Monthly Newsletter

April 2021

Monthly Newsletter

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Do Your Medical Records have "Appeal-ability"?

Providers don’t typically view medical records as necessarily being appealing, attractive, charming or even alluring.  The “appeal-ability” of documentation is all about getting paid when a claim is wrongly denied.  When a lot of money is on the line, suddenly the provider may start to see the record as being more “attractive”.


So, how can we encourage our providers more engaged to increase appeal-ability before a major insurance audit or investigation?


Defending the reimbursement your providers deserve starts with accuracy of the entire medical record, including proper authentication by anyone make an entry (not just the treating provider).  Procedures, progress and operative notes all play a role in telling the patient’s medical story, supports medical necessity, improves coordination of care and mitigates financial risk posed by potential insurance or government audits.


When your office receives a request for documentation, it is critical to review the request to determine if it is a routine audit, probe or an investigation.  A routine audit example would be an RFI (Request for Information) from CERT (Comprehensive Error Rate Testing), which is a CMS audit contractor.  If the claim and documentation “fail” a routine audit, APPEAL.  Wining this type of appeal is critical to avoid further investigation, which is likely to happen (the point of carriers conduct routine audits).


Expect more Evaluation & Management (E&M) audits from payers due to the outpatient code descriptions and guidelines. The new 2021 Evaluation & Management outpatient guidelines have streamlined the documentation process, or at least it seems that way.  Since the January 1, 2021 launch of the outpatient medical office code descriptors, it appears there are more questions and confusion than ever.  Time and Medical Decision-Making (MDM) are now the 2 deciding factors for selecting level of service, but ONLY for codes 99202-99215.  The old 1995 and/or 1997 guidelines still apply to hospital encounters, emergency department visits, and anything “not” outpatient office. 


CMS has finally updated their Evaluation & Management Guide for 2021, but it isn’t much help (download your copy). The American Medical Association (AMA) has provided much guidance, including revisions and clarifications since launching the new codes January 1, 2021. Is this enough?


Who is designated within your organization that is qualified to handle both routine and special external audits?  Having a Certified Outpatient Clinical Appeals Specialist may be a consideration for group practices, clinics and outpatient services.  This position would report to the Revenue Cycle Manager as an integral part of the financial team; provide documentation feedback to providers to reduce denials which lack “appeal-ability”; and work closely with your Certified Medical Documentation Professional and Certified Healthcare Auditor responsible for clinical documentation improvement.  Creating a professional team of certified specialists will not only pay for itself, but provide proof that your organization is doing everything necessary to implement an effective coding, billing and documentation compliance program.  Watch the Video “What Prosecutors Do When Evaluating Your Corporate Compliance Program” or An Audit, Now What? How to Request a Fair and Reasonable Process during a Pandemic” on our Educational Channel.




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Is There a New Healthcare Crisis?

Brain Fog After Mild Cases of COVID on the Rise

A new health crisis is emerging as we turn the corner on the COVID-19 pandemic.  Read the latest AIHC Article – Is There a New Crisis? Brain Fog after Mild Cases of COVID and subscribe to our Blog. 


Avoiding the virus is important to present the “long hauler” after effects of COVID-19.  Learn more about COVID-19 Infection Among Health Care Personnel, First Responders & Frontline Workers posted March 29, 2021 by the CDC reporting  “Those who were fully vaccinated were 90% less likely to get infected”.

 


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COVID-19 Pandemic Has Significantly Strained Health Care Delivery

This March 23, 2021 report, published by the Office of Inspector General (OIG), is from the perspective of front-line hospital administrators through a February 2021 survey of 320 hospitals. 


The report provides a glimpse of how the COVID-19 pandemic has affected our hospitals’ capacity to care for their patients, workforce and communities due to extended operations in a “survival mode”.  The COVID strain has exacerbated the many challenges our health care industry already faces, including intensifying existing disparities in access to care and health outcomes.


The survey demonstrates looking beyond the immediate needs in responding to COVID-19 because it has forced hospitals to explore improvements to reduce disparities in access to health care, outcomes, building and maintaining a more robust workforce.  Hospitals realize more now than ever, the need to strengthen resiliency of our health care system to respond to pandemics and other public health emergencies and disasters.  Download a copy of this report.




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COVID-19 Fraud - DOJ Takes Action

As of March 26, 2021, the Department of Justice (DOJ) has publicly charged 474 defendants due to COVID-19 pandemic fraud schemes.  These cases involve attempts to obtain over $569 million from the U.S. government and unsuspecting individuals.  The types of fraud schemes involve:

  • PPP (Paycheck Protection Program) Fraud
  • Economic Injury Disaster Loans (EIDL) Fraud
  • Unemployment Insurance (UI) Fraud

Compliance Officers should review and make sure your organization is in compliance with PPP loan forgiveness and any application made for EIDL assistance.  As with many employers, work closely with Human Resources to report inappropriate Unemployment Claims made by people stating they have worked for your health care organizations.


Also, due to scammers around the world attempting to sell fake and unlawful cures, treatments, and personal protective equipment (PPE), the DOJ has brought dozens of civil and criminal enforcement actions to safeguard Americans’ health and economic security.  Read more from the DOJ.




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Violating Patient Right of Access Case Settlements are Mounting

The Office for Civil Rights (OCR), HIPAA’s enforcement agency announced the 17th and 18th settlements of enforcement actions related to its HIPAA Right of Access Initiative March 24th and March 26th.

  • #17  Arbour Hospital, a Behavioral Health Service (BHS) in Massachusetts, is paying $65,000 and agrees to take corrective actions to include 1 year of monitoring.  Even BHS providers must respond to request for medical records within 30 days of receipt or within 60 days if an extension is applicable.
  • #18  Village Plastic Surgery, a New Jersey provider, is reported as the 18th settlement case and is paying $30,000 due failing to respond timely to a patient’s request for medical records.  In addition to paying the settlement fee, the practice is undertaking a corrective action plan which includes 2 years of monitoring.


"Health care providers have a duty to provide their patients with timely access to their own health records, and OCR will hold providers accountable to this obligation so that patients can exercise their rights and get needed health information to be active participants in their health care," said Acting OCR Director Robinsue Frohboese.


Learn more about HIPAA, Right of Access, Privacy and Security Online or attend the Live Las Vegas Event.



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NEW!

Outpatient Clinical Appeals (COCAS)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

NEW!

Outpatient Clinical Appeals (COCAS)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

Clinical Documentation Improvement (CMDP)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

Clinical Documentation Improvement (CMDP)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

Auditing for Compliance

(CHA)

Online Certification Course


Earn your CHA (Certified Healthcare Auditor) credential online. No classes to attend.  Course materials are on-demand and available to you for 6 months. Experienced compliance officers and coding/billing auditors complete this training in 2-3 months.  If you need more than 6 months you can purchase a course extension for a small fee.  There is additional time after course completion to certify.

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

Auditing for Compliance

(CHA)

Online Certification Course


Earn your CHA (Certified Healthcare Auditor) credential online. No classes to attend.  Course materials are on-demand and available to you for 6 months. Experienced compliance officers and coding/billing auditors complete this training in 2-3 months.  If you need more than 6 months you can purchase a course extension for a small fee.  There is additional time after course completion to certify.

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

HIPAA Compliance Officer (CHCO)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

HIPAA Compliance Officer (CHCO)

Online Certification Course


Online, On-Demand with no scheduled classes to attend during your 3-month access to course materials. Access your course information 24/7, by logging into the AIHC website. A qualified, certified instructor is available upon request to address questions you may have during your training experience 

  • Approved for 18 continuing education units by the American Institute of Healthcare Compliance for certain AIHC Certified Professionals.

Register Today!

Network with other professionals, Earn Continuing Education Units, and become certified online, after camp with a remote proctor (optional).

Corporate Compliance

Training Camp

OCT. 6-7, 2021

Tampa, FL

Medicare Cost Report

Training Camp

OCT. 20-21, 2021

Nashville, TN

HIPAA Compliance

Training Camp

OCT.  26-27, 2021

Las Vegas, NV

Network with other professionals, Earn Continuing Education Units, and become certified online, after camp with a remote proctor (optional).

Corporate Compliance

Training Camp

OCT. 6-7, 2021 Tampa, FL

Medicare Cost Report

Training Camp

OCT. 20-21, 2021 Nashville, TN

HIPAA Compliance

Training Camp

OCT.  26-27, 2021 Las Vegas, NV

Network with other professionals, earn CEUs, and train to become Certified (Optional) Online, after camp!

Corporate Compliance Training Camp

OCT. 6-7, 2021 Tampa, FL


Medicare Cost Report Training Camp

OCT. 20-21, 2021 Nashville, TN


HIPAA Compliance Training Camp

OCT. 26-27, 2021 Las Vegas, NV










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