In Context

An “Easy” Button for Healthcare

 

Challenge

 

As tax time looms around the corner, we all relish getting a refund and dread having to pay anything additional. We all fear getting audited down the line and maybe even having to come up with funds to pay the IRS if any errors were discovered in that audit. Imagine having to pay large amounts of money back that you probably do not have in easy reach but that is exactly what is happening to healthcare providers.

Problem

 

 Due to complex multi-agency audits that are now the norm, huge amounts of overpayments are being discovered. Just recently the Office of Inspector General (OIG) found through an ongoing probe of hospitals and physicians that an overbilling of Medicare for the breast-cancer drug Herceptin was occurring.¹ Overpayment errors were found in more than three-quarters of all claims that it audited!  Either through mistakes in not being familiar with medical necessity policies, code description misunderstandings or not enough coding and billing staff education, the OIG found that each time the drug was administered the whole vial was being billed instead of what was actually used. Through this audit, the OIG has asked Medicare MAC contractors to put system edits in place to audit any claim where a whole vial of Herceptin is billed on a single claim. CMS is requiring the contractors to recoup the overpayments that were well over $1.2 million per the jurisdictions audited.

In another OIG finding reported by Joe Carlson of ModernHealthcare.com, “If a hospital discovers that a nurse practitioner had been receiving payments at the full physician Medicare rate instead of the discounted 85% rate that most nurses receive, that facility will now have to go back and audit five years' worth of billings for which that nurse's services were billed, instead of just three.”²

In another move to curb overpayments and scrutinize claims further, CMS and private payers recently announced a fraud prevention partnership designed to share claims information and best practices in an effort to improve detection and prevent fraudulent billing across payers. The membership include CMS, the Justice Department, Blue Cross and Blue Shield Association, eight private payers and the Coalition Against Insurance Fraud.³

Imagine that you are now one of those providers getting these letters for huge overpayments – funds that will be taken out of your future A/R impacting your business financially in both re-payments and re-education of coding and billing staff not to mention scrambling to find a way to catch these types of claims before they are submitted for payment. These claim errors can easily viewed as fraud if a provider does not police themselves.

Or perhaps you are the payer contractor that has paid these claims and now are faced with having to perform a forensic audit of your own and designing system edits to prevent future overpayments. Where do you start and how do you prevent this or any other similar situation from occurring? Is there an “Easy” button out there for healthcare billing errors?

Solution

 

 

An exciting and revolutionary way to utilize and audit your own data whether it resides in a practice management system, electronic healthcare record or revenue cycle management system is finally here. Context⁴ Healthcare has developed a new tool to help payers, providers, billers, coders and auditors with the way to view data from anywhere in your own system, compare it to current compliance rules and if acceptable to change the information before it is submitted for reimbursement, with a click of a button. No integration is necessary. It’s quick and easy and all done online, and can be used anywhere in your workflow. Let Context⁴ Healthcare show you how easy it is to take data in one system and be able to review it for errors and overpayments seamlessly without messy integration. Call us today and let us show you how we can help you be successful with your auditing, billing and editing challenges.

1. http://www.modernhealthcare.com/article/20130121/NEWS/301219959

2. http://www.modernhealthcare.com/article/20130103/NEWS/301039951        

3. http://www.partbnews.com January 21 2013 Vol. 27 Issue 3