Key Performance Indicators to Direct Audit Plans

Transcription

1 Key Performance Indicators to Direct Audit Plans Lori Laubach, Principal MD Audit User Group June 15 17,

2 The material appearing in this presentation is for informational purposes only and is not legal or accounting advice. Communication of this information is not intended to create, and receipt does not constitute, a legal relationship, including, but not limited to, an accountant client relationship. Although these materials may have been prepared by professionals, they should not be used as a substitute for professional services. If legal, accounting, or other professional advice is required, the services of a professional should be sought. 2

3 WHAT IS A KEY PERFORMANCE INDICATOR? Numerical factor used to measure performance o Revenue cycle o Financial assets o Business processes o Volumes o Service lines 3

4 LANDSCAPE Recovery Audit Contractors (RACs) Medicaid Integrity Contractors (MICs) Medicare Administrative Contractors (MACs) Zone Program Integrity Contractors (ZPICs) CERT Health Care Fraud Prevention and Enforcement Action Team ( HEAT ) Medicare Fraud Strike Teams HHS Office of Inspector General (OIG) Department of Justice (DOJ) 4

5 FUTURE AUDIT AND MONITORING Continuous monitoring Predictive modeling and data analytic capabilities o CMS predictive modeling objective Leverage data available in internal systems Use available industry data (e.g. PEPPER, CMS) for benchmarking Real Time focus on risks identified by OIG, CMS and other regulators Limit performance of retrospective claim audits 5

6 PURPOSE OF KEY PERFORMANCE INDICATORS Assess current situation Determine problem areas Trend performance or corrective action Set goals/targets 6

7 GOALS OF THE KEY INDICATORS Analyze data real time Establish goals/targets Prioritize for auditing and monitoring Develop audit plans Identify Outliers / Target risk areas Develop compliance scoring system 7

8 DATA SOURCES OIG Annual Work plan OIG Audits o Specific Hospitals o Investigations Recovery Audit Contractors o Approved List o Other region RAC approved items PEPPER Internal Data 8

9 WHAT DID WE DO? 9

10 ANALYSIS FOR KPI KPI Analysis for prototype.xlsx 10

11 KPI Detail OIG WP CMS Audit PEPPER RAC VOLUME Inpatient claims with high severity level DRG codes Per OIG Work plan Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. Claims must be completed accurately to be processed correctly and promptly. (CMS s Medicare Claims Processing Manual, Pub. No , Ch. 1, ) For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Our review will include claims for beneficiaries who received over 96 hours of mechanical ventilation. X X X X 11

12 PEPPER TARGET AREA TARGET AREA DEFINITION CONCERNS Stroke Intracranial Hemorrhage (Stroke ICH) Numerator (N): count of discharges for DRGs as follows: 061 (acute ischemic stroke with use of thrombolytic agent with MCC), 062 (acute ischemic stroke with use of thrombolytic agent with CC), 063 (acute ischemic stroke with use of thrombolytic agent without CC/MCC), 064 (intracranial hemorrhage or cerebral infarction with MCC), 065 (intracranial hemorrhage or cerebral infarction with CC), 066 (intracranial hemorrhage or cerebral infarction without CC/MCC) Denominator (D): count of discharges for DRGs 061, 062, or 063, 064, 065, 066, 067 (nonspecific CVA and precerebral occlusion without infarct with MCC), 068 (nonspecific CVA and precerebral occlusion without infarct without MCC), 069 (transient ischemia) This could indicate potential overcoding. A sample of medical records for DRGs 061, 062, 063, 064, 065 and 066 should be reviewed to determine if coding errors exist. 12

13 RAC ISSUES No Issue Name Specifics DRG Abortion with D&C, Aspiration 1Curettage or Hysterectomy Medical Necessity Abortion with D&C, Aspiration Curettage or Hysterectomy MS DRG 770 C Acute Ischemic Stroke Acute Leukemia w/o Major O.R. 3 Procedures with Use of Thrombolytic Agent with MCC: MS DRG 061 (At this time, Medical Necessity excluded from review) CMS Issue Number: C At this time, Medical Necessity is excluded from this review) CMS Issue Number: C No Med Necess 4Acute Readmission No B4 CMS Issue Number: C Inclusion Add on codes without primary 5codes CMS Issue Number: C Add on 6Adenosine Dose vs. Units Billed (At this time, Medical Necessity will be excluded from this review) CMS Issue Number: C C No Med Necess 13

14 LISTING OF KEY INDICATORS 14

15 KPI Inpatient claims with high severity level DRG codes Readmission 30 days Inpatient transfer claims Inpatient and outpatient claims paid in excess of charges Inpatient and outpatient claims involving manufacturer credits for replaced medical devices. OIG WP CMS Audit PEPPER 15

16 KPI Outpatient claims billed with modifier 25 Cardiac Catheterization and heart biopsies Provider based billing Inpatient stays billed separately Outpatient drugs OIG WP CMS Audit PEPPER RAC 16

17 KPI 72 hour rule Outpatient drugs incorrect HCPCS Outpatient claims with payments greater than $25,000 or $50,000 Inpatient hospital acquired conditions and present on admission indicator reporting Outpatient surgeries billed with units greater than one OIG WP CMS Audit PEPPER RAC 17

18 KPI Inpatient claims for blood clotting factor drugs Inpatient claims with payments greater than $150,000 Outpatient claims billed with modifier 59 Outpatient claims billed with modifier 74 Outpatient claims billed with modifier 91 OIG WP CMS Audit PEPPER RAC 18

19 KPI Outpatient drugs non covered use of drugs Minor surgery and other treatment billed as inpatient 72 hour rule with psych hospitals Bone marrow or stem cell transplants DRG 460 spine procedures OIG WP CMS Audit PEPPER RAC 19

20 QUESTIONS? 20