It seems as though changes in our industry are coming fast and furious now. The implementation of the Affordable Care Act (ACA) has resulted in an increased scrutiny of our processes. With a larger focus on audits and overpayments, we are facing a future with a much different payment landscape – including bundled payment programs based on clinical outcomes.

The onus is on skilled nursing providers and others in the LTPAC sector to substantiate clinical outcomes through data analytics. Examples would include hospital readmission rates and other quality measures. LTPAC providers need to prove their worthiness of inclusion into preferred partnerships such as ACOs or bundled payment programs. Only the strong will survive. To do so in this new environment, providers need to look to their systems and processes from a fundamental perspective. It’s time to go back to basics.

Federal Audit Programs

Federal audit programs such as RA, ZPIC, etc. are all looking at algorithm based analytics to determine if providers were improperly paid. Of course, the majority of findings indicate that billions of dollars were overpaid, not underpaid. The reasons for overpayment relate directly to processes at the provider level. These include documentation of medical necessity and in support of continued need for care. In addition, the care provided should be documented according to the established guidelines that portray the story of the resident’s care, progress and outcomes. Documentation should be consistent between nursing, therapy and essentially all disciplines. We have to ask ourselves “How confident are we in our documentation?” Are we relying too much on hospital transfer information in order to properly assign diagnoses? Do we completely review our claims prior to submission to payers to check for billing errors? Are we completing a Triple Check? The Triple Check process, when done correctly, requires us to validate everything from simple demographics to more complex clinical assessment information such as the reason for the Minimum Data Set (MDS) assessment. Does nursing documentation support the need for therapy services?

Documentation for an Audit

Providers must prove, through documentation alone, not just the need for skilled services but that the care provided has improved the patient’s overall well-being and physical function, from start of care through discharge. Additionally, providers are required to gather information to support billing of services, and to prove due diligence in regards to determining payment sources and beneficiary eligibility. Providers have to ensure that physicians have not just ordered the skilled services but that they have certified and recertified the need for services within set time frames. Without this basic documentation, providers face delayed cash flow and increased labor to substantiate services, nonpayment or recoupment from negative post payment audit findings.

The Centers for Medicare and Medicaid Services (CMS) have been gathering and publishing results of the various federal audit programs mandated to determine if improper payments may have been made to providers, which points to deficiencies on the part of providers to meet documentation requirements. Putting an emphasis on a “Back to Basics” approach is the first step to aligning processes. Providers need to ask themselves, if we cannot properly demonstrate the requisite compliance to prove our services worthy of payment, how will we prove ourselves to be a desirable partner to other acute and post-acute care providers in this new world?

For more tips on preparing your processes for an audit, Contact Richter Healthcare Consultants at 866.806.0799.