Tracking, Trending and Auditing Across a Multi-State Health System

Transcription

1 Tracking, Trending and Auditing Across a Multi-State Health System Fifth National Medicare RAC Summit March 10, 2011 Susan Shiflett, RHIA, CHC Director Corporate Responsibility Catholic Health Initiatives 1

2 Catholic Health Initiatives (CHI) CHI is the nation's third-largest Catholic health care system CHI operates in 18 states: 70+ hospitals; 40 long-term care, assisted living and residential facilities; two community health services organizations; and home health agencies. 65,000+ employees In FY 2010, CHI provided almost $590 million in charity care and community benefit Annual revenues of approximately $9 billion 2

3 Challenges Different Health Information Systems Meditech McKesson Different release of information tracking tools/services Manual Automated various vendors Financial resources Four RAC contractors 3

4 CHI RAC Locations WA OR ND SD NE KS CO NM IA MN AR WI OH KY TN PA MD NJ States where CHI entities are located.. \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ 4

5 CHI RAC Efforts CHI RAC Workgroup co-chaired by Director Corporate Responsibility and CHI HIM Director Local entities handle RAC requests Central reporting system Oversight through CHI s Audit and Compliance Committee Ongoing auditing based on RAC focus areas initially moving to a risk-based methodology 5

6 CHI RAC Tools Developed an internal tracking tool Integrated approach designed to track all aspects of the revenue cycle team activities Meditech McKesson Collaboration with CHI Business Intelligence (BI) Roll up reporting of entity RAC activity for entity and national oversight needs BI facilitates AHA RAC reporting 6

7 RAC Tracking Tool 7

8 RAC Tracking Tool 8

9 RAC Tracking Tool 9

10 Other Resources Executive Health Resources (EHR) contracted to handle second-level medical necessity reviews and appeals Catholic Health Audit Network (CHAN) conducted assessment of RAC target areas as part of system coding compliance audit plan Medical necessity screening criteria 10

11 RAC Activity thus far Acute Inpatient and Outpatient Denial Activity Volume Automated Review Denials 383 Complex Review DRG Validation Denials 470 Complex Review Medical Necessity Denials 133 Total Denials 986 Non-Hospital Denial Activity Volume Physician Practices 505 Durable Medical Equipment (DME) 60 Total Denials

12 RAC Focus Audits FY 2010 Purpose Identify educational opportunities Mitigate financial and compliance risks Methodology Utilize data analysis to identify potential areas of vulnerability Perform testing of a small random sample Designed as quality reviews 12

13 Internal Data Mining Efforts FY 2011 Purpose Develop internal capability to mine data Identify potential vulnerabilities Identify educational opportunities Mitigate financial and compliance risks Ability to compare data across CHI entities IPPS hospitals Critical access hospitals 13

14 Data Mining Efforts continued Methodology Risk-based auditing approach Pull from OIG/DOJ/RAC focus areas Utilize claims data from CHI data warehouse PEPPER data as benchmark Identify potential risk populations and outliers 14

15 Inpatient Risk Areas PEPPER target areas Medical and surgical short stays MS-DRG with and without complication / comorbidity Cardiac procedures (stents, defibrillators) 15

16 Sample PEPPER Target Area 16

17 Sample 3-Day Stay with SNF Transfer 17

18 Outpatient Risk Areas Inpatient-only procedures performed on outpatients Duplicate surgical procedure codes Evaluation and Management visits Observation Transfusions Injections and infusions Debridement procedures 18

19 Other Recovery Efforts Medicaid Integrity Contractors (MICs) State Medicaid RACs Zone Program Integrity Contractors (ZPICs) Office of Inspector General (OIG) Department of Justice (DOJ) And the list goes on 19

20 Next Steps Improve RAC tracking tool functionality Ability to track all audit contractor activity Enhance reporting capabilities Continue risk-based auditing Increase internal data mining efforts by utilizing CHI s enterprise patient data repository Include non-acute services Explore external data mining resources with clinical services 20

21 Questions? Susan Shiflett, RHIA, CHC Catholic Health Initiatives 21