In addition to the Corporate and Financial Investigation Department?s (CFID)
role in preventing fraudulent practices against IBC, CFID is also tasked with
conducting audits of facility, professional, and ancillary service providers.
CFID?s goal in these audits is to control medical costs and prevent increases
in member premiums by ensuring that all claims submitted to IBC have been coded
and billed correctly and have been paid in accordance with our provider
agreements. The audit staff is comprised of nurses and coding professionals, as
well as experienced claims data analysts, who collaborate with IBC medical
directors and reimbursement specialists to identify and correct questionable
trends and patterns in coding and billing.
Facility provider audits:
Credit balance audits correct overpayments that can adversely affect the
balance sheets of both IBC and its hospital providers. Credit balance audits
are conducted onsite by CFID auditors or HIPAA-compliant vendors selected for
productivity and reliability.
DRG audits focus on the correct coding of documented medical information by
analysis of medical records for inpatient claims. Based on the recommendations
of the Office of the Inspector General and the Centers for Medicare & Medicaid
Services, IBC auditors select a number of high-risk inpatient claims to review
each year for almost every provider of inpatient care.
Outpatient fee schedule audits select claims for review based on either
government edits (e.g., National Correct Coding Initiative [NCCI] edits,
Medically Unlikely Edits [MUEs]) or on those procedure codes that have been
identified as frequently miscoded and incorrectly billed, such as surgical
debridement versus wound care, or cosmetic procedures.
IBC medical policy audits are conducted to ensure that facilities are aware of,
and follow, IBC medical and claim payment policies as they pertain to our
members. Likewise, CFID conducts audits to make sure the rules and guidelines
outlined in the Hospital Manual for Participating Hospitals, Ancillary
Facilities, and Ancillary Providers are applied correctly when billing IBC.
Never Event audits are audits of claims containing code information about
Serious Reportable Adverse Events (also known as ?Never Events?). These audits
fulfill government reporting requirements and ensure that our members are
receiving quality care in a safe medical environment.
Facility audits may change and expand as new issues are identified that affect
patient care. CFID can identify new issues when needed using specially designed
data-mining software.
Professional provider audits:
Inpatient and outpatient evaluation and management (E&M) services audits ensure
that appropriate levels are billed and paid, including consultation codes and
the use of modifiers 24 and 25 with E&M claim submissions.
Office site-of-service audits ensure that services receiving a site-of-service
differential were rendered and billed in the office where the service took
place.
Modifier 25 audits look at E&M codes billed with modifier 25 on the same day as
preventive medicine codes were billed to ensure that the documentation that
supports the E&M service was for a significant and separately identifiable
service from the preventive medicine service.
New patient E&M code audits verify that a patient has not received a new
patient E&M service, within the past three years, from any physician of the
same specialty in the group. If the patient has, a follow-up E&M would need to
be billed.
Electronic health record audits ensure that medical records do not contain
inaccurate information that may indicate that the provider documented more work
than he/she actually did or needed to do.
Single- versus multiple-unit audits ensure that the correct units are billed as
defined for CPT
® codes.
High-dollar medications audits focus on high-dollar medications that are
administered in a physician?s office to ensure the accuracy of claims billed.
Duplicate billing audits ensure that duplicate claims are denied appropriately.
Split billing audits look at claims for the same member, from the same
provider, for the same date of service and visit.
Ancillary provider audits:
High-dollar medications audits review high-dollar medications administered in
the home setting to assure the accuracy of claims billed.
Durable medical equipment audits ensure that claims accurately reflect services
rendered.
Medication compounding audits ensure that necessary and appropriate compounding
and billing are done only when commercially prepared mixtures are unavailable.
Health care fraud is a violation of state and federal law. An easy-to-use
process exists for reporting any suspected fraud, waste, or abuse. If you are
suspicious of any health care-related activity, please visit the
Anti-Fraud page on our website or call
our toll-free Corporate Compliance and Fraud Hotline at
1-866-282-2707. These tips can lead to audits, fraud
investigations, or both, that may result in monetary recoveries that help keep
health care costs down.