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Revenue Cycle Assessments
Fee Schedule Analysis
Our analysis of the Fee Schedule(s) currently in use by the practice includes the applicability of billing codes (CPT, HCPCS,IDD-10) and the fee specified for each procedure. Recommendations are provided to support both billing compliance and effective revenue capture.
We review a targeted sampling of processed claims submitted for a range of the services provided by Providers of the medical practice. We evaluate the use of Procedure Codes (CPT and HCPCS) as stand-alone services as well as when they are included as part of a bundled service. We evaluate the accuracy of each Diagnostic Code (ICD-10) as well as the applicability of Laterality and Specificity of these codes.
We Review Remittance Advice data associated with the selected claims to determine how the payer adjudicated the claim.
We review revenue reporting records for timeliness of claim submission, processing time by the payer, appropriateness of payment classification allocation by the practice, and we verify claims are properly closed.
Accounts Receivable Assessment:
We review a 3 month Detailed A/R report to verify that all appropriate revenues have been captured or that corrective action has been initiated to resolve open issues. We evaluate the practice A/R management process for best practices and compare the overall performance to like type/size practices.
Whether you simply wish to determine if your practice and its providers are compliant with professional standards, or you wish to have a second opinion of an audit performed by Medicare or another healthcare plan, our audit will be helpful.
Based on your practice size and medical specialty(s) we determine the appropriate size and scope of a statistically supportable audit.
We typically conduct our audits either on-site or via remote access to your Electronic Medical Record System (EHR). If neither of these options is available we also accept mailed copies of all pertinent records to be reviewed.
We require access to all of the following records so that an accurate and complete assessment of each providers compliance performance. We frequently work closely with your practice attorney to help ensure privacy of all information.
All chart notes for the specified patient and date of service
All orders requested (labs, radiology, etc.)
any previous records in the patients chart that was referenced as a source of information in the current chart
all diagnostic and procedure coding specified for the services provided (even if the coding is recorded by another person)
the claim that was submitted for payment for the specified date of service
the Remittance Advice confirming payment or non-payment for the specified date of service
If the requested audit is to evaluate an audit previously performed by Medicare or another healthcare plan, in addition to these listed items, we also require:
Copies of all correspondence received from the auditing entity including original request for records, audit details reports and audit summary reports.
Medicare Policies & Procedures
Medicare policies impact medical practices because they are frequently followed by most other healthcare plans. This is true even when a provider chooses to "opt out" of Medicare because federal regulations provide limitations on the services a "opted out" provider may offer to a Medicare Beneficiary.
Frequently medical practices are confronted by one or more of the following issues regulated by Medicare. The Sage Associates has many years of experience in addressing and resolving issues related to each of these items.
Opting Out of Medicare
Using a Physician Assistant or Nurse Practitioner in the Practice
Using a Medical Resident in the Practice
Requirements of the Teaching Physician Guidelines
Using a Locum Tenens in the Practice
Incident to requirements
Forming a FQHC
Medicare Provider Enrollment and Revalidation
HIPAA Privacy and Security
Medicare or other Healthcare Plan billing audits
Medicare Incentive Plans (MIPS)
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