July 20, 2022
How effective is your compliance program?

How effective is your compliance program?

With paymentrelated audits on the rise, here are some compliance priorities

Has your behavioral health program been targeted for a payment-related Medicare or Medicaid audit?

Centers for Medicare and Medicaid (CMS) contractors are ramping up the number of audits targeting post-acute care providers, including behavioral health, in response to a recent directive from the Office of Inspector General (OIG).

In its most recent biannual work plan, the OIG called for more investigation, auditing and inspection of all healthcare providers, according to Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.

Skehan recommends behavioral health programs prioritize compliance, focusing on both internal and external evaluation to determine where they may be at risk and shore up weaknesses with staff training.

“The best insulation against these types of audits is a knowledgeable staff with understanding of billing regulations as well as clinical documentation requirements,” she said.

Skehan also recommends considering outsourcing billing and other revenue cycle services to reduce the risk of payment related audits. As staff shortages and frequent turnover in key positions place physician practices and inpatient psychiatric facilities at increased risk of knowledge deficits, a growing number are opting to mitigate risk by outsourcing full revenue cycle management to SimiTree.

Audit triggers

Understanding what leads to payment related audits is an important step in reducing the likelihood of an audit, Skehan said.

“Payment-related audits can be triggered by both aberrant billing practices and government data analytics,” she said. “For example, a pattern of error or omission might trigger an audit. So will data that shows the provider is operating outside the state or national average in some regard. The purpose of the audit is to identify improper payments, so those are the kinds of red flags that will trigger one.”

Infinity’s compliance experts work with providers to assess knowledge deficits and provide training to both clinicians and billers to help avoid audit triggers.

Compliance experts also work with physician practices, inpatient psychiatric facilities, and other behavioral health programs to explain the role of data analytics in identifying and understanding patterns leading to audits for the particular type of provider.

The same data may not be applicable to all types of providers. Infinity consultants work with providers to help make the distinction, showing which data will apply, where to easily find it and how to interpret it.

Compliance priorities for behavioral health

Skehan recommends the following priorities for behavioral health providers to strengthen compliance programs in response to increasing payment related audits.

1. Use OIG recommendations as a blueprint. Start by making certain your facility has in place all the components of compliance set out by the OIG in the 7 Elements of an Effective Compliance Program, provided below.

2. Use data to identify patterns triggering scrutiny.  Federal reports (PEPPER when applicable or other organization specific reports) provide dashboard measures, patterns, and percentages, revealing how and where a facility may deviate from state or national averages. Monitor these reports regularly and carefully, and check for updates on CMS, OIG, and DOJ web sites, to stay abreast of areas of audit focus.

3. Set up internal monitoring programs. Skehan recommends developing quarterly and annual audit plans for oversight, focusing on identified problem areas. “Self-monitoring reduces the likelihood of abusive or reckless habits and potential overpayments,” she said.

4. Consider external evaluation as well. Using objective external auditors for quarterly or annual audit and education is a good idea. SimiTree offers services ranging from prebill audits to full compliance assessment. Each assessment carefully examines billing practices and ensures that medical records are meeting clinical requirements for medical necessity and Medicare eligibility. “We look for the same things auditors will look for,” Skehan said.

5. Provide targeted and ongoing education. In the same way HIPAA education is required to be repeated and updated, training for proper clinical documentation and requisite billing practices should be provided frequently.

7 Elements of Compliance

The OIG sets out 7 Elements of an Effective Compliance Program to guide providers in implementing effective compliance efforts.

Skehan said having these fundamental elements of compliance in place will help behavioral health facilities with all aspects of compliance, including meeting HIPAA requirements and Medicare Conditions of Participation (CoPs) as well as payment-related compliance issues.

The OIG recommends:

  • Implement written policies, procedures and standards of conduct.
  • Designate a compliance officer with the experience and training needed to implement and enforce policies. Establish a compliance committee as well. Multi-location providers will need leaders at both the corporate and agency level in designated roles.
  • Conduct effective training and education.
  • Develop effective lines of communication and reporting, including establishment of anonymous reporting processes.
  • Conduct internal monitoring and auditing. In addition to quarterly or annual audits for payment-related issues, SimiTree compliance experts recommend facilities conduct mock surveys at least annually to evaluate compliance with CoPs. Ensure ongoing review and observation to ensure staff knowledge of policies and procedures.
  • Enforce standards through well publicized disciplinary guidelines.
  • Respond promptly to detected offenses and undertake corrective action.

Infinity can help

Our compliance and regulatory experts provide comprehensive compliance and regulatory support. We offer prebill audits, full compliance assessments, mock surveys, and other assistance in evaluating your compliance risk. In addition to payment related compliance issues, our current, former, and certified surveyors provide best-in-the-industry comprehensive compliance and regulatory support.

Reach out to us to begin the conversation about shoring up your compliance.

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