In a world of multiple audit agencies looking at providers’ claims for the sole purpose of identifying inappropriate payment, not to mention additional scrutiny from Medicare Administrative Contractors (MACs) and other federal agencies under the direction of the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG), it cannot be said enough how important it is for Skilled Nursing providers to audit themselves first. The most effective way to accomplish this is through the Triple Check Process – prior to submitting claims for payment.
The Triple Check Process for Compliance and Audit Preparation
The triple check process allows for an objective review of the claims and all supporting documentation. Prior to submitting claims, the business office or financial lead meets with (at the least) the MDS Coordinator and a representative from the Therapy department (or vendor, as the case may be). Optimally, any discipline involved in resident direct care and resident assessment should be represented in order to review and VALIDATE the information included on the claims.
This review should be routine. It should be well documented – with a checklist and meeting minutes. Outcomes of the review should be tracked. From this information, training needs or other issues can be identified, incorporated into the organization’s QAPI program, and process improvement can be achieved.
The triple check process should not be overly formal, nor onerous in any way. It should simply follow the information on the claim from top to bottom:
Dates of service (statement from and through dates) correct? Do they overlap any other provider episode in any way?
Bill type (initial, continuing or discharge) appropriate?
Resident demographic information confirmed?
Does the name match the beneficiary record?
Medicare number and/or other insurance information verified with the payer?
Admission date/hour – does this match the transfer record?
Patient status – still in house or discharged?
Condition, occurrence and value coding appropriate?
Charge detail has sufficient documentation to support services?
Services certified and ordered by a physician?
All disciplines are telling the same story about the resident in their respective progress notes, treatment and care plans?
Resident payer information is verified?
Diagnostic coding is valid, and inclusive of active conditions and appropriate specificity?
Attending physician information validated with the NPI Registry?
Why Triple Check?
Each area of the claim that is reviewed requires some form of supporting documentation. Dates of service, bill type and patient status are driven from the census record. Resident demographic information, including all health insurance identification, should be verified with the payer.
Admission information is supported by the hospital transfer record, or by the insurance authorization. Charge detail is supported by assessment scores or service vendor invoices. Diagnosis codes are consistent with the patient medical record. In order to support medical necessity, all areas of documentation have to be consistent in telling the story of the resident’s status as well as the individual plan of care and the goals of treatment.
The triple check process allows for those who are directly caring for the resident to ensure that the care provided is well documented and ultimately reimbursed. It further helps to ensure that payment received from governmental agencies or insurance carriers is safe guarded with proof of medical necessity. This process can should be an integral part of provider’s compliance plan.
So, why Triple Check? With all of these agencies looking to recoup monies from providers, the better question is “Why not?”