Self-identification of errors in billing or documentation is a powerful tool toward minimizing medical review risk. Recognizing and correcting deficient practices on the front end contributes lasting impact to realizing and sustaining reimbursement. Establishment of an internal auditing process will contribute to success in the following ways.
- It provides opportunity for reflection within the organization
- It verifies medical necessity of source documentation
- It defines areas of opportunity
- It identifies areas of survey risk
- It is essential to a successful Quality Assurance & Performance Improvement program
Through review of PDPM component capture for Part A claims, and individual CPT code utilization for Part B claims, outlier patterns may be determined. CMS’ PEPPER Report clearly defines capture, as compared to other providers. Likewise, routine analysis of Part B billing provides a snapshot of frequently utilized codes that face risk for selection as a basis for audit. Consistent internal auditing identifies compliance with clinical/billing requirements and expectations, validates effectiveness of prior training, and confirms current training needs (e.g., PDPM component/CMI capture, and defining the scope as facility wide, or limited to a specific team member).
