Risk-Based Auditing for Healthcare OrganizationsMedicalComplianceRiskAnalyze_

The following Questions and Answers are in response to the Risk-Based Auditing webinar conducted by Frank Cohen. The webinar is an introduction to risk-based auditing with a focus on the CMS’s use of new and advanced fraud detection technologies and a presentation of strategies that healthcare facilities can use to be prepared for the inevitable audit. In the front end, before an audit occurs, there is a lot a practice can do to get a handle on whether they are at risk, how large a risk there may be and specifically where the risk is focused. By understanding these three things, a practice can begin to lower the latent risk they face should an audit occur.

Questions and Answers

Q: How do you account for the sub-specialty physicians when using the top 25 frequency comparison?

A: Right now, CMS and the Fraud Prevention System are not using subspecialty taxonomies. They were supposed to in 2020, however, no updates have been communicated at this time. The taxonomy set is already built, and we are are waiting for the CMS to pull the trigger.

Q: Can you explain how to get the variance again? 

A: Take the frequency distribution for your provider, divided by the national frequency distribution and subtract 1.

Q: Can you include the mathematical equation to come up with a variant?

A: Take the percent distribution for the practice, divide it by the national percent distribution and subtract 1.

Q: For Pediatric Specialty & Primary Care practices with little to no Medicare business, what national or regional benchmarks would be used for CPT Code frequency comparison?

A: It is important to note that only some 65% of Medicare recipients are aged 65 or older. As such, we have some 9 million lines of pediatric data. In addition, we had several million lines from our cohort data set. Having said this, Pediatrics does not have the most robust comparative data.

Q: What year is the RVU comparison chart for?

A: We use the most recent RVU data. As of right now; we are using the 2020 data set with 2018 frequencies.

Q: Are there specialties at greatest risk of an audit? Or certain CPTs/Modifiers at greatest risk of audit?

A: The CERT study is a great resource for that. In general, those that have a greater variety of services, like IM or GS as well as those that report very expensive procedures, like NS and OS

Q: Does the top 25-frequency comparison change for academic medical centers?

A: There will always be differences based on a more homogenous grouping. Therefore, yes, academic centers, in general, will look different

Q: Do you offer project plans/templates for setting up a risk based audit plan?

A: Yes. We will be demonstrating Compliance Risk Analyzer after we cover Risk Based Auditing. Please stay for that portion of this webinar, if you have time.

Q: What percentage of accuracy do set as acceptable?

A: That’s a tough one and is often quite different for different organizations. In general, we find that most organizations want their providers to have a 90% pass rate.

Q: I am the business administrator for a growing specialist practice. This growth has happened rather quickly. This is all very overwhelming and I don’t know where to begin. Any suggestions for first steps?

A: I would begin by setting up a call with Courtney to see who at DoctorsManagement might be able to help you get started.

Q: For the program where is that data coming from?

A: Benchmark data usually comes from both the PUF and P/SPS files from CMS. Our cohort data comes from third-party claims aggregators. The training data for classifications comes from our claims audit warehouse.

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CRA creates an audit plan of the top five critical risk issues for each provider reporting a moderate to high risk. Rather than using your limited resources to search for potential risk issues by conducting initial probe audits, direct them to validating real risk. Our audit action plan is based on a statistical review of 100% of your claims — something that is virtually impossible any other way.

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CRA was developed by The Frank Cohen Group, a division of DoctorsManagement.