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in today's webinar hosted by sei global today's webcast is titled reviewing claims for compliance lessons learned from lig corporate integrity agreements before we get started I have a few housekeeping notes all phone lines are on mute to avoid interruptions during the broadcast if your audio pin in your audio panel you may select to listen to the broadcast using your computer's mic and speakers or you may select telephone to receive a dial in to download the slides simply expand the handouts panel located to the right of your screen and click on the PDF icon during the session we will present the audience with several polling questions please note your individual responses will not be shared with the audience we are offering CCB CEU credits for today's presentation to access your certificate expand the handouts panel and click on the PDF icon after the session you can submit the certificate to the CCP to obtain your CEU credit at the conclusion of today's presentation we will have a Q&A session however you may submit your questions or any kind using the questions panel located to the right of your screen finally we want email attachment to all attendees on today's call within the next five to seven business days for those of you that aren't familiar with Fei global we are a privately held company with our executive offices in Chicago and operations around the globe sar Global offers customers an integrated suite of proven risk and compliance solutions to manage and assess their operational strategic risk and compliance obligations we bring innovation to integration combining transparency accountability risk agility and ethics to improve your future business outcomes and build your organization's risk culture the FAI global compliance risk solution enables an integrative approach to regulatory compliance risk management and audit management we are entrusted an established partner for health care provider and health insurance organizations with solutions designated designed excuse me to address the complex compliance and risk needs of the healthcare industry our configurable workflow helps you to take control of your compliance risk program by automating processes and acting as a virtual compliance coordinator before I introduce our speakers I'd like to remind everyone to submit your questions at any time using the question panel on the lower right hand corner in restraint our presentation is scheduled for 60 minutes and will take as many questions that you can at the end of the presentation we have two presenters today the first is dr. Cornelia Burke Schmid dr. Gork Schmidt has over 25 years of private and government and sector experience and compliance consulting the majority of which was in management and executive capacities she is a recognized expert in the areas of corporate compliance HIPAA and compliance risk assessments Enterprise Risk Management rapt staffs staffs and sampling and overcame and estimate estimation estimation excuse me and litigation consulting dr. Doronin has served as interim or designating a compliance officer for several healthcare organizations she is particularly experienced in compliance risk management including control reviews and revenue cycle risk analysis and oversight of oversight she has presented and various associations and professional organizations and events and as such as on such issues as risk management and methodologies risk areas benchmark compliance program effectiveness and HIPAA privacy and security she is a certified healthcare professional holds a master in information systems from George Washington University and is a certified project management professional she is a member of the health care compliance association American lawyers Health Lawyers Association excuse me and the American of college health care trustees our second speaker is Rachel price miss price has been working with strategic management since February 2016 and joined the team full time in May in May of 2006 she is a registered nurse and a seasoned certified outpatient and inpatient coder and is certified documentation and improvement professional as well as certified home care coder with many years of experience in the health care field she conducts many different client reviews for the firm some of them also involved ROI claims reviews of providers she has experience with CPT icd-9 icd-10 and PS pcs guidelines compliance audits and medical documentation risk reviews focusing on Medicare and Medicaid accurate coding and billing for physician practices hospitals most acute and post acute facilities she has conducted clinical documentation improvement projects and reviews and she also has and she also provided education training and coding and client documentation improvement she is a member of the American Academy of professional coders American Health Information Management Association the association of home care coding and she holds a Bachelor of Science and theirs in nursing from Stevenson University and now I would like to turn it over to our presenters take it away guys good afternoon everyone this is Cornelia and I'm very pleased to speak with everyone Rachel and I are very happy to share what we have learned over the years through these claims reviews that are conducted under CIA's and I just want to have a caveat it's really our opinions and experiences is obviously not the OIG any federal health care programs or even our clients experiences so it's really what we have learned and then just one a note I'm no longer associated with the American College of Health Care Board of Trustees I just couldn't handle all these memberships and so that is one I have to let go so just wanted to be accurate on this I wanted to go briefly over the agenda then dive right in well we wanted to talk briefly over CIA's in general and then of course some of the most significant changes in recent CIA's and the roles of the iroh's in that context we wanted to explain and share what we thought how CIA's could use be used as tools to improve your own practices and improve your claim systems and especially conducting your revenue integrity efforts speaking a little bit about data and scoring and how you can learn from CIA's and use some some of these features data issues it's always about data nothing works without the data being right supplemental materials and then we get into how you can take these approaches or maybe take some similar approaches modify within the cia's and last but not least we will have some comments and documentation and then some practical examples so this was the agenda I just went through now let's go and go through claims reviews and CIA's and hopefully you can hear and see well just a reminder CIA's are really for designed for a variety of reasons but one is they facilitate government monitoring and the iroh's role is to assist in this type of monitoring through typically retroactive retrospective audits and other types of reviews and the philosophy here the way at least we understand is that if you're under CIA there is still some oversight that is needed and that oversight will mitigate fraud risk and if you are in this category then you're subject to monitoring you agree to monitoring to mitigate compliance risk so from where we are sitting and what we have experienced some of this monitoring while it is tough it's often also a very good learning experience and so the MA monitoring has aside from really being a very tough situation also a lot of benefit and helps the organization's improve their our ways and particularly claims and claims processing there are so many entities that decide not to enter the cia's in their then categorized in a different risk category by the OIG but they may also benefit from these methods and CIA's and do self monitoring and use similar methods so what are the basis they are the corporate integrity agreement they also impose centralized risk assessment in internal review corporate integrity obligations not done by the iro but they tie into what I always do in especially findings and so on they have a monitor that's the government person or the HHS person from the OIG that oversees the CIA and all these activities biess the OIG may visit the monitor may come and visit over the course of the years and then of course they have oftentimes independent review organizations such as ours them that's what we'll be talking about then they're the three-year integrity agreements so they're for the smaller entities typically and they are they have different types of reviews most importantly the distinction is that their quarterly reduced though that pace is very very rapid and more reviews more frequent more quicker feedback which is maybe for smaller entities not a bad idea that they quickly learned what's wrong and six rather than waiting until the years up and there may be bad news and they have arose as well so why are we so interested in CIA's and iro reviews or claims reviews and CIA's it may be a good idea to remind ourselves that oh i g and various other associations have pointed out in the practical guidance to healthcare boards that corporate integrity agreements can be used as a baseline as a baseline tool to assess risk and they would be useful for boards and management in determining determining that that risk areas and looking at specific functions that you may have to look into to make sure your compliance program is effective so oh I G and the American Health Lawyers Association the American Association they all point to this so why not really take that seriously and consider the cia's as a tool and this is really why we're here we want to share some of these aspects and how you could use them as a tool so to understand why they may be beneficial to be studied really points us to the what's called the corporate integrity obligations or integrity obligations and we want to look into those that impact claims reviews so the fasting is well if you get monitored and audited and there's good oversight well it's good to involve an independent and objective auditor and that's the iro so the independence is important so it's an outsider looking in also to be fair and objective and having some representatives statements from let's say smaller samples or smaller studies to a larger context requirements require random samples statistical packages come into play and rap stats the OS software packages typical now it's required very often then there are clear expectations that the iro in these reviews must report instances actually that should be instance is not incidents instances of certain types namely occurrences of certain types in their studies and they deal with well these things go wrong with respect to medical necessity that has to be separately tracked was there an overpayment yes or no a West era billing and coding error yes or no so a few aspects or instances that need to be separately tracked and well that leads you to to think well these are the key criteria I should measure maybe then that's what I also can use to track performance then there's the financial error rate and that is probably a subject of a whole other power but it's one of these rates that has changed over the years and is an important one the mean find estimate which is the the overpayment estimate for purposes of extrapolation needs to be calculated and then as I mentioned before the frequency of the reviews are set and if you are on an annual sky cycle you have five reviews and five reports if you are a shorter for your psyche we have twelve reviews and trust reports and then the population is another aspect that means the population of claims may be limited by the OIG and they may focus on prior Curren is what happened in the past would led to settlement or any other areas that they might think of that would be helpful to limit the study supplemental materials is another aspect we get into later and then last but not least whatever comes out of the overpayment analysis has to be refunded within 60 days unless it's even a shorter time window stated in the CIA and reports typically have to be prepared within 60 days after so conducting the whole review and getting through it in sixty days is the government expectation and it's it's a tough tough call but it's doable and so what can we learn from this well you shouldn't take you nine months to get through one claims review and it can be done in a shorter period if everybody gets together and that's their part it would be helpful to just point out a few things about old-style CIA's how they were versus what is happening now especially the five-year ones they used to be when it came to claim you had a discovery sample you calculate an error age typically a net financial error rate where you were allowed to to take into account any under payments and then if you exceeded or you were larger than 5% so 5% of the net overpayment in the sample if you exceeded that then it triggered a full-scale review and expanded review and all no longer the common way so the new way is much more like this well there's a hundred claims or sometimes a multiple of a hundred and if if if you if you have the they still have to be selected randomly and typically not with rap steps not with [Music] limitations especially in the law art right here not uncommon that like risk-based auditing is a good idea that's my interpretation so try to narrow down a population to really focus on what to a large [Music] and tracking and listing particularly instances or that are required nearly medical necessity coding and overpayment are key but as I said they may also look into the past and look at what were the incidents would where the occurrences that led to the to the settlement that may affect the population but the main change that I see and that is really important of in the context of the CMS overpayment rule is move away from the air raid even trends moving away from the net to that growth error rate which is now to be reported so you don't really get any credit for errors that are not in your favor it's really about the overpayments only and that is a big big change and the area it in itself it's no longer a trigger of anything and I will talk about this in a minute on these smaller smaller CIA's it's similar trends there is also before there was the fight with an air raid there was a critical threshold that is now more and more gone and it's becoming a lot more ambiguous what the provider needs to do with all of these results and the other aspect is really the the what's important to remember is these quality reviews typically have 360 claims in total that you have to get through unless there is higher sample sizes so that's what we see is quite common but again what you do with the results in each of these 12 studies and whether to extrapolate or not it's really the decision of the entity meaning the those that are subject to the CIA so what am I saying here really well we learn a few things well a sample size situation has gotten simpler so quality reviews 30 claims may be a useful sample size and if you have larger scale reviews 100 it's not a bad approach and that helps I mean you don't have to it's not rocket science anymore what you have to think through you can design your own internal procedures based on that rule of thumb it would also be consistent with a self-disclosure protocol in the mean point estimate is also consistent with itself disclosure protocol where a hundred Peaks veins are typically expected you can disclose was to pay back the mean point estimate that's my understanding of the updated protocol metrics well as I said before the error rate is one that is worth studying and you should develop if you do your own claims reviews but you still have to study both the growth rate as well as the net and they both tell a story then the other metric is really just tracking did the submitted claimed differ from the correct exam yeah RNA then tracking medical necessity separately and also traffic tracking tracking over payment errors separately so these four metrics are listening to tabulate and create logs the review sheet that is also a requirement in the cia's that has the few elements that are mandated along with criteria and conditions of the particular subject is something that you can use as a tool and design your audits that way what is also more and more of a folk has become more and more of a focusing it's more clear in the expectations in the appendices of the CI a is that are open to look more clearly at the internal controls as well as the people and systems that are impacted by these controls to see whether the billing and coding processes work properly and then there's the systems review that has in itself as a report and separate review gone away to some degree and is more integrated into just eight claims review that deals with the transactions as a root cause analysis so that's our interpretation so supper systems reviews are just no longer the standards from what we have seen other than in arrangements review is where they are still there are separate transactions and systems reviews but the addition element that is important if the CMS overpayment rule that is now part of all the cia's and what is really the new and tough aspect related to this is that the burden is now on the provider to to decide whether or not extrapolation should be conducted and an overpayment should be based ah they should be identified at what payment should actually be killed beyond the sample and should include an extrapolated overpayment so I just felt led out it and this is how these CIA's typically read and as you can see you have to pay the money back within sixty days and if the entity determines that the that there should be an extrapolated overpayment so they determine whether to do that then they must pay back the mean point estimate is calculated by the or iro so there's no more five percent the iro does not decide that it's the entity and how do they decide that so that is for purposes of internal policies internal review procedures thinking ahead of what happens in twelve reviews every year an important aspect that decision and that decision can still be impacted by your internal guidelines you can still consider the five percent net or gross rate and sample you can consider transaction volumes you can consider a lot of things but the burden is literally on the provider and that is literally the headache in the industry of the way I CH to what to do when it's really not that clear-cut and we'll all learn together so I'll just point that out centralized risk assessment I mentioned those before and internal reviews are mandated in many CIA's and they're the entity's obligation oops I think I think we're at the okay I think read at the right slide again my apologies anyway so these centralized risk assessments and internal review activities are something the entities have to do the healthcare providers and plans and whoever is under the CIA but clearly whatever the iro finds and whatever the iro recommends may impact what risks has been identified and that may go beyond what the I row is go before guess let's say they audit a certain facility or they audit one of five hospitals or only a certain type of code what if you learn that there are some problems that is systemic issues if you do your dis process well you may have to think beyond just fixing whatever the iro files you may actually have to add something on your risk radar and you may add more new areas that could come out of iro review results so that's something that is important because you can't look the other way if you begin to learn we have a systemic issue or that whole problem could be happening elsewhere you can't just ignore it because you're mandated to conduct a reasonable centralized risk assessment and an internal review that is sufficiently diligent we also sometimes get somewhat confusions initially as we start out with our iro clients and it just have to make clear we are the iro we cannot go outside the scope of our work we cannot do any of these other types of works but we also cannot do some test reviews and tell you how how we would review claims and then gives you some idea so that you can for sure get it right so we have to literally do what is in the CI a audit at the end of the year the quarter and we cannot conduct other reviews or other consulting so that is just something that it has to be understood we also suggest that if you if you refund these claims or parts of the claims that are found in air keep very good logs so that in case somebody else comes for the same type of claims and and once refunds or considers them and part of an audit that you can show that you have resolved them that's even more important if you if you refund on an extrapolation basis where you may not rebuild or refund the individual sample claims so it just keep good look good a good track record what happened to these samples that were part of the iro review or for that for that matter any other claims for you that you do that is a similar type of approach has a similar type of approach so what you do I said that before use the 3100 approach for maybe quarterly and annual reviews and if it gets more complicated get some outside help especially if you have a lot of money at stake but this is not a bad rule of thumb to go with and if the revenue amounts get really large so the transaction volume gets really large you may want to really think of going through more careful planning of your statistical aspects and then the develop a full sample that fits your needs but the 31 30 and 100 is a good practical approach conduct periodically independent reviews I think that's what we can learn from iOS because we're all biased we're all favorable to ourselves more than anything sometimes and so having an outsider look at it critically is helpful now if you're not under CIA you don't have to do this 12 times or five times so maybe one time every other time it's helpful to get a fresh perspective what goes wrong following up on guidelines and changing guidelines is a good idea I also want to mention supplementals as you may be familiar with the CIA's there are supplemental materials requirements once the iro is reviewed the initial review is done they have an opportunity to go back and ask for additional supplemental materials if they deem that necessary but it shouldn't happen a lot and it shouldn't be a lot because either the iro doesn't ask properly for things or the audited target doesn't have things that they should have but it's a formalized process and it goes to documentation management on both sides and if if these materials cannot be had in a complete and reasonable time there may be a route cost that more and follow up namely how the medical records and the billing records are maintained and organized on your end think of these error rates and it may not be a bad idea to prepare a policy on how you use errors and how you determine when a certain error rate beat net growth 510 percent whatever it is that makes sense in your environment is used to take the next step take it to the next level have some sort of escalation process so that you are prepared in any review not just iro review to handle these results that may come at you as total surprises so avoid if you can ad hoc decisions still I think the 5% rate is not a bad threshold it worked well for many years and cia's I don't see you I at least on an internal basis it could still feed some of the determinations whether or not to refund on an extrapolation basis the report template or review template or Excel sheets or whatever you might call it is one thing that you can use as a tool and just structure it just as the ir o--'s have to and i'm listing some of these typical fields that should be in there that'll help you track and then just include some of these instances as something you track like medical necessity is to claim what it's submitted correctly yeah you're a western overpayment yeah you a and if you do that all of a sudden you have some standard metrics and it will allow you to compare a lot of different types of claims reviews that you might do as part of your internal monitoring and it would be nice to use that for purposes of performance tracking as you know iro claims review that really retrospective so they're looking back in time there's clearly a lot that means that you can do on a prospective basis or pre billing paces but still these types of reviews can be helpful in validation testing and as part of concurrent review you can do some of these up some of the aspects as well let me move on to risks and how you can identify risks one of the on this slide i just want to point out two aspects really one is the limit eight limiting populations the idea that that wedgy limits populations is the good one and you should consider that for yourself as well because you wait you may want to limit to as much as possible to the problem context especially if you expect extrapolation down the road so narrow down the universe is tight the problem focused as possible if you do most likely if there is a problem you get very far with a hundred paid claims if it's a vague universe with too much in it and you try to accomplish too many things in one go you may just need to get larger sample sizes and it may be a waste and then if you go through these reviews try to go through incremental steps and move from a small sample or small study maybe quarterly to then annually try to have some sort of progression on the scale as I said before the 100 claims is a good it's still wise to get some statistical help if you have a lot of dollars at stake if you have hundreds of thousands of dollars of millions because you might then really go into design that figures in confidence intervals and precision levels and design a sample that makes sense in it's a little bit more sophisticated than just using the 100 and then medical necessity has become really really more and more important and it's worthwhile just tracking that separately and also having physicians and staff and coders and whoever is involved in documenting and checking documents documentation being familiar with medical necessity criteria including those documentation criteria and LCDs and so on so what can you do emulate CIA Tibor youth but on the other hand you can do whatever you feel like if you the CIA other than you know if you identify you go about it you have a lot more freedom and one thing I just want to raise here is that the mean point estimate which is simply the average over payment growth over payment times the size of the universe which is mandated as the type of estimate in the CIA is not mandated period for everyone for example if you take they typically in CMS under the CMS medical program integrity guidelines they collected the lower bound of the confidence interval which is a smaller number than the mean point estimate also the OIG in the combined Hospital audits they don't ask for typically or recommend for refunding the mean point estimate they typically recommend refunding at the lower bound so it's something you need to be aware of and consider on the other hand if you sign on the dotted line and a CI a RI a you commit to the mean point estimate and thatis that is just always more than what may be allowable in other cases but the difference should you should at least be aware of in case you get into very complicated situations and you may have to make some hard choices and then if you if you design these reviews and if you hip critical issues it's good to have your team together and not just work in stovepipes and things don't work well we found that there's always either the the report writers or the h IM at IT guys or the reimbursement folks they're not all in one room bring them all together so that you can make the most of it when you design your reviews and talk about issues well for purposes of monitoring or designing metrics it's all about data right so as I've said this before so you may want to really just track some of the metrics that are these instances that are mentioned in these newer cia's and again that is the medical necessity is it is it a yea or nay in that area what's the coding error rate what is the overpayment error rate and then you may when you get through and I'm by that I mean the occurrence of errors is there an overpayment error or not and then the financial error rate which is the percentages of monies in era meaning the percentage of monies that were the O that are an overpayment in the sample and use the main point estimate understand what that is medical necessity is good to track it's it can be an issue but it's harder to fix and sometimes it's simply because it means workflow changes it needs physician participation it needs education it needs a lot of follow-up so getting that documentation corrected typically a bit more work but it's one that is really a big focus think of these metrics think of these these rates and again use them so that you have demonstrable and measurable performances that you can showcase I want to just go through document data issues briefly and then I think I soon pass it back to Rachel practice makes perfect it's my my philosophy because we have not seen it that in the first go-around the data that are needed the paid claims data are can be submitted and are ready for for primetime so that needs to be rehearsed and the extraction needs to be rehearsed they need to make sense they need to the provider or the whoever I want to conduct sampling and possibly overpayment extrapolation because there is an issue needs to be able to assemble the universe correctly and is it's not an easy task sometimes because you have multiple systems and if you have actually legacy systems is even worse but there's a few elements that need to to work the correct payers obviously have to be included only and sometimes it's simply the claim ID that we don't have consistently that is an issue we found and we have to work around that and and figure out what to do there so rehearsing and testing is important have a team ready that's my thought that can really get all this done and could you really do all of this in 60 days that's what the iro has to do but it only works if everything works like a charm and everybody does their part on the Supplemental materials I think I don't have to say much more but clearly when when the material is asked for explicitly and clearly and it's clear what is expected to be given then it should be available if it's not that can be a documentation issue but if you get more and more late in more and more around that can become a serious issue because you begin to question whether this all this material is authentic why was it not available in the first instance and it's it's probably worth the test how quickly can you produce a record where are your bottlenecks do you need to get materials from a vendor that you haven't planned on and or do you rely on a practice providing you something so that's kind of the main issues we see in supplemental materials I think I don't see much more on documentation I think the slide speaks for itself I led Rachel continue with what she has to say on documentation do than don't all right hello everyone so I'm going to go over some overall general documentation issues that we typically see in our reviews and then I'll get more specific as we go along in my PowerPoint here so some typical issues that I see is insufficient documentation conflicting information and the documentation typically I see this with my evaluation and management reviews just making sure that the history of present illness whatever is documented in the history of present illness carries through to the exam and is consistent with the medical decision making and then we sometimes will see inadequate support for medical necessity ambiguous information making sure that the documentation is clinically relevant to that date of service that's being reviewed and I say here watch watch over documenting we typically see that sometimes and then missing signatures dates times and illegible documentation I think we're off of our slides here yes I'm not sure what happened there I apologize if you could advance it to the side you react that would be great you have control now apologize for that we're just having a technical difficulty there well 24 all right great we're back here so so let me go over some areas where we typically see problems evaluation and manage an encoding specifically to modifier 25 chronic care management services face to face documentation typically we see that with home health and hospice medical necessity LCDs and McD's physician orders copy/paste errors and then DME durable medical equipment claims proof of delivery lab billing with lab billing we see institution documentation support medical necessity missing orders missing requisition forms and sometimes missing documentation to support the intent to order and unbundling lab panels okay and then in relation to inpatient rehab facility coding just making sure there's a lot of documentation that has to be and maintained in the record making sure that all the pre admission and post admission screenings and physician evaluation forms are in there making sure that all of that supports medical necessity meeting all the regulatory timeframes documentation of the overall plan of care admission orders that's a big one and then making sure that the required inpatient rehabilitation facility patient assessment instrument also known as Earth Pi is included in that documentation and then also typically we see within patients coding we see problems with the to midnight rule and short-stay claims and then emergency department billing all right nothing's Orangina alright now we're on to evaluation and management and modifier 25 so some important points to remember in relation to modifier 25 knowing when this is appropriate to use this modifier and making sure that the documentation supports it modifier 25 should only be used when services provided are beyond those considered part of the procedure performed so modifier 25 should only be attended to an evaluation and management code typically the patient's coming in for a minor procedure and in some cases the patient will maybe have another problem going on and so what's really important here is that the physician that that's translated into there documentation so I'm going to give you a clinical example so let's say the patient's coming in for an injection and during the during this time the patient happens to mention that they're having some back pain so it's really important that the physician document a history of present illness regarding the back pain they document the exam of the patient and then also the medical decision making perhaps they order an x-ray or an MRI perhaps they discuss conservative method measures such as using ice heat or over-the-counter pain relievers perhaps they prescribe a PT evaluation and the really important thing here is that this is all documented and in this case it would be appropriate to code the procedure meaning the injection and then also the appropriate evaluation and management code and appends modifier 25 all right another big risk area that we see is with chronic care management services this is a relatively new code it was implemented in 2015 and there is a lot of documentation that has to be maintained in the record prior to filling this code so some of the things a physician should ask themselves prior to billing this code is this patient appropriate for chronic care management does this patient have multiple chronic conditions they have to have two or more chronic conditions that are expected to last 12 months or longer or until death of the patient do these chronic conditions place the patient at significant risk of death or functional decline if the answer is yes to these questions then the patient is probably a good candidate for this service next the patient needs to the physician part of me needs to ensure that they obtain consent from the patient so they either can get verbal consent or written consent now when the code was first implemented it was required to have written consent now as of 2017 the regulations change and the position is allowed to obtain verbal consent but it's really important that the physician document this clearly in the medical record also the patient's should be aware that at any time they can opt out of the service and also the physician is responsible for implicating a care plan and coordination of care and also it's very important that only one physician one of the patients physicians build of codes so that coordination of care comes into play there information what you're saying there's a lot that has to be done before you really can begin yes a lot of prep works they really have to know what they're doing the other important thing with this code is that it's a timed code and that the physician keep a log of whatever or not if this is non face-to-face so this is phone calls with the patient so it's really important that they keep a log because they have to spend at least 20 minutes of non face-to-face time with the patient in order to build this code and then also it's important to note that there's an add-on code so if they spend more than 20 minutes with the patient they can actually bill another code in addition to the primary code all right another area that we see problems and specifically with home health and hospice claims are problems with the face-to-face documentation for purposes of this presentation I'm going to focus mainly on home health and this is probably one of the biggest errors that I see whenever I do a home health claim review problems with not having all the required elements all the documentation elements in the documentation the physician has to support medical necessity say the reason for the home health need and all the clinical findings to support medical necessity so sometimes the patient will see the physician perhaps or seeing them for something else and they're not there for the home health reason and so sometimes the certifying positions will have a form of face-to-face form some of the pitfalls with that is that it's very they have very very generic forms so if they do use a form it's extremely important that they be very specific as to why is this patient need home health what is their home health home down status and that they put the beneficiary's name on there that there's all the signatures and dates etc and in addition if they do use any sort of form like that they include the encounter notes for the face-to-face visit other problems that we see are that there's problems with the time frame of the face-to-face it's not within the regulatory time frame and that sometimes we see missing or illegible signatures and or dates all right and then physician orders there's all sorts of different physician orders sometimes we there's missing orders altogether missing signatures on the orders timeliness of signature of posting matures so either for procedures test and patient admission to hospital acute facility this poses a risk as for most claims in order is a condition of payment the order substantiates the services billed as well as supports medical necessity in the interest of time li+ in the interest of time we're going to forego this polling question we'll be asking an additional polling question in a couple of minutes so you guys can proceed with your science okay thank you all right okay another huge risk area that we see is with the copy paste function and this has become more of a problem with some electronic medical records what's really important here is that the physician if they do use the copy paste function that they review all their documentation making sure that it's pertinent to the date of service also sometimes with the copy paste is very evident especially when you're documenting the same position and you're documenting you're reviewing multiple claims you can kind of tell that they've used the copy/paste so just because their notes become very lengthy and redundant and it's really not about the quantity but it's about the quality of documentation ensuring that it supports that it's meaningful and that it supports medical necessity and then documentation air problems I see with durable medical equipment specific to proof of delivery it's really important with proof of delivery that you have a date on there without a date the proof of delivery is invalid and this is a huge error that I see when reviewing durable medical equipment claims also making sure that the beneficiary's name is on there the delivery address is on there and also if it's delivered to the patient to their home and not in person making sure that the provider go into the database of FedEx UPS and printing out the proof of delivery and the signature of the patient the the name whatever was ordered whether it's a wheelchair crutches back brace that should be on the proofs of delivery the quantity that was delivered the date and then the printed name of the beneficiary as well as the signature just a comment here I mean let's say you have an annual review or an annual claims review be sure that you can access the proof of delivery to rely on EPS or FedEx or any kind of web portal right it's still maintained so that's what yep saying scan it and make it part of your records exactly to be able to prove that later on yep years later yes because the proof of delivery becomes the data service and the state of services what's on the claim form lot again a lot of documentation that has to be done and maintained in the record I'm gonna hand it back over to Cornelia and I'll just get us to the end here very quickly just keep in mind that an iro is not a consultant and try to make them but get your consultants to help getting ready for the IRA or follow you know similar practices be mindful when you're under CIA be sixty days in during which these reports have to be generated are very short it's a good good idea to test it out whether or not you're under a CI whether you can actually live with these short timelines and then focus on your audit scope in particular if you're under the CIA know your audit scope and sometimes I have to say no your CIA study your CI a if you don't understand it walk through it get get to understand it sometimes that's almost a side feature we have to get through in the first quarter our first round to explain a little bit more what the language in the CIA's mean and that's all right so takeaways just a couple emulate to the 30 60 samples for simplicity that's you know a no-brainer try that think carefully about the gross and net financial error rate especially if you are nor CIA and you might be in a situation where the error rate that only looks at the overpayment this may be 5% but or 10% but the net overpayment net error rate may be negative meaning you have more under payments than overpayments so know the differences and study that rate carefully and try to come up with some sort of internal policy and procedure how you use such a rate in your own internal reviews understand the differences between lower bounds and mean points and use them as is it makes sense what's your modifiers modifier billing is this can be tricky and follow-up throughout these reviews once the audit is over it doesn't really stop errors can come back so watching out and doing small Probot it is always important to survive and then last but not least again two aspects that help you down the road signature and date signature and date and watch the copy/paste errors and I think that's where we have to say I'll pass it back to Debbie great thank you thanks Cornelia and Rachel for presentation today I found it to be very informative and I hope you all did as well before we take your questions we wanted to provide you with a quick polling question and that polling question is would you like to learn her and how si global and strategic management can assist you with your compliance challenges a yes please contact me regarding s AI global BES please contact me regarding the strategic management or si not right now but possibly in the future as you are answering that wanted to start transitioning over to a Q&A so I'm not like to hand it over to my colleague brandy who will conduct the Q&A session hi alright our first question is what are your thoughts on independence and objectivity of our own how much interaction should that iro have with the provider under a five-year CIA well that's an easy answer they should develop some sort of plan what they're going to do so that expectations are set and then they have to interact clearly to enough to be able to understand some of the systems to understand some of the policies or descriptions and to carry out the work I mean they should be there like a monitor being you know there for lengthy periods of time but these claims reviews a lot of them can be done remotely but not all of them so me in on-site review but it depends on the type of claims on the type of entity but there's clearly back and forth that's normal it's an auditor but then they go away and do their audit and come back with their results and then there is a time for feedback and review of a financial draft and then they finish up great and one other question what if we don't have a lot of money and need an internal review of about 30,000 plus claims and a quarter with thirty and a hundred proach speed representative well I mean you have to 30,000 claims well the CIA will spell this out the CIA may say 30 or the CIA may say a hundred so it's not a choice that the iro the entity may make it it's written in the CIA of course it's a subject to negotiation between the entity and the OIG and Department of Justice but as an IRA we just have to execute what's in the appendices and they typically spell out what you start out with 30 or 100 or whatever other number all right and if an organization suspects a possible documentation issue what is the best course of action when auditing and monitoring what is the recommended number of claims to look at a look at her eyes well I mean my recommendation is always always always start small you might begin with 10 15 as a judgmental sample if you're not sure I would begin with a probe sample of 30 that's what I would begin with and then move on to 50 to get a better picture but if you have a problem within the 50 then it's time to look at this more closely great thank you great thank you so much guys before we conclude the webinar we want to provide you with some information about upcoming events join sei global an strategic DCP on Thursday December 13th at 2:00 p.m. as we discuss in sites surrounding active shooters in the workplace and how the best equip your organization's with tactics tactics to be prepared if you're interested in attending please click on the registration link to register and that concludes our webinar for today thanks again to our presenters and thanks to all for attending we hoped everyone has a great rest of your afternoon