under performers. In effect, a compliance program that also focuses on charge capture will, in the final analysis, have a positive impact on revenue.
Determine why they are outliers. There are a number of legitimate reasons that a particular physician may higher significantly higher level 5s, critical care time etc… Some of the causes to look at are:
1. Triage acuity pick ups
2. Shifts worked
3. Admission percentage
4. How long out of residency
5. Percent of charts with a well thought out differential
6. number of hours worked with mid level coverage versus the group average
Perform periodic education for all physicians and mid-level providers. At least annually present to your group some form of documentation training. Document this training and have everyone sign off on completion of the training. For example, have an annual dinner/company retreat and include a ~3 hour presentation on documentation training/reminders, group and individual performance measures and annual updates. Just about everyone looks forward to this as sort of a group retreat and open forum on these issues.
Provide a documentation guide. Whether your ED physicians use EMR, dictation, templates or another form of documentation, a readily available reference is vital to compliantly capturing all of your services in the ED. We perform so many different procedures and services in the ER (everything from cerumenectomy to observation) that many physicians not only find themselves not knowing exactly how to document them, but sometime physicians do not know what they don’t know so that either they fail to document services rendered or do so in a non compliant manner. We have found that having a comprehensive guide to documenting specific to the practice and that is group specific and done in consultation with your coders is vital to charge capture and compliance. Every coding department or system will have slight variations on exactly what they want to see to capture a service (for example, for a splint procedure, do that want to see documented that the physician was present when the splint was applied or just examined afterwards and what are the best words to communicate etc…)
Here is an example from a section of one of our documentation guides:
Observation Care:
Increases RVUs by ~one RVU on each case, this is significant. Usually 2-6% of ED patients are eligible.When is it used? Three requirements: 1. Meet the Time requirement 2. Admission is a possibility 3. An Order for Observation is on the chart
Time is being used as diagnostic tool Either 8 hours of medically necessary observation or any amount of time that spans one calendar day (11pm on one day to 1am meets the requirement)*
Admission is a possibility
Order for Observation is on chart
What is required?
A timed order for observation on the ER face sheet
A dictated note in a separate paragraph which contains:
The time and date that the observation started and stopped
The medical necessity of the observation (i.e. an intoxicated patient who had a fall in order to rule out serious injury or an asthmatic patient in order to decide to admit or not)
The results, reassessment and disposition of the observation.
Scott Korn who have all of the above elements in the compliant charge capture and who can produce this whenever an auditor comes along will have a the best chance of not only capturing all of their charges for services rendered but also not being subjected to findings of overpayment and keeping all of their collections.