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Robert Freedman

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Leveraging Peer Collaboration and Information Sharing: 3 Things to Think About

Posted by Robert Freedman on May 24, 2017 at 9:00 AM

An article in Inc. Magazine outlined five reasons why collaboration is crucial. While the article was focused mainly on business organizations, the concept is just as important for those in healthcare generally and for compliance and auditing professionals specifically.

The key reasons for working with peers in your industry are:

  • Self-awareness – Collaboration forces you to clearly describe areas of strength and weakness
  • Scale – “Two heads are better than one”
  • Creative Abrasion – Converting energy from people who are different into positive action
  • Take the long view – Ideas may not have an immediate impact but could be beneficial down the road
  • Learn, learn, and learn some more – Collaboration sets an expectation of continuous learning to expand the knowledge base of the organization.[1]

No person – or organization – has all the answers. The more you can work with peers at similar institutions facing similar challenges, the better the chances you can effectively address and successfully solve them. There are three things to consider that can help energize peer collaboration in your organization.

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Topics: mdaudit, Data analytics, Risk-based audits

4 Opportunities Analytics Can Provide

Posted by Robert Freedman on March 29, 2017 at 9:00 AM

The risks of non-compliance in the healthcare industry have never been greater. In fy2016, the HHS Fraud and Abuse Control Program returned $3.3 billion to the Federal government and private parties. The Department of Justice (DOJ) opened 975 new criminal health care fraud investigations.[1]

In fy2015, Medicare Recovery Audit Contractors (RAC’s) identified and corrected 619,000 claims resulting in $441 million in improper payments - $360 million in recovered overpayments and $81 million in underpayments repaid to providers.[2]

With both top and bottom lines continuing to shrink, you can’t afford to be hit with a massive overpayment penalty or to undercharge for patient activity by hundreds of thousands of dollars.

The key to managing both risk and opportunity is getting into your billing and collections data, and for that you need a robust analytics solution. Here are four opportunities you can take advantage of with a comprehensive analytics program.

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Topics: mdaudit, Healthcare Analytics, Risk-based audits

How Analytics Can Benefit 4 Key Members of the Compliance Team

Posted by Robert Freedman on February 1, 2017 at 9:00 AM

As healthcare organizations have reached near universal adoption of EHR and practice management systems, the amount of available billing and claims data has grown exponentially. This data has the potential to offer insight to issues that can adversely affect the organization both from a regulatory and financial standpoint. Compliance and revenue cycle leaders are both coming to realize the benefits of collecting and analyzing this valuable information.

However, as compliance teams move from static auditing schedules to proactive risk-based programs to help identify and manage risks, it has become clear that it’s not just managers and supervisors who can benefit from data analytics. A robust analytics program can provide valuable insight that can help every member of the compliance team perform his or her job better.

In particular, use of analytics can significantly improve communication between the compliance team and other departments in the organization. There can often be friction between an auditor and those being audited, but focusing on data and providing a bigger picture view for both parties helps foster better working relationships and more effective issue resolution.

Using actual data instead of hypothetical situations can diffuse disputes and make audit finding discussions positive and more productive. It can also provide a wider view of a potential issue that can aid in instituting effective corrective action, both huge benefits for the compliance team.

For example, an auditor may find an instance of an incorrect E&M billing. It can easily be written off by the physician as a one-time error. However, analytics can reveal a pattern and show it was not an isolated instance. The auditor and physician can then rationally discuss the issue backed by data. That can be a tremendous advantage for compliance teams and helps take the emotion out of findings discussions.

Here are four key members of the compliance team that can get significant value from an organization’s analytics program.

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Topics: Healthcare Analytics, compliance programs

Defining Your Terms: Do You Have the “Analytics” Solution You Really Need?

Posted by Robert Freedman on November 16, 2016 at 9:00 AM

Big Data. Bandwidth. Paradigm. Analytics?

It’s almost universally accepted that the first three have crossed over into buzzword territory and are in danger of losing any real meaning (if they haven’t already done so.) But is the term “analytics” heading down the same road?

We’re not saying analytics aren’t important. In fact, they are critical for healthcare organizations facing the onslaught of changes resulting from MACRA, increased oversight and the rush to value-based care.

But it’s important for us to define our terms. “Analytics” does not mean the same thing in all situations. In order to get maximum value, you need to make sure the analytics solution you’re using is appropriate for the task you are trying to accomplish. If it isn’t, you’re not likely to achieve your desired goals.

We spoke with one prospect recently who said, “Analytics is off the table. We already have so many analytics products. We don’t need any more.”

His situation may not be very different from your organization where you have no doubt deployed a number “analytics solutions.” You may have a large, expensive enterprise system in place. But if you’re like many organizations, those analytics programs are often focused on “bigger picture” issues like population health. While that is an extremely important initiative, as a compliance organization, you still need to leverage data for other operational goals like improving revenue flow and minimizing risk.

You may also have a number of system-specific analytics programs and visualization solutions that can provide valuable insight. Unfortunately, although these applications fall under the broad heading of “analytics,” they don’t provide answers that relate directly to your set of issues.

The end result is that even though your organization may possess powerful “analytics” solutions, you can often be left hungering for “analytics” that help you focus on your key risk areas. You may have trouble getting directly to the raw data you need but instead have to rely on filtered data provided by someone in an IT group. Such data sets compiled outside the compliance group can reflect a different purpose from the one you need. 

Actionable analytics requires iterative refinement of available data with subject matter experts who can pull out the “learnings” that are real and worthwhile. To accomplish that you certainly need “analytics,” but analytics that use raw billing and coding data to uncover risk areas before they can cause reputational and financial damage. These types of “analytics” solutions are much more specific. They are built on an analytics platform, but they are actually applications.

When looking for an analytics application best suited for risk and compliance management, here are five things you need.

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Topics: Healthcare Analytics, Risk-based audits

False Claims Act Penalties Doubling: Time to Beef Up Your Compliance Program

Posted by Robert Freedman on September 28, 2016 at 9:00 AM

If you mistakenly submit a single claim that results in a $100 government over reimbursement, you could now be subject to a penalty of over $20,000, according to the lawyers at Mintz Levin, specialists in healthcare law.[1] And that’s for every single claim.

To quote Alec Baldwin’s character in the famous Glengarry Glenn Ross monologue, “Have I got your attention now?”

The Department of Justice recently passed an interim final rule that has nearly doubled the civil penalties under the False Claims Act (FCA) from an already oppressive $5500 minimum to $11,000 maximum per claim to a minimum of $10,781 and maximum of $21,562. The increases – which went into effect August 1 - are the result of a “catch-up” clause in the 2015 Adjustment Act that amended the Federal Civil Penalties Inflation Adjustment Act of 1990.

The act mandates agency heads to adjust civil monetary penalties based on the difference between the Consumer Price Index in October of the year they were established and October 2015. After this initial catch-up, agencies must make additional annual adjustments, so the costs are only going to increase from these new dizzying heights.

The impact for the healthcare industry is seismic. The cost of any slip up in Medicare and Medicaid claims can be financially disastrous and the doubling of penalties means a doubling of “whistleblower” rewards, so organizations can expect increased scrutiny from employees, former employees and competitors looking to cash in.

To make matters worse, because of the sharing of Medicaid costs, the act incentivizes individual states to pass FCA laws in addition to Federal statutes. The pressure on healthcare organizations to “get it right” when it comes to claims submittal has never been greater. With the financial stakes ratcheted even higher, it may be time to refocus your efforts on compliance.

Here are five ideas to help strengthen your compliance program.

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Topics: billing compliance software, mdaudit, compliance programs

Understanding and Leveraging the 2016 OIG Work Plan

Posted by Robert Freedman on February 10, 2016 at 9:00 AM

In fy2015, the Office of Inspector General (OIG) recovered more than $3 billion in audit and investigative receivables as a result of their oversight activities. That’s great news for U. S. taxpayers but not so wonderful for the many hundreds of provider organizations that had to dip into their shrinking revenues to come up with these repayments.

If you are among the many organizations that took a proactive approach to auditing by following the recommendations laid out in the OIG annual Work Plan, chances are you avoided that expensive fate.

Each year the OIG releases its internal Work Plan detailing areas of emphasis for their yearly compliance audit activities. Providers who begin to focus their audits on the risk areas the OIG has outlined sooner rather than later, stand a much better chance of addressing issues before they have a problem with government auditors. Following such a strategy allows you to self disclose overpayments and pay back the government prior to an official oversight audit. Even better, focusing on these high-risk areas early helps you avoid overpayment problems even before they occur.

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Topics: audit preparation, Office of Inspector General, paybacks, compliance monitoring program

It’s Almost October 1. Do You Know Where Your Documentation Is?

Posted by Robert Freedman on June 17, 2015 at 9:00 AM

The curfew for ICD-10 is fast approaching and with it comes a slew of changes for your documentation. Do you know what you’ll need for a successful implementation? Here are a few helpful suggestions:

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Topics: EMR, implementation, compliance, ICD-10, EHR, coding, revenue cycle management, documentation

3 Steps: Drive Your Compliance Checkup Using the OIG Work Plan

Posted by Robert Freedman on February 25, 2015 at 9:00 AM

Nearly five billion dollars.

According to a report to Congress, that’s the amount returned to Uncle Sam in FY2014 as a result of healthcare oversight and investigations conducted by the Office of Inspector General (OIG). Avoiding this type of negative impact to cash flow and the bottom line is a matter of revenue integrity and is a high priority to most healthcare organizations.

The OIG Work Plan details areas of emphasis for their yearly compliance audit activities. Providers are encouraged to use the plan to prepare for potential audits. Using the Work Plan as a guide to review specific risk areas that impact your organization is the best way to create an effective compliance audit program and avoid paybacks.

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The Tide has Turned on Internal Auditing

Posted by Robert Freedman on July 29, 2013 at 7:30 AM

Last year, few healthcare organizations were truly concerned about external auditors such as the RACs. Many states were in deferred status (so that recovery auditors could not yet audit them). Others found that the auditors’ forays were surprisingly superficial. However, this year, all that has changed! Healthcare organizations are talking about how external auditors ask and obtain the maximum allowable numbers of audits/cases to be reviewed.

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Topics: RACs, recovery contractors, billing compliance software, mdaudit, billing compliance

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