Today’s Billing Forecast- Audits On The Horizon!

You’d have to be practically dead to not know what’s going on in America today regarding the healthcare debate. Our new President is leveraging his political capital and the very legacy of his Presidency early in his first term in order to champion the cause of healthcare reform. Everyone’s talking about it regardless of which side of the debate you happen to find yourself on.

Of course, the key issue is how the President plans to pay for his ideas on healthcare. Combine this problem with the forecasts that Medicare is going broke, private healthcare insurance premiums are rising well ahead of the inflationary pace and the prescription is in place for someone, somewhere to take a critical look for any place possible to squeeze more money out of the system to pay for all the pending new stuff. The “someones, somewhere” that are taking a look are the auditors.

More than ever before…

At no time previous in the healthcare billing industry has this industry seen such a flurry of audit activity. Medicare Administrative Contractors (MAC’s), Program Safeguard Contractors now known as Zone Program Integrity Contractors (ZPIC’s), Recovery Audit Contractors (RAC’s) and our old buddies at the various Inspector General offices are all hard at work taking a deeper look into the millions of medical claims that appear in their radar cross-hairs every day. They are approaching their tasks with new zeal and a mandate to find dollars to shift from one program to another. And….yes, they are looking at ambulance claims!

Is there justification for all of this? Sure there is.

Let’s face it; we all know that there are people and organizations out there – yes, even ambulance suppliers and providers – that are completely and utterly unscrupulous. We have them to thank for the microscope that we all find ourselves under right now.

Large ambulances, small ambulances, for-profit services, not-for-profit services, career-based companies, volunteer-based companies, emergency transportation and non-emergency transportation providers- all are subject to audit.

An audit can be sparked by a statistical flag that is raised when you happen to run more of one type of call than other similar services. A certain type of trip can spark an audit, like dialysis runs (the number one type of ambulance claim to currently be audited in the Nation!)

A certain number of trips can trigger an auditor’s wary eye. Large amounts of denials can do it too or someone (maybe a competitor) can even lodge a complaint. Maybe you’ve been audited before and they want to take another look. All of these factors can lead to audit.

Quite simply, your number may have just come up- a reverse lottery so to speak!

Also, beware of other healthcare providers being audited with your service’s being sucked in on their coat tails….for example, the skilled nursing facility you work closely with is being audited for their practices and now you are dragged into the affair by association.

So what are they looking for…?

Auditors can be looking at one issue or a combination of issues. They can be looking at one issue and while reviewing those claims they find something else. Let’s just say you’ve now won the daily double of trouble!

As stated before, dialysis transports are front and center on everyone’s audit screen. So beware!

Also, depending on the focus of the audit the auditor(s) may be looking at Physican Certification Statements (PCS or “the Medical Necessity Form”). They may be taking a look at some hospital discharges you have done or they may ask to review hospital to hospital transports. Medical necessity is a key issue in just about any audit… ask the question…..”Can this patient be safely transported by any other means other than an ambulance?” If the answer is YES then that would be a good reason why you have invited an audit.

Other items they may be looking for are upgrades in service. Some auditors are taking a close look at ALS Assessment Only claims (because they don’t understand the rules in most cases). Mileage is also one of the key elements that can spark an audit (so don’t guess- record the actual odometer reading and don’t forget the tenths!) Some audits can be triggered when Medicare should not have been billed as the primary insurer and others have arisen from modifiers, perceived incorrect coding. Did you know that even a crew member who’s certifications have lapsed can cause an auditor to review and subsequently ask for money to be returned as they deem the crew was not an acceptable crew for transport of the patient.

Now they’re nitpicking, huh? But, remember the rules are on their side.

What should I do?

First, take a deep breath! It may or may not happen, but if it does it’s not necessarily the end of the world. Bottom line…..keep your proverbial “ducks” in a row. Here’s a quick list of things to put in place right away….

  1. Make sure your billing people know what they are doing! If you belong to a service that contracts with Enhanced Management Services, you can check off that you have met suggestion number one!
  2. Take a careful and critical look at your policies and practices.
    1. Are your crews well trained and practicing thorough documentation guidelines? If you are unsure, ask them. Review their charts regularly. Contact someone that can provide them with correct training (again, your billing company may be a resource- Enhanced certainly can help!)
    2. Have you reviewed your call-taking procedures recently? Are your call-takers asking the right questions to weed out those people (in the non-emergency world, of course) that truly don’t need an ambulance?
    3. How long has it been since you’ve had a conversation with the administrators at the facilities you serve? Do they understand how the world has changed for your service and have you educated them on how they can assist you by providing key pieces of information when they call to request a transport?
    4. Are your people aware of what to look for in order to report a non-medically necessary patient? A savvy ambulance crewmember should know when a patient needs an ambulance and when he/she doesn’t need one. Does that same crew member feel empowered to request a review for another mode of transportation in this event?

There’s more but…

We’ve just begun to scratch the surface of the Audit dilemma. But there’s too little time and just not enough space on this go-around.

In future Blogs we’ll take a look at the type of audits, how they are conducted, how to correct issues before they become audit issues and a whole lot more.

Keep checking out this space for more details.

Remember…..audits will happen and they just might happen to your service. Don’t panic. Watch your steps all the time and you won’t be caught unaware….and make certain that EVERYONE in the billing loop is aware of how important they are to your organization but most importantly how important it is that each claim be submitted correctly using the proper information.

Your comments are welcome on this subject. By the way, if you’re not a client and don’t feel you have the peace of mind on this subject that our clients have, then give us a call today.

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