Deliver Results Effectively - How to educate providers
By: Sean M. Weiss, V.P. and Chief Compliance Officer "Doctor, your documentation does not support the level of service you billed
to the insurance company..." These are the dreaded words every auditor delivers
and the words every provider despises hearing. But, what if we as an auditor
are wrong; what if the level is supported based on complexity, but as non-clinicians,
we were not able to make the correct assessment? Auditing should be looked at two (2) ways: as a qualification and quantification
process. According to Merriam-Webster, qualification is "a special skill or
type of experience or knowledge that makes someone suitable to do a particular
job or activity." In the world of auditing, we have special skills that make
us qualified to review medical documentation and determine whether the level
of service billed is correct, but correct based on a quantification process.
Again, according to Merriam-Webster, quantification is "to find or calculate
the quantity or amount of (something)." Hold your thoughts and I will explain
where I am going with this. For 20 years now, I have been known throughout the industry as a compliance
expert and someone who focuses solely on writing policy and procedures or representing
clients in appeals (ALJ, MAC, or Federal Court). However, I have been serving
as the Director of Coding for one of the Nation's largest health systems since
2013 with more than 105 coders/auditors, 2,000 providers, and a very demanding
Board of Directors. Just like many of you reading this article, I grew up in
this industry as a coder (first certification in 1997), so when I write about
these types of issues, I am speaking from personal experience. In my weekly travels (which by the way on June 30th 2014, for the third year
straight I will hit Diamond Medallion Status at the half way point of the year
on Delta), I hear providers talk about how the last audit they had was a colossal
failure because the auditor/coder tried to tell a clinician what defined low,
moderate, or high Medical Decision Making (MDM). As an auditor/coder, we possess
a very specific set of skills, but unless you have RN, LPN, PA, NP, MD, DO,
etc., your skills end at arguing with a provider about what truly defines a
level of decision making, unless of course, you are talking about it from a
pure "bean-counting" perspective. The 1995 and 1997 Documentation Guidelines are just that: guidelines. They
are an attempt to quantify various levels of complexity by assigning point values.
They are not absolutes and they should be approached with the utmost caution
by anyone attempting to audit or code select on behalf of a provider. What drives
many auditors/coders to select a level of service that differs from a provider
is that providers go through a complex process of arriving at a plan of care.
They have to take into account differential diagnosis, chronic systemic illnesses,
prescriptions, family history, and a whole host of other items to arrive at
a course of care for a patient. Nothing drives a provider crazier than when an auditor/coder tells them that
because there was no Rx written or they did not order test(s), the level of
service is not supported. Believe it or not, it takes more effort and thought
process to do nothing than it does to put pen to paper and give the patient
something they may or may not benefit from. Yes, in the black and white world
that auditors/coders love to live in, you have to satisfy 2 out of 3 in the
MDM to reach a specific level of complexity. However, I am here to tell you
that there is no black and white, just various shades of grey. I spend close
to 150 days per year working various types of appeals or arguing demand for
refund requests on behalf of providers and health systems and I assure you that
when you present before an ALJ and now even at the QIC, the guidelines go right
out the window and clinical judgment stands front and center. For some reason, auditors/coders take an argumentative and even adversarial
position when having to confront providers about their most recent audit. So, what I am presenting here is a guide to those tasked with the often
difficult role of providing feedback to providers: I hope this mini guide serves to help you in your quest to be the best auditor/educator
you can be. Sean M. Weiss is the Vice President and Chief Compliance Officer for DoctorsManagement,
LLC a full-scale medical consulting, health law, and data analytics firm based
in Knoxville, Tennessee. Sean holds multiple certifications in auditing, coding,
compliance, and practice management. To learn more about Sean or DoctorsManagement
visit their website at www.doctors-management.com
or at sweiss@drsmgmt.com