Data reduces audit risk for behavioral health providers
Billing errors, aberrancies top red flags for audits
Is your behavioral health organization effectively monitoring its own data to determine the risk of a Medicare or Medicaid payment related audit?
Monitoring the right data can help behavioral health providers identify and correct trends and patterns that trigger program integrity or payment related audits by Medicare contractors, according to compliance experts at INFINITY’s strategic partner, SimiTree.
But many behavioral health providers either don’t know how to use data for this purpose or don’t have data tracking built into their operation.
“Most of the organizations we work with lack the ability to effectively track and trend data,” said SimiTree Senior Manager Laurie Newlun, Compliance and Regulatory. “They don’t have the right organizational processes in place.”
Newlun and other compliance and regulatory experts at SimiTree work with behavioral health clients to help them unlock how and where they are incurring risk and show them how to make corrections.
Red flags for Medicare audits
Data analytics can identify potential risk by showing where a behavioral health program is operating outside state or national averages, a red flag which often triggers Medicare audits. Correcting aberrancies greatly reduces audit risk.
Although most providers audited are simply making mistakes instead of perpetrating intentional fraud, the audit experience can be unpleasant and expensive, and most providers are eager to learn how to use their data to identify and mitigate the risk.
“It can be a harrowing, time consuming and costly experience to go through an audit, and most providers would prefer to avoid it,” said Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.
SimiTree compliance experts work with substance abuse programs, physician practices, inpatient psychiatric facilities, and all other behavioral health providers to explain the role of data analytics in identifying and understanding patterns leading to audits for each particular provider type.
“The same data may not be applicable to all types of providers,” Newlun said. “So it is important for providers to understand the metrics that can be red flags for that type of provider.”
SimiTree consultants work with providers to make the distinction, showing which data will apply, where to find it and how to use it.
OIG calls for more audits
Identifying areas of risk is becoming increasingly important due to a rising number of payment related Medicare audits in 2022. Medicare program integrity and payment related audits are ramping up in response to a recent directive by the Office of Inspector General (OIG), the federal agency in charge of investigating fraud and abuse.
“In its most recent work plan, the OIG recommended more investigation, auditing and inspection of all healthcare providers,” Skehan said.
Increasing audit scrutiny is part of an attempt to identify providers who cheated the system during the pandemic, she said. Medicare contractors use payment related audits to reclaim any overpayments, and, in some cases, prosecute providers for fraud or abuse.
Billing errors trigger audits
Billing errors and inconsistencies also garner audit scrutiny from Medicare contractors, according to Eloy Paez, Executive Vice President Behavioral Health, INFINITY.
“When Medicare contractors determine which providers will be audited, they look hard at a couple of things,” Paez said. “One of those red flags will be any aberrancies in the data indicating that providers are operating outside the norm, and the other will be recurring problems with billing practices, any areas where the provider is not correctly billing or following best practice standards. Those are the red flags that will get providers noticed, and audited.”
Knowledgeable billers with regulatory expertise are key to avoid those mistakes, Paez said, and the reason more behavioral health providers are seeking to partner with reliable outsourcing providers such as INFINITY.
“The labor shortage and growing behavioral health crisis make the right outsourcing partnership crucial for a provider’s overall profitability,” Paez said.
“Billing efficiency isn’t enough on its own,” Paez said. “The right outsourcing partner needs to deliver to the provider full proficiency in finance, operations, and compliance to mitigate risk and ensure peak revenue cycle performance.”
INFINITY can help
INFINITY delivers topnotch revenue cycle outsourcing services for timely and optimal reimbursement, driving cash flow and optimizing profitability.
From prebill audits to full compliance assessments, INFINITY also helps providers understand risk and shore up compliance.
INFINITY works with the SimiTree compliance team, made up of clinical experts who are certified in healthcare compliance with extensive experience in government audits and appeals at all levels, including ALJ expert witness.
In addition, current, former, and certified surveyors provide best-in-the-industry comprehensive compliance and regulatory support to meet the needs of behavioral healthcare providers.
Schedule a full compliance assessment today to evaluate how well your organization is meeting billing and payment requirements. Each assessment includes corrective plan recommendations with additional compliance and regulatory implementation support.
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