Users Group Portal > IMA Quarterly > Q3 2009 page 3

The IMA Quarterly: Q3 2009 page 3

THE FISCAL CORNER

Are You Ready for the Auditors?

2009 is definitely a year for audits, and it is likely audits will continue with vigor in the future. Here are some tips to help you be ready at any time for the audit process.

Read the NY State OMIG Work Plan

A good place to start is reading this. Although the points raised in the work plan and in this article relate to the NYS OMIG, they are also valid and applicable to other audits such as the federal OMIG, the NY State comptroller, the counties and private insurance companies. http://www.omig.state.ny.us/data/images/stories/work_plan/omig_work_plan_2009_2010.pdf. Scanning through this 70-page document you will learn specifically what the auditors will be looking for, and you will also learn that their goal is to recover $322 million in 2009. The goal of this article is to make sure as little of this as possible will come from IMA customers.

A couple of practical observations

Looking back at IMA's experience in working with customers through many of their audits, the following recurring themes emerge:

• Everything covered in the above 70-page document is important, but the biggest yield to the auditors comes from about half a dozen items.
• Missing documentation issues account for the bulk of all charge-backs. IMA system controls are available to monitor all of these. However, they are effective only when the checkpoints are placed prior to the issuance of the bill. If billing is done first and docs are followed up to be completed later, effectiveness drops precipitously.

The critical half dozen:

1. Basic Documentation – The most basic requirement is documentation for each bill. The OMIG work plan states “The Medicaid program requires participating providers to maintain adequate records to support their billings to the program.” To our knowledge, OMIG auditors have accepted the IMA “Detail of Billing Transaction” display and printout as “adequate records”. When you are using the IMA Progress Notes function, every billing transaction is automatically cross-referenced to the corresponding clinical note. In most cases, the IMA system is configured so that bills are generated only after a progress note is written, thus guaranteeing there is a progress note for each bill.
2. Appropriate Progress Notes – Signed progress notes with appropriate content to back up each bill are a focus of OMIG audits. You can create templates and/or use the Wiley documentation datasets to help service providers write appropriate progress notes, including clear statements of medical necessity. If your IMA system is set for the progress notes to generate the bills and also to require a signed progress note before billing, you’re off to a good start.
3. Treatment plan Coverage – OMIG auditors look for a treatment plan, signed with a credentialed signature, which is in force for each service billed. The IMA Treatment Plan module alerts you to create and sign plans in a timely manner. Optionally, it will also hold back billing for any service provided on a date with no valid plan on file. The system may be configured to send reminders and warnings to the responsible staff and their supervisors when plans are due and when billing is being held back due to missing plans. All this is available even when the full online EMR system is not used, except that only the reminders are issued; you’re on your own to assure that the actual paperwork is created and signed appropriately.