Many others are taking on the burden themselves and utilizing their inhouse team of Regulatory, Finance, and IT staff.

For you, KHC can help in the following areas:

• Answering questions regarding the rules and their specific application.
• Performing a review of your results – as a quality check.
• Help you handle certain portions of the updates needed – you define and you control.
• Training staff on ways to facilitate the data burdens and the Hospital Price Transparency rules.

If these or other areas of assistance are needed, please contact Sara Rivenburgh (srivenburgh@kohlerhc.com) or Linker Mills (lmills@kohlerhc.com).

Hospitals are being subjected to increasing audits and reviews by Medicare and contractors, as well as other payers and regulatory agencies. The advantage those reviewers have is the power of data analytics, or ‘data mining’, which translates into inconsistencies, the ability to use a hospital’s claims data to identify potential vulnerabilities and compliance problems.

By using claims data analysis these reviews identify errors, trends, and other issues readily identified, thereby allowing for prospective resolution before any significant repayments or even identifying trends of concern. Most hospitals and other health care providers don’t have the tools or dedicated resources to do comparable analysis and get ahead of the Government and other auditors. As a result, the errors are only identified once the audits are done and repayments made. As the hospital focuses on fixing those issues, the auditors have moved onto others.

In addition, the inability to conduct data analysis can cause lost revenue when billing opportunities are missed and money is left on the table. With the challenging regulations and intense audit environment, health care providers absolutely need to create a level playing field and know their own data.

The Solution

Kohler Healthcare Consulting utilizes a data analytics tool that can identify regulatory risks lurking in your claims data, and can also identify potential lost revenue. This tool, referred to as the Balanced Analytic Revenue and Compliance Reporter (BARCR), allows us to analyze the risks for lost income and compliance concerns present in your 837 claims files. This tool, combines with edits from all MACs, RACs, CCI, clinical indicators and OIG focus issues, and MEDPAR data to analyze individual data fields and the claims in total (services and diagnoses). It includes comparison of your data to the data of peer organizations to identify outliers and trends. It helps point to the direction of actions needed in a time of limited resources.

Whether you are undertaking a change in your organization, such as a merger or acquisition, or sprucing up an existing program, we can help with making sure that you are in line with current regulatory and industry standards. In addition, we can provide support in developing policies, procedures, audit tools, risk assessments, educational modules, or work plans, based on our extensive experience with managing compliance programs and healthcare operations.

Which Level of Assistance is Right for You? You Choose:

• Compliance and/or Privacy Program Assessment – We can review what you have in place currently, and compare to industry standards and regulatory requirements (both State and Federal), to provide specific recommendations on where your gaps may be and specifically what is needed to fill those gaps.
• Department/Function-Specific Reviews – KHC can focus strictly on a functional area or department to assess compliance with regulatory and industry requirements, such as Physician Contracts, Privacy, Charge Description Master, or Documentation/Coding, and provide expert recommendations and support for those areas.
• Risk Assessment – Annual risk assessments are an expected component of an effective Compliance Program. A risk assessment can be conducted to target those areas where healthcare providers frequently have risk, or are targeted by regulatory agencies. This assessment can be multi-department, and can include, in addition to a summary of risk findings, a useful risk assessment tool for the organization to use going forward to conduct internal reviews. The tool can be developed specifically to meet the needs of your specific organization and the lines of business that you are managing.
• Data Mining Analytics – Uncover hidden patterns that can point to compliance risks. Analyzing claims files can provide account level information that can give you clear insights into potentially troubled areas, focusing audit plan initiatives and ongoing support can help you monitor remediation efforts.
• Ad-Hoc or Ongoing Support – Sometimes organizations just need a little help, maybe with updating policies or pulling together an educational program for Compliance, Privacy, or specific compliance risk areas. We can help, either for one specific project or on an ongoing basis.

Compliance and Litigation support areas include:

• Compliance Program Development and Implementation
• Compliance Program Assessments
• False Claims/Qui Tam Investigations
• Anti-Kickback Statute (AKS) Investigations
• Fraudulent Billing Investigations
• Complex healthcare claims review (underpayments/ overpayments)
• Billing and Coding Audits (State/Federal level)
• Clinical Documentation Reviews and Financial Impact Analysis
• Medical Necessity Reviews
• Corporate Integrity Agreements (Negotiations and Independent Review Organization Services)
• Payer/Provider Litigation: Damage Estimates/Calculations
• Out-of-Network Billing Reviews
• Staffing and Training Needs: Compliance, Coding and Billing
• Voluntary Self Disclosure Analysis
• Internal Investigation Support
• Deposition and Trial Strategy Assistance (case analyses and attorney work product development)
• Expert Testimony

When efforts to fix compliance are failing, KHC can help mitigate your risk and resolve operational issues.

KHC works closely with providers and their internal / external Counsel on various discovery, case preparation, data and document analysis with the necessary tools to assist in preparing and managing cases, including Expert Testimony. In cases with critical deadlines, voluminous records, and complicated issues, we provide you with support and solutions.

Hospitals continue to face the challenges from the MACs, RACs, and the OIG on whether hospitals have submitted claims in accordance with many regulations and criteria—and whether they have been reimbursed appropriately for costs associated with the new services and technologies. Focus is on “high acuity” patients, admission criteria, and re-admissions. The need is to anticipate regulatory changes and develop strategies to comply with CMS.

All of these health care providers—Hospitals, Nursing Homes, Home Healthcare Organizations, Durable Medical Equipment Companies who bill Medicare—are going to be subject to audits to review improper payments.

According to the OIG, skilled nursing facilities (SNFs) increasingly billed Medicare for higher paying resource utilization groups (RUGs), while beneficiary characteristics remained largely unchanged. Long Term Acute Care is subject to increasing regulations, and financial reimbursement changes.

While many of these areas are highly dependent on the need to improve physician documentation, the challenge for many is the increased need for the unavailable experienced coder. To meet this growing need, any review, if appropriate, will include training of the coders to improve performance.

Our Approach to Providing Assistance

Kohler HealthCare Consulting offers experienced health care professionals with the necessary tools to assist hospitals in evaluating, measuring and monitoring processes, procedures while complying with the governing regulations. Because of our hands-on experience we understand and can help you work through the challenges and the hurdles faced by your facility.

What Can We Offer Your Hospital?

• Coding and Documentation Audits
• Medicare/Billing Claims Audits
• MS-DRG Validation
• LTAC-DRG Validation
• RUG Validation
• Medical Necessity Documentation Reviews
• Inpatient Short Stay and Observation Reviews
• Regulation/Compliance Policy and Guidelines Reviews
• Implementation of Coding, HIM and CDI Best Practice

Our Approach to Providing Assistance

Kohler HealthCare Consulting provides organizations with the necessary tools to assist them in meeting their quality, risk and compliance obligations. In situations involving regulatory oversight, critical deadlines, voluminous records, and complicated issues, we can provide you with support and answers. Our clinical, quality, risk and compliance professionals are experienced in providing assistance and expertise on a myriad of issues including:

• Assessing organizational quality goals, including metrics, benchmarks and management accountability, integration into overall corporate policies and operations, and effectiveness of internal controls
• Assisting internal and external counsel and compliance officers with investigation and remediation of critical quality, risk or compliance matters
• Developing strategies for identified compliance issues and implementation of corrective action plans
• Conducting quality and compliance risk assessments
• Assisting medical staff leaders in assessment and implementation of effective peer review processes
• Developing compliance plans, policies and procedures that address quality of care and patient safety issues
• Reviewing reports of quality of care concerns and medical errors to assess organizational exposure and potential liability
• Providing general and specific training at hospitals on quality, risk and compliance
• Serving as IRO for several providers related to CIA obligations and implementation of compliance program elements

The emphasis on mandatory compliance programs, ever-changing regulations and heighted scrutiny requires compliance officers to proactively focus on elements that impact all aspects of the organization’s operations, especially the effectiveness of controls (such as billing and coding), regulatory issues (State and Federal regulations such as Stark and Anti-Kickback) corporate culture, compliance training and employee satisfaction.

Approach to Improvements

It has been KHC’s experience that periodic reviews of compliance program elements results in the most effective programs. Effective compliance programs eliminate, reduce or mitigate an organization’s risk, and build awareness of the compliance effort at all levels of the organization. KHC and Client personnel work together as a team to plan and perform the review, resulting in an effort that is cooperative, as well as efficient. KHC professionals have designed, implemented and/or reviewed comprehensive compliance programs at hospitals, physician practices, ASCs and DMEs. The exposure to, and expertise in, such diverse organizational models gives KHC professionals the unique advantage of being able to address the myriad of challenges that exist across the healthcare continuum.

Our Review can be comprehensive or focused exclusively on selected areas.

Some areas we can assist with include:

• Review of the seven elements of an effective compliance program; identify and prioritize compliance and noncompliance risk.
• Develop tool(s) for monitoring and reporting areas of compliance risk, especially those identified as high risk.
• Provide assistance in the development of a Corporate Compliance Work Plan.
• Improve and develop internal compliance controls and standards.
• Write and implement necessary policies and procedures for the compliance program and provide operational implementation.
• Assess the Compliance Committee and Subcommittee structure and areas of responsibility and provide recommendations.
• Review employee compliance training education.
• Assess response to reported non-compliance matters.
• Review physician contracting including employment, directorships and leases.
• Review coding and documentation compliance.

Kohler HealthCare Consultants will assist you to:

• Define physician supervision
• Apply the right physician supervision rules for each outpatient service area
• Provide guidance to your management staff to apply requirements
• Determine how the current changes will impact your business decisions
• Manage the current physician supervision rules
• Audit for compliance with all physician supervision rules

Our detailed work plan for your hospital includes:

1.   2009 physician supervision requirements

• Non-physician practitioners (NPPs)
• On campus facilities
• Limitations on enforcement

2.   Changes for 2010 and 2011

• Non-physician practitioners (NPPs)
• Qualifications of the practitioner
• Definition of immediately available

3.   Diagnostic services

• Under arrangements services

4.   Cardiac rehab, intensive cardiac rehab, and pulmonary rehab

5.   Develop risk assessment tools for your use

6.   Corrective action plans

• Policies and procedures preparation or revision
• Physician and auxiliary staff training

7.  Auditing of all years for compliance

8.  Establishing an internal process for remaining compliant with CMS MPFS quarterly updates and CMS interpretation of the outpatient hospital physician supervision rule.

Get a start on this little understood CMS requirement. We have a one-hour educational program to introduce the hospital management team to the issues and concerns.

Specialized Services for Medical Practices—Revenue Assurity

Periodic Practice assessment is a necessary, critical component in determining a medical practice’s health and efficiency. If personnel in your Practice aren’t coding services properly, the outcome can be significant income loss and increased compliance risk. A robust procedural and diagnostic analysis of coding practices affords an organization the opportunity to identify irregularities that exponentially increases income, and decreases compliance risk.

Like peeling the layers of an onion, Kohler HealthCare Consulting (KHC) uncovers the fiscal, operational, and compliance strengths and weaknesses of revenue creation impacting your organization’s bottom line and risk profile.

Unique and complex compliance issues KHC addresses include:

• Understanding Medicare differences among payers
• Establishing uniformity when using CPT and HCPCS codes
• Clarifying regulations regarding non-physician providers, shared visits, teaching regulations and use of ‘incident to’
• Resolving conflicting answers from facility and professional providers

Our client results are achieved by focusing on three (3) targeted procedures: Baseline Audits; Provider Documentation, Coding and Billing Reviews; and Compliance Training.

Baseline Audits

Our approach to baseline audits is streamlined, yet comprehensive. KHC conducts a baseline audit that evaluates current documentation and coding practices. We use a pre-determined number of encounters per physician/provider to summarize results for comparative purposes. Based on our review, we can prepare a Bell Curve analysis that compares our findings to national benchmark data. This approach, along with our specialized reporting tool, provides compliance rating results for each physician, and helps each provider understand the components that need to be addressed to enhance revenue and ensure compliance.

In addition, prior audits are evaluated to determine whether: (a) the right conclusions were reached; (b) the providers understood the results; and (c) changes have been implemented in response to the reviews. KHC’s baseline audits are a holistic evaluation of the current state of a Practice, and the first step in our process of helping a Practice attain fiscal and compliance good health.