The expansion of outpatient services continues to be a high priority for hospitals across the country.  What continues to drive this transition?  Value-based reimbursement models and patient demand. The proof is in the numbers – in 2013 there was an average of 2,145 outpatient visits per 1,000 people up from an average of 2,105.6 days in 2011[1].  With increasing volumes and the continued shift to providing care in the outpatient setting, how can a hospital obtain transparency into its areas of outpatient risk/opportunity?

#1 ASSESS – Data.  The government and commercial payers look to data and so should every hospital.  Where do you start? Begin to slice your data into different views allowing you to compare outcomes both internally and externally.  For example, select a specialty and manipulate the claims data to view high volume/high revenue services and services on the radar of government auditors/payors.  Overlay this data to your high volume/revenue physicians within that specialty.  Next, within that specialty, compare physicians and their billing practices and look for outliers.  Finally, take this data and compare to regional/national data collected by the Centers for Medicare & Medicaid Services to benchmark against peers.

#2 AUDIT – Using the Assessment from #1 above, develop an Audit Plan that includes probe audits of identified areas of risk (e.g., physician outlier billing practices, risk areas on OIG Work Plan such as observation, HBO, therapy services).  Each audit should focus on both code selection and documentation practices.

#3 REMEDIATE – Remediation activities should occur post-audit as well as on a regular basis to ensure each practice is up-to-date with changing industry standards, government regulations and payer contract requirements.  Remediation efforts should include:

  • Updates to electronic or paper forms
  • Review of all hard-coded charges and system algorithms
  • Training on both coding and documentation practices
  • Updates to policies and procedures

For more information on Provident’s Outpatient Audit and Education services, please contact contact@providentedge.com.

[1] http://www.beckershospitalreview.com/lists/50-things-to-know-about-the-hospital-industry-2016.html

Recent Insights

Newsletter Sign-Up