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CASE STUDY
Compliance |
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Following retrospective claims review, a publicly owned and operated health services agency identified potentially inappropriate billing practices for certain behavioral and mental health services. After refunding overpayments received in error from Federal healthcare programs, the agency engaged Sinaiko Healthcare Consulting, Inc. to serve as its independent third party review organization (TPRO) to: |
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Initiate focused reviews of its coding, claim submission and billing practices; |
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Assess the effectiveness of its standard operating procedures related to documentation practices, service activity code selection and reporting, staff qualifications, and internal monitoring processes ; |
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Provide targeted training to its clinicians and providers; |
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Assist the agency’s Quality Management Division in the review and final disposition of appeals by affiliated facilities to initial denials of treatment; and |
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Conduct regular chart - to - bill coding audits.
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The agency selected representative samples of claims submitted by its providers for focused reviews by Sinaiko on the basis of the supporting documentation in the corresponding medical records. After our reviews noted inappropriate or inaccurate selection of codes to describe the services rendered, we identified opportunities for process improvement in documentation practices as well as in practice efficiencies. Sinaiko’s professionals continue to assist the agency in the implementation of these recommendations.
Additionally, Sinaiko applied standard sampling technologies to randomly select probe samples consisting of 30 claims each to perform regular chart - to - bill coding audits by payor class and provider category. These audits are ongoing at this time. The agency intends to rely on our audit findings to refine its practices, remain compliant with applicable rules and regulations and optimize its revenue cycle. |
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