EE Audit Tool 2007-08

Informations

• Publié par: Veseb
• Nombre de lectures: 20
• Langue: English

Extrait

TML Intergovernmental
Employee Benefits Pool
2007
2008
Revised October 2007
Employee Audit ToolTABLE OF CONTENTS
INTRODUCTION ...................................................................................................1
STEP I
How Much Time Did the Service Take? ......................................................................... 1
Commonly Identified Billing Errors ................................................................................ 2
Unknown Provider Billing ............................................................................................. 2
Bundling Procedure Codes ........................................................................................... 2
Identifying Upcoding 2
After Hours Charges .................................................................................................... 3
Physician/Team Conferences and Care Plan Oversight .................................................... 3
Preventive Medicine and “Evaluation & Management” Services ....................................... 3
End Stage Renal Disease Services ................................................................................ 3
Anesthesia Billings ...................................................................................................... 4
Review of X-Rays Made Elsewhere ............................................................................... 4
Special Reports ........................................................................................................... 4
Services Performed Outside of an Office Setting ............................................................ 4
Supplies/Surgical Trays/Pap Trays ................................................................................. 4
Unlisted Special Service, Procedure or Report................................................................ 4
STEP II
Evaluation and Management ........................................................................................ 4
Office or Other Outpatient Services .............................................................................. 5
Preventive Medicine and Other Counseling .................................................................... 9
Other Preventive Medicine ......................................................................................... 10
Prolonged Physician Service with Direct Face-to-Face Patient Contact ........................... 10
STEP III
Information Necessary for Covered Individual Review .................................................. 11
Patient Advocacy Information .................................................................................... 11
EXPLANATION OF BENEFITS REMARK CODES OVERVIEW
Accident ................................................................................................................... 12
Additional Information Needed ................................................................................... 12
Addinformation Requested/Not Received .......................................................... 15
Adjustments/Re-open ................................................................................................ 15
Copayment/Deductible .............................................................................................. 15
Dental ...................................................................................................................... 16
Discounts/PPN .......................................................................................................... 17
Amera-Net ................................................................................................................ 17
Eligibility .................................................................................................................. 19
Filing Deadline 19
Forward/submit to .................................................................................................... 20
Hospital .................................................................................................................... 20
Maximums/Benefit Limits ........................................................................................... 20
Miscellaneous ........................................................................................................... 21
Not Covered ............................................................................................................. 21
Other Insurance/Medicare ......................................................................................... 23
Right of Recovery ..................................................................................................... 23INTRODUCTION
To manage increasing healthcare costs, Covered Individuals will benefit from education on
how to audit healthcare bills, utilization trends, provider billing practices, vendor charges
and provider network discounts. Experts estimate that between 5%-10% of claim dollars
are spent on erroneous charges.
Cost containment procedures that protect the employee and the benefit plan from excessive
benefit costs include:
1. Investigation of possible erroneous billing and plan abuse;
2. Systemic audits of all medical bills, using for comparison a table of usual, reasonable
and customary charges by Current Procedural Terminology (CPT) code in the geographic
area is helpful to determine how the usual, reasonable and customary amount is
calculated;
3. Utilization Review to ensure providers are using the most appropriate and most cost
effective treatment interventions; and
4. Large Care Management is helpful in engaging a medical consultant to work with
providers delivering the healthcare services.
Covered Individuals have many tools that they can use to become educated healthcare
consumers. Some of the resources available to Covered Individuals include medical trend
information, healthy lifestyles articles, provider regulatory compliance information, provider
cost analysis comparisons, outcome management statistics comparisons, Covered Individual
claim audit information, benefit book guidelines, provider benefit reference material and
helpful definitions for key healthcare terms.
STEP I
Covered Individual Checklist to Review Provider bill
1. How Much Time Did the Service Take?
For the first time in the history of procedural coding, the physician/provider time is
just a component of the Specific Evaluation and Management Code. The specific times
expressed in defining the code are identified in ranges of face-to-face time spent with
the Covered Individual. Time may be higher or lower than the ranges represented
depending on actual clinical circumstances.
There are two types of time defined:
A. Face-to-Face Time ~ Time that is spent face-to-face with the Covered Individual
and/or family. This is more typical of an office and other outpatient visit.
B. Unit/Floor Time ~ Time that is spent in a hospital unit on a Covered Individual’s case.
In this time, the physician reviews and updates the Covered Individual’s medical
records, reviews test findings, examines the Covered Individual, and communicates
findings to the Covered Individual, family or other professionals.
12. Commonly Identified Billing Errors
A. Erroneous Procedure Codes
If a provider bills for a new patient procedure code every visit, TML Intergovernmental
Employee Benefits Pool (TML IEBP) will only recognize the new patient procedure
code on the initial visit.
B. Upcoding for Additional Services
Changing charges for a lower cost service or medication are coded as ones that are
more costly.
C. Unbundling Procedure Codes
This occurs when a provider bills for a procedure code that is included in another
procedure billed on the same day.
D. Duplicate Billing
Make sure you are only charged for services you have received. Also, make sure that
you are not charged more than once for the same service, supply or medication.
E. Number of Days in the Hospital
Check the dates of your admission and discharge. Were you charged for the discharge
day? Most hospitals charge for the admission day, but not the discharge day.
F. Incorrect Room Charges
Make sure you are not billed for a private room if you were in a semi-private
room.
G. Operating Room Time
Compare charges billed by the hospital for operating room time with the
anesthesiologist’s bill for operating room time.
H. Cancelled Work
The provider bills for services that was cancelled. Services never received by the
Covered Individual should be reported to TML IEBP.
3. Unknown Provider Billing
Unknown providers who bill Covered Individual should be reported to TML IEBP.
4. Bundling Procedure Codes
This occurs when a provider bills for services that should be billed separately. The
provider bundles the services due to benefit variances for multiple same day services
or multiple surgery services. Multiple surgeries are frequently bundled and the error
should be identified.
5. Identifying Upcoding
The potential for upcoding exists for every evaluation and management code. The
Covered Individual should suspect upcoding when the highest available procedure codes
are consistently used. For example, procedure codes 99205, 99215 and 99245 are some
of the codes that may be over utilized.
If the provider always codes using “unlisted services” although an exi