Preparing for Coding Audits: Protecting Physician Revenue

Nancy, welcome to the podcast. 

Nancy Clark: 

Thank you so much for having me, Tony. I am looking forward to today. 

Tony Davis: 

Yeah, excellent. Well, I'm thrilled for the audience's sake to get a chance to hear from Nancy about her background and the work that she's been doing here at EisnerAmper, and a very specific skillset that is very much needed within the healthcare space. And so with that, we'll get into our discussion today. 

So Nancy, just a little bit of background. Tell us a little about yourself and how you come to be here today with us. 

Nancy Clark: 

Certainly. Thank you. So the skillset you refer to, I am a certified professional coder with multiple specialties, and I have worked with the healthcare team at Eisner for over 10 years now. I currently lead the coding and documentation services, perform coding and documentation reviews, education for physicians and staff, and contribute to revenue cycle assessments, perform implementation of best processes, interim management, utilize the experience to support physician groups and hospitals to maintain their optimal revenue as well as processes. 

So I was in finance and accounting before I began this and I enjoyed it, but I was always interested in medicine and just didn't want to have hands-on. So this is a way that I could dig in depth to anatomy and physiology and help physicians without actually being... 

Tony Davis: 

Yeah. Yeah, no, I think a lot of us that end up in the healthcare space sort of have that inclination around wanting to be part of that medical system, but finding your home there or finding your path to that is always fascinating to me how we all end up where we end up. And I think one of the things I appreciate a lot about what you do is you are very much a teacher, we'll get into that a little bit later in the episode. But more so in some of the things that you do around the country with respect to speaking and writing. 

Talk a little bit about what you do when you're out and about speaking to audiences and who do you typically speak to? 

Nancy Clark: 

Absolutely. So I just got back last week from presenting to the HFMA, and I also speak with my home organization, the American Academy of Professional Coders, MGMA. Because it is a specialty skillset, I feel obligated to share the knowledge I have and at the same time learn from others with the interaction. It helps me to understand what's going on that we need to address. I also author articles. I'm in several publications, healthcare, coding, billing. I've been very honored and privileged to be requested to do many of these national presentations. And as a result, I've met the most wonderful people and had excellent experiences. 

Tony Davis: 

I want to lay on that a little bit because when I think about folks that are listening to this podcast today that are healthcare professionals themselves, running a practice, running a department at a hospital or a health system or a physician leader, obviously the coding component of what we do in the healthcare delivery is such a fundamental aspect, without it goes nowhere. And so it's full of regulatory components, it changes constantly. I always think of that sort of struggle around the risks that come with not doing it very well, to say it simply. 

So when you think about the type of work you're doing, which you nicely covered a long list there a moment ago, how would you start a process of working with somebody, with an healthcare organization? What's typically the first thing you might do and the Eisner team might do coming into a healthcare organization with respect to the coding aspect of it or the broader revenue cycle pieces? 

Nancy Clark: 

So on a broad interaction, we'd listen. No healthcare organization is like their neighbor. And one thing I believe we as a team do acutely well is listen to the provider's concerns, practice manager. We often go in and interview staff members. We don't want to just hear from the top managers, we want to hear from the people processing, doing the everyday work. Sometimes there are things we can pick up on because all of us have been in the field before. You, yourself know that, we understand the difficulties and sometimes it's easy fixes. Sometimes it is a little bit more intensive. But having done so many over the years and my colleagues having such excellent skills as well, we complement each other very well. 

Tony Davis: 

Yeah. That sort of broad approach in the beginning, would you say it sort of allows you and the team to provide some feedback to the organization relatively quickly to say, look, we've taken a broad brush of this, here's some areas that we think there might be some additional need to sort of dig a little deeper. Is that sort of typically how it goes? 

Nancy Clark: 

Yes. Yes. So each one of us will hone in on our specialties. What I typically ask for is a billing productivity report, be it CPT, HCPCS, DRGs, whatever, depending on the payment methodology that the practice or facility is using. If we take the example physicians, CPT productivity, I can very quickly tell, A, are they benchmarking aligned with their geography and their specialty? What are they billing that has a recent change in coding guidelines or state or area specific regulation guidelines? And I can target based on other clients and spending hours every day understanding these regulations where they're most at risk. 

Tony Davis: 

Along that same line, are these projects typically... I'm thinking about it from, again, if I'm sitting in the C-suite role or a physician leader role, and I'm like, okay, there seems to be a lot in that. Is there an opportunity to do that on an ongoing basis versus sort of a one-off project? Do both? How does that generally work? 

Nancy Clark: 

So, I do. So usually I'm initially brought into a client, it could be due to a group revenue assessment where we always provide a very small high level coding review and they see the value. They may see the value in understanding or working towards the OIG compliance requirements and mitigating risk. But I have several clients now that retain me on an annual basis for as needed services and to perform their objective external coding reviews and know that there is no bias, that the review is being done by someone internally. And the luxury that I have is I spend my days keeping current. When you're an internal coder, you are wearing different hats and your goal is to get those claims out, get them coded, get them billed, whatever your responsibilities are. It's pretty difficult, as you mentioned, the OIG, federal government, state government, CPT annual updates, HCPCPS quarterly updates, it can very well overwhelm the most cognizant, knowledgeable professional coding individual. 

Tony Davis: 

Yeah. That's I think, having sat in that seat a bit, the thing that keeps you up at night a little bit is what don't we know or what are we missing? And even the best, well-run coding department cannot catch at all. So how do you factor that into your assessment work that you do with respect to risk? Let's touch on that a bit. Is there a tolerance within this space from a payer's perspective or from a government regulatory perspective? I can't expect that perfection is the standard. How do you work through that a little bit? 

Nancy Clark: 

I don't know that it's perfection, but insurance carriers have to report to their stakeholders. They have to spend their money appropriately. So take Medicare for example. They have to report to the federal government, the GAO, the OIG has oversight. When we go through the claims adjudication process, when we're contracted with an insurance payer, we submit a claim. Unless it hits very minimal front-end edits, they will pay that claim. But there's no guarantee that the documentation in the medical records supports these very detailed requirements of the codes, well in excess of a code descriptor, CPT assistant, AHA clinic, ICD-10 clinic. 

So it's very normal to have audits. And audits will occur a few at a time, they may increase once a pattern is established, so a pattern of non-compliance in an area, that's when a payer says, "Whoa, we've audited you three months, four months, and you're doing the same thing." So at times they can allege the intent for non-compliance and extrapolate previously paid revenue in excess of contractual limits and statutory limits. And that just kind of blindsides a lot of practices who think that they're doing well. 

The improper payment, so when money is retracted like that, when Medicare identifies it, it's referred to as an improper payment. Last year alone, over a billion dollars was identified in Medicare and Medicaid alone, about 7 to 11%. And if you consider the very narrow operating margins that practices and hospitals especially are functioning on, can you afford to lose 7 to 11% plus pay your staff to dig out these records, which may even go into paper files? 

Tony Davis: 

Yeah. And I think those are the questions that are very valued in the work that you guys do in educating the staff as well as the management team and the physician leadership on where their areas of exposure could be. And working through, again, as you say, sort of the myriad of opportunities to get it wrong even with the best intentions. I want to touch on a couple of things, Nancy, just while we have a few more minutes left. One is, as far as today's modern coding processes, a lot of it's done through the EMR systems, the electronic medical records systems, automatically. I'll use that word automatically, I know there's templates built. I'm assuming that you worked with all the various kinds of EMRs, there's no sort of limitation on that, but maybe speak on that for a moment. 

Nancy Clark: 

Yeah, so that's a double-edged sword, Tony. Several years back, I guess it's more than a decade, providers were given a bonus if they migrated to EHRs. Not all of the EHRs actually had a certified coder's input. And a lot of the errors that we see in documentation is actually, if not caused by the EHR, just increased. For example, diagnosis codes are selected by the beginning, not the end, and providers get dinged for unspecified codes. Guideline changes that aren't clear, that really can't be supported with templates. I'm not a fan of templates. I prefer prompts. I'm an advocate for physician education. Physicians are very intelligent. Mid-level providers, nurse practitioners, physician assistants, in all their years of schooling, they have very little, if any, education on how to document to support codes. And they get out of school sometimes hundreds of thousands of dollars in debt, by the way, your livelihood depends on your ability to follow these guidelines. Sorry, if you've just spent seven or more years learning how to document clinically, now you have to do it the way we want. 

So what I try to do is communicate clinically. We take the provider's medical record documentation, redact it, no PHI, and illustrate how these sometimes ambiguous concepts can be applied. So the provider doesn't need a template, they need to know what is occurring in their medical decision making usually in their brain that they have to do very quickly that should make it to paper. Once that's clear to them, it's like a sigh of relief. I see their shoulders are starting to drop. 

Tony Davis: 

Exactly. That's a wonderful picture and a wonderful illustration of, I think, the way you approach these projects. And I always want to finish on that note. You've spent a bit of time today talking about how you like to leave the educate and then monitor going forwards and continue to educate. It's very much part of your makeup. The question is sort of why EisnerAmper? Why would someone engage our team, your team, particularly in the coding space versus other vendors that are out there that work in this environment? Maybe I think you've touched on a few of those elements, but maybe broaden on that a little bit. 

Nancy Clark: 

What a great question. You wouldn't think EisnerAmper for coding, would you? But other coding organizations, many of them are wonderfully done and wonderfully run. Most of the roles are to review the documentation and come back with is the code supported or not? And there's not a next step to that. The ones that provide education and they do so well, usually can, it's not customized because it's more effort. And I find that providers don't retain that type of grid work, matrix learning. Provider's retention and communication is better, and I'm not looking to code 100 charts for the heck of it. I'm looking to find revenue opportunities for the client. I'm looking to find some way to work with that client's thought process to make it to paper. 

I've sat in the shoes of the coder in many specialty offices, so I also have that empathy for the multiple demands of sometimes different systems, disparate bolt-on systems. We have excellent feedback and we have specialists in every area that work together, we can bring the revenue and we can mitigate the risk. While it's not my favorite part of the job, I do serve as support for litigation when clients haven't come to us proactively and there's not a doctor or practice manager that says, "You know what? That amount of money for the coding review really doesn't seem so much. I wish I had done it if for no reason than to get the insight." 

Tony Davis: 

Yeah. Yeah. That's I think a wonderful place to stop. I think as listeners out there would be recognizing, I think, and nodding their heads on the fact that to get ahead of the game somewhat don't wait for that letter, that email, that whatever, that visit, knock on the door, let's get ahead of it. It's very manageable when done well, and I think you've shown that over your many years of work and expertise. I look forward to continuing our conversation in our future podcast as we can maybe dig a little deeper into some of these issues. 

So Nancy, I really thank you for your time today. It's been much appreciated, very valued. Thank you. 

Nancy Clark: 

Tony, thank you so much for the opportunity and thank you for talking to what I call myself a coding geek. I love what I do, and this has probably been the best 20 minutes of my day so far. Thank you. And thank you to the listeners for taking the time. 

Tony Davis: 

Well, that was Nancy Clark, a wonderful summary and a broad understanding for everyone listening about how we go about the coding audits and the rev cycle work that we do here at EisnerAmper, and look forward to having Nancy on future episodes. 

So with that, I'd like to thank everyone for listening and we'll catch you next time.