EALTH CARE AGENCY EDICAL ILLING PROCESS For the ......LTS tive #1: O ate to ensu mendations tive #2:...

American Institute of Certified Public Accountants Award to Dr. Peter Hughes as 2010 Outstanding CPA of the Year for Local Government

GRC (Government, Risk & Compliance) Group 2010 Award to IAD as MVP in Risk Management

2009 Association of Certified Fraud Examiners’ Hubbard Award to Dr. Peter Hughes for the Most Outstanding Article of the Year – Ethics Pays

2008 Association of Local Government Auditors’ Bronze Website Award

2005 Institute of Internal Auditors’ Award for Recognition of

Commitment to Professional Excellence, Quality, and Outreach

RISK BASED AUDITING GAO & IIA Peer Review Compliant – 2001, 2004, 2007, 2010

Inte

rnal

Aud

it D

epar

tmen

t INTERNAL CONTROL AUDIT:

HEALTH CARE AGENCY MEDICAL BILLING PROCESS

For the Period March 1, 2010 through June 30, 2011

AUDIT NO: 1018

REPORT DATE: DECEMBER 13, 2012

Director: Dr. Peter Hughes, MBA, CPA, CIA Deputy Director: Eli Littner, CPA, CIA

Senior Audit Manager: Michael Goodwin, CPA, CIA Senior IT Audit Manager: Autumn McKinney, CPA, CIA, CISA

Audit Manager: Winnie Keung, CPA, CIA IT Audit Manager: Wilson Crider, CPA, CISA

Our audit found that internal controls over the Medical Billing Process are adequate to ensure the billings are allowable, valid, and adequately supported. Key controls such as pre-billing and post-payment reviews are in place to help detect incomplete or improper billings. Our audit also found IT application controls over the medical billing process are adequate in the areas of: (1) user access (password and account management), (2) segregation of duties, (3) system edit checks, (4) system enforced holds/queues, and (5) transactional audit trails. Additionally, IT general controls as related to the medical billing systems (IRIS and Practice Expert) are adequate in the areas of: (1) change management, and (2) backup and recovery. The medical billing process is complex and involves an extensive coordination of efforts between clinics, medical billing, quality assurance, and system personnel. We commend HCA on their established controls and process. During FY 10/11, HCA’s annual medical billings totaled $73 million for services provided under HCA’s Behavioral Health, Public Health, and Medical and Institutional Health Services Programs. We identified four (4) Control Findings where HCA should continue efforts to complete business continuity planning documents; consider reducing the extent of its pre-billing and post-payment reviews; and evaluate generating management reports from the IRIS system for monitoring the effectiveness of the medical billing process.

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Page 1

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Medical Billing ProAudit No. 1018

OC Int

Objective #5Control FindBehavioral Hsystem to gen

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s. 16-18)

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te post paymprocess ovefor Family Pm with consiifying the fre

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te the ability ate IRIS manas to help monte the process for behaviomedical serv

ed and billed

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e identified post-billing resider utilizing

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Management?

Yes

Yes

Yes

Yes

Page 2

three (3) eviews of

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BACKGROU(See Detailed

HCA’s Missioand our diverplanning & pfollowing four

1. Behaviordrug abusfor the yeservices month’s bincluding BHS claim

2. Public Hdevelops HCA’s bidifferencethrough M

3. Medical services tFY 10-11differencebilled thro

4. FinanciaAccountis the Meprovided

Medical BilliThe MBU profor reimburseCounty-operaMBU does nhe service ar

County-OClinics

ContractContract

BHS ContracHCA contracproviders arehe County’s

same electrobut does not o their cont

provide BHS udit: Health Care Aocess

ternal A

UND SUMMAd Backgrou

on Statemenrse communipolicy develor service area

ral Health Sese treatmentear. This amreceived. If billings. DurState Realig

ms are billed

Health Servipreventive

illings totalees exist betwMedi-Cal.

and Institutto persons fo1, HCA’s bes exist betwough Cal-Opt

l and Adming Servicesedical Billinin County-op

ng Unit ovides speciement for serated clinics, not prepare reas provide

Operated

t Entities/ t Providers

ct Providerscts with vende responsibleIRIS systemnic file as thepass throughract agreemservices on

Agency

Auditor

ARY nd of Medic

nt: Dedicatedities through opment, prevas:

ervices (BHt to eligible remount include

self-pay invring FY 10-1gnment Fund through Med

ces (PHS) strategies to

ed $1,849,11ween amount

tional Healtor whom the illings totalween amountima. We did

ministrative s, an Auditorng Unit (MBperated clinic

alized medicrvices providHCA also usor process d through HC

For Mentaand for CoAlcohol & DServices For Mentaand AlcohoServices

s dors (contrace for entering

m. The contrae County’s clh payments t

ment. There behalf of HC

r’s Rep

cal Billing Pr

d to protectinpartnerships

vention & ed

S) provides cesidents. Dues “self-pay” oices are no

11, HCA recds, are receivdi-Cal.

monitors theo maintain a14 for the yets billed and

th ServicesCounty, by lled $111,81nts billed andd not include

Services pr-Controller SBU), which pcs.

cal billing sered to its clienses contractany claims CA/County-o

BHSl Health Servic

ourt-ordered Drug Abuse

l Health Servicol & Drug Abus

ct providers)g their medicact providerslaims. The Cto them. Inst

are 33 CoCA. We did n

ort

rocess in At

ng and promos, communityducation, an

countywide muring FY 10-billings to cli

ot paid in fulleived paymved in arrear

e incidence and improve ear and recepayments re

(MIHS) provaw, has resp6 and reced payments MIHS in our

provides inteSatellite Accoprovides spe

rvices and snts in Countytors to providfor contractperated clini

ces County eservices and OranHome

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None

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not include co

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oting the optiy leadership, d quality se

mental health-11, HCA’s Bients who hal, the invoice

ments totalinrs, so timing

of disease athe health o

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ernal suppoounting Unit.ecialized med

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imal health oassessmentrvices. HCA

h care servicBHS billingsave a financiaes are includng $41,458,1

differences e

and injury inof the publicents totaling

e majority of P

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es and/or alcs totaled $71al obligation ted in the su34. These pexist. The m

n the commuc. During Fg $1,852,665PHS claims

and essentiauch servicesng $59,719. y of MIHS cllume of billin

and includA Accounting services for

ng billings anBHS, in additmportant to he table belos:

PHS ublic Health es

ces. TheseMedi-Cal) dirate for paymract providers in arrears a

ntract providcope of this a

Page 3

, families, ity needs, ed of the

cohol and 1,026,950 to pay for bsequent

payments, majority of

unity and FY 10-11, 5. Timing are billed

l medical . During Timing

laims are ngs.

des HCA Services services

nd claims ion to the note that

ow shows

e contract rectly into ent in the

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As such, HCservices are regulations; acompliance is

Correctin Deducting Refundin Paying an Submittin

Medical BilliHCA utilizes

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Overview of The medical services provbilling procesDetailed Bacprocesses for

1. FinanciaRegistratperforms (Medicareclient’s fiproducedfinancial i Encounteknown asservices/t Data Entrdata valid

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CA has onlyprovided; ve

and providingssues by the

g and resubmg void claimsg any amounny recoupmeng Medicare o

ng Informatthree key sys

tem: For BHare, Medi-Caclient regist

nce and mane production the billing m

Expert Sysphic informat

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Medical Bilbilling proc

vided and susses and sysckground in r BHS and P

l Evaluationion/Intake: Pa financial

e, Medi-Cal, nancial resp

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ers: Each tims an encounttreatments a

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Agency

Auditor

y administraterifying propg training. Ncontract pro

mitting any ds from future nts identified ent and/or peor third party

tion Systemsstems/softwa

HS, HCA useal and other ttration and snagement of and exchangodule of IRIS

stem: For Ption, reportin

HCA utilizes g billings andta validations

ling Processcess starts wubmitting elestems for BeAttachmentHS:

n and Clinic Prior to provevaluation tCalOptima, e

ponsibility. Aystem for thes entered int

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iews are pers follows:

r’s Rep

tive responsper documenNeither the Coviders. The

denied claimsclaims (systduring a pos

enalties resulty claims direc

s are to suppor

es the Integrathird parties, scheduling, m

billing activige of health S.

HS and MIHg, and proce

EDIfecs softd claims to ths.

s with the regiectronic billinhavioral Heat C. Below

Visits iding clinic sto determineetc.) and comAn UMDAP e client to sigo the applica

t visits a clinress Note anrt the medica

ed into the an is being ent

rformed to en

ort

sibility over tation is maounty nor HCcontract prov

s that are ideem automatist payment/bting from a S

ctly (not part

rt the medica

ated Recordsand reportin

management ties in compcare informa

HS, HCA useessing billings

tware to perfhe State and

istration/intakng documentalth and Pub

is an overv

services, the e eligibility fompletes the e(Uniform Me

gn up for BHable system (

nic where a nd Encounteal billing.

pplicable systered for BHS

nsure claims

the contractintained; ensCA have anyviders are re

ntified by HCcally withholdilling audit

State claim auof County pr

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s Informationng to the Sta

and reportinliance with Sation with ext

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s are accurat

tor operatedsuring compy financial obesponsible fo

CA ds)

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Page 4

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OC Int

All BHaccurstatusHolds

PHS

Revieare p“Hold

3. SubmissClaims foedits to vare batchfile is whMedi-Calfile/claim created fo Acce

Medic

Rejecreturn

4. AdjudicaOnce BHreview) is Appr

Denie

Medi-rebillihealth

Adjudicat

5. PaymentHCA rece

6. Post-BillOnsite poif the claim BHS:

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ternal A

HS Medicareracy prior to sses, which ins). Upon pas

claims, excews at #6 berocessed in s.” The pre-

sion of Billinor BHS servicvalidate the ched into an eat is sent to ’s local editswill either b

or third party

epted Claimscare.

cted Claimsns the entire

ation of ClaimS claims are

s downloaded

roved Claims

ed Claims. -Cal claim wng. The dehcare plans a

ted claims fo

t to HCA eives paymen

ing Reviewsost-billing revm needs to b

All BHS Mren and YouMental Heal

In generalrmed. MBUtment (FPAC

Agency

Auditor

e and Medi-Csubmission. ndicates a sssing the pre

cluding Familow) are selePractice Exp

-billing review

ngs to Claimces are geneclaim. Claimelectronic 837

the State ors by the EDIbe accepted

y healthcare p

s. File passe

s. A rejected837 file/claim

ms – Approve adjudicatedd into the IRI

s. Approved

A denied stawill be automenied claim care processe

r PHS and M

nt for all claim

s views are perbe credited o

Medicare paiuth Services lth Service pa

, PHS claimU does condCT) Program o

r’s Rep

Cal claims go These claim

specific reviee-billing revie

ly Planning ected to go thpert. Practicw occurs prio

ms Processoerated by the

ms are gener7 file on a wer to MedicareIfecs softwar or rejectedplans and ma

es the edit ch

d status is nom to HCA, wh

val or Deniad, an 835 batS/ProFit mod

d claim paym

atus is a finalatically placecan be appeed manually.

MIHS are dow

ms submitted

rformed to idr refunded.

id claims hago through

aid claims do

ms have preuct post-payon a sample

ort

o through a pms are electro

w is neededew, the electr

Access Carhrough pre-be Expert doe

or to entering

r e applicable srated as eleceekly basis fe by HCA, are prior to bed by the EDailed to the in

hecks and wi

ot a final adjhere it will be

al tch file (the 8dule and incl

ents are pos

l adjudicationed in the Teealed by sub

wnloaded and

d, including c

dentify inaccu

ave a post-ba post-billin

o not go thro

e-billing revieyment reviewbasis as it d

pre-billing revonically routed (e.g., Coderonic hold is r

re and Treabilling reviewses not have athe billing in

system afterctronic claimsfor BHS or oand is validateing transmitIfecs softwansurance car

ll be adjudica

judication fore researched

835 file is creludes the foll

sted into the c

n for a specifchnical Deni

bmitting a co

d recorded in

contractor-op

urate or inco

illing review.g review on ugh a post-b

ews; therefows on the Fadoes not go th

view to ensued in IRIS. IRer Holds, Qreleased by t

atment Progrs on a sampany system e

nformation int

r going througs. Medicare n a daily basted against Htted to the c

are. Paper Crrier.

ated (accept

r a claim. T for correctio

eated after thowing:

correspondin

fic claim. Thial work queorrected claim

nto Practice E

perated clinic

mplete paid

. Paid BHSa sample b

billing review.

ore, post bilamily Plannihrough a pre

ure completeRIS has vario

QIPC Holds athe reviewer.

ram (see Pople basis. PHenforced or eto Practice E

gh a series oand Medi-C

sis for PHS.HIPAA standclaim processCMS-1500 cl

ed) by the St

he State or on and resub

e State or M

ng IRIS accou

he denied Meue for correcm. Denials

Expert.

s.

claims and d

S Medi-Cal cbasis. BHS

ling reviewsng Access C

e-billing review

Page 5

ness and ous ‘Hold’ and MRT .

ost-Billing HS claims electronic

Expert.

of system Cal claims

The 837 dards and sor. The aims are

tate or by

Medicare mission.

Medicare’s

unt.

edicare or ction and for other

determine

claims for Medi-Cal

s are not Care and w.

InMA

SOta 1

2

3

4

5

SO

MISpaswcCc IBocAbdA


OC Int

SCOPE ANDOur audit evahe period M

and testing of

1. Evaluatiooperated

2. Evaluatioclaims anMedi-Cal

3. Evaluatiofor BHS M

4. Evaluatioaccount holds/que

5. Evaluatioareas of c

SCOPE EXCOur audit did

Billing an Billing an Billings a IT genera

were movaudit of H

IT applicascope. W

Complian Complian Patient’s Controls Controls

Managemenn accordanc

Systems: “Alpart of their mand maintainstrengtheningweaknesses,control structControl Audicontinuing em

nherent LimBecause of ioccur and nconstraints, uAlso, projectibecome inaddeteriorate. Accounting’s


ternal A

D METHODOaluated internarch 1, 2010f relevant do

on of manualclinics to en

on of controlsnd PHS Medclaims to en

on of controlsMedi-Cal andon of IT App

managemeneues, and traon of IT Genechange mana

CLUSIONS not include a

d claims for d claims subnd claims foral controls inved from HC

HCA as a whoation control

We did not pence with HIPAnce with billineligibility for over cash reover cost rei

t’s Responsce with thel County dep

managementning the interg internal co when detecture is the Cit enhances mphasis on c

mitations in Anherent limitot be detecunintentionalon of any evequate becaAccordinglyoperating pr

Agency

Auditor

OLOGY nal controls a0 through Jucuments ove

and systemsure medica

s over pre-bildi-Cal claims,nsure medicas over post-bd PHS Medi-Cplication Connt), segregatansactional aeral Controls agement and

a review of th

Medical and bmitted to thirr services pro

n the areas oCA to the OCole. s reviewed

erform a comAA or other png rules and rmedical benceipts and ambursement

sibilities for Auditor-Copartments/agt practices. Trnal control sontrols.” Cocted, must b

Committee ofand compl

control activit

Any Systemtations in anycted. Specifl errors, mavaluation of tause of chang, our audit wrocedures, ac

r’s Rep

and processeune 30, 2011er the followin

m controls anl claims are aling reviews, and b) Qua

al claims are billing/paymeCal claims. ntrols (IRIS tion of dutieudit trails. related to th

d backup and

he following:

Institutional rd-party healovided by coof IT adminisC Data Cente

were limitedmprehensive aprivacy laws. regulations e

nefits. ccounts recet for medical

Internal Conntroller’s Co

gencies shallThis is becausystem. All lontrol systembe promptly f Sponsoringements, buties and self-a

m of Internal y system of fic examplesnagement othe system toges in conditwould not neccounting pra

ort

es over sele. Our methng:

nd processesallowable, vaat: a) HCA’s

ality Improveallowable, vant process a

and Practices, system

he medical bid recovery.

Health Servith plans, inclntract provid

stration/strateer); and secu

to those mapplication re

established b

eivable/collecservices fun

ntrols ounty Accou maintain effse managemlevels of ma

ms shall be corrected. T

g Organizatiot does not assessment

Control internal cont

s of limitatioverride, circo future periotions or the decessarily diactices, and

cted aspectsodology inclu

s over medicalid, and adeqs Medical Billment & Progalid, and adeat QIPC for B

ce Expert) oedit checks

lling systems

ices (MIHS). luding Denti-

ders (non-paregic planningurity administ

edical billingeview of IRIS

by Medicare a

ctions pertainded by grant

unting Manufective intern

ment has primnagement mcontinuouslyThe criteria ons (COSO) substitute foof control ris

trols, errors ons include, umvention bods is subjec

degree of comsclose all wcompliance w

s of the mediuded inquiry

cal billings inquately suppling Unit (MBgram Compliequately suppBHS Medi-Ca

over user ac(e.g., data

s (IRIS and P

-Cal and Cal-r). g; physical setration. We

g objectives S or Practice

and Medi-Ca

ning to medicts and State

ual Section nal control symary respons

must be involvy evaluated for evaluatincontrol fram

or, HCA ansks.

or irregularitbut are not

by collusion, ct to the risk mpliance witheaknesses iwith County

ical billing pry, auditor obs

itiated at theported. BU) for BHS ance (QIPC)ported. al claims and

ccess (passwvalidations)

Practice Expe

-Optima.

ecurity (sincedid not perfo

covered by Expert as a w

al.

cal billings. allocations.

S-2 Internaystems as ansibility for estved in assesby Managem

ng an entity’smework. Oud HCA Acc

ies may nevt limited to,

and poor jthat proced

h the procedn the HCA’spolicy.

Page 6

rocess for servation,

e County-

Medicare ) for BHS

d at MBU

word and ), system

ert) in the

e servers orm an IT

the audit whole.

l Control n integral tablishing ssing and ment and s internal r Internal

counting’s

vertheless resource

udgment. ures may ures may

s or HCA

InMA

AWpM A D


OC Int

AcknowledgWe appreciapersonnel duMichael Good

Attachments

Distribution P

MembersMembersRobert J.Steven EJeff NageJan GrimKimberly Leslie SoTeri SchuAdil SiddiJohn MooDoug PhaThea BulDavid HoForepersSusan No


ternal A

gment ate the courturing our auddwin, Senior

s

Pursuant to A

s, Board of Ss, Audit Overs Franz, Interldred, Interim

el, Ph.D., Depes, Chief DeEngelby, Ma

orrells, Managultz, Chief Infiqui, IRIS Dirore, IRIS Opean, Managerlock, Chief C

orner, Divisionon, Grand Juovak, Clerk o

Agency

Auditor

esy extendedit. If we caAudit Manag

Audit Oversig

upervisors sight Commiim County Ex

m Deputy CEputy Agency

eputy Auditoranager, HCAger, Medical formation Offrector, HCA/Ierations Manr, HCA/InformCompliance an Manager, Qury of the Board o

r’s Rep

ed to us by n be of furthger at 834-60

ht Committe

ittee xecutive Offi

EO, GovernmDirector, Fin-Controller

A Accounting Billing Unit,

ficer, HCA nformation T

nager, HCA/Imation Technand Privacy OQuality Impro

of Superviso

ort

the Health Cher assistanc066.

e Procedure

cer ment and Pubnance/Admin

Services HCA

Technology nformation T

nology Officer, HCAovement and

rs

Care Agencyce, please co

No. 1:

lic Servicesnistrative Serv

Technology

d Program Co

y and HCA ontact me di

vices, HCA

ompliance, H

Accounting irectly at 834

HCA

Page 7

Services’ 4-5475 or

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Me

l Control Audit: Hel Billing Process

No. 1018

ed Resugement

ctive #1: Evess to ensure

k Performederformed the

Obtained andPolicies and P

Obtained a deServices and re-billing rev

Obtained repoYears 2009-10

Conducted mesponsibilitie

Program Com

Conducted moncerning the

Performed sitend Children

nterviews, peegistration, eeviews of Me

Observed theExpert at the c

Reviewed doche medical bi

Obtained an ocuments sh

Obtained an u

clusion d on our audnd Medicarellowable, sup

An extensive ost paymentccurate prior

he quality asMedi-Cal, etc.nsure contin

ealth Care Agency

ults, FinRespo

valuate the ae the billings

e following to

d reviewed HProcedures p

etailed underPublic Healtiews, submis

orts of total m0 and 2010-1

meetings withs over med

mpliance, and

meetings witheir roles in th

e visits at fou& Youth Sererformed wa

encounter anedi-Cal and M

e processingclinics and in

cuments andilling process

understandihowing the de

understandin

dit, we founde claims are apported, and

quality assut audits perfor to submissio

ssurance pro.) that is deteued eligibility

y

ndingsonses

adequacy ofare allowable

o accomplish

HCA Behaviopertaining to t

rstanding of th Services, ssion of claim

monthly billing11 for each o

h HCA mandical billing, d Claims and

h HCA Divisihe medical bi

ur HCA clinicrvices at the alkthroughs,

nd billing infoMedicare BHS

g of billings n the Medical

d reports gens, including th

ng of the menial and rep

g of the re-b

d manual andadequate andvalid. Key c

urance proceormed for BHon for payme

ocess includeermined duriny for reimburs

, Recom

manual ande, supported

our audit obj

oral Health Sthe medical b

medical billinstarting with

ms to the Stat

gs and claimof the above

agement to including MFinancial Re

on Program illing process

cs (17th StreeManchesterand obser

ormation, obS & PHS clai

and claims l Billing Unit.

erated from he various w

medical billinpayment of cl

illing process

d system cond effective to

controls that w

ss is in placHS & PHS cent.

es re-verifyinng initial intaksement prior

mmend

d system co, and valid.

jective:

Services andbilling proces

ng process a patient regite, and post-

ms submitted,divisions.

obtain an uMedical Billineporting.

Managers as.

et Clinic, Sanr Office Buildrved the proserved pre-bims.

in IRIS (Pro

IRIS to undeork queues a

g submissiolaims.

s when claim

ntrols over mo ensure billinwe identified

ce that is achlaims to ens

g the client’ske and registr to submitting

dations

ntrols over H

d Medical Biss.

and controls stration, pati

-payment rev

and paymen

understandinng Unit, Qu

and HCA/Inf

nta Ana Cliniding). At theocessing anbilling and/or

oFit billing m

erstand how and system h

on process a

ms are rejecte

medical billingngs and claim under this o

hieved througsure they are

s program eltration for BHg claims for p

and

HCA’s medic

lling Unit’s O

for Behaviorient visits/enviews.

nts received

ng of their rality Improv

formation Te

c, Costa Mee clinic, we cnd inputting r post-billing

module) and

the system iholds.

and reviewe

ed or denied.

g processes ms for reimbobjective inclu

gh the pre-be valid, comp

igibility (for MHS only. Thispayment.

Page 8

cal billing

Operating

ral Health counters,

for Fiscal

roles and vement &

echnology

sa Clinic, conducted

patient’s payment

Practice

s used in

d related

for Medi-ursement ude:

billing and plete, and

Medicare, s helps to


DetaileManag

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No. 1018

ed Resugement

he quality auch as patien

naccurate or dentified and

here are woillings are suor quality aspproved.

When errors, ocumentatiohe billing. Rillings.

HCA has adolaim is impeimbursemenny billings or

audit found dination of eram Compliaon the contr

gs are allowa

uch, we hav

ealth Care Agency

ults, FinRespo

assurance prnt charts, clinincomplete resolved bef

rk queues aubmitted. Thssurance. E

inaccurate cn is returned

Re-billings go

pted a conseroper, incomnt. HCA will r claims when

that HCA’seffort betweeance (QIPC)rols and procable, supporte

ve no finding

y

ndingsonses

rocess ensurnic notes, anclaims that dfore being su

nd system hhese reviewsExplanations

laims or unsd to the clinio through the

ervative apprmplete or inattempt to c

n there is a p

s medical ben HCA clin, Administracesses they ed, and valid

gs and recom

, Recom

res that claind other docudo not have ubmitted for p

holds in places include med

are docume

upported clac/health caree same wor

roach in mednaccurate, itorrect the bil

possibility tha

billing procenics, the Metion, and Infestablished o

d.

mmendation

mmend

ms are adequmentation othe necessa

payment.

e that requiredical team cented when

ims are detee provider fok queues, h

dical billing, at does not lling issue in at the claim c

ess is compedical Billingformation Syover the med

ns under this

dations

quately suppof medical seary supportin

e reviews to hart reviewsclaims are

ected in the por correction olds, and re

and if there isget submittorder to re-b

could be rejec

plex and in Unit, Qualiystem persodical billing p

s objective.

and

ported by doervices providng document

be conducte, coding reviput on hold

pre-billing revand resubm

eviews as the

s any indicatted to the Sbill, but will ncted or denie

volves an eity Improvem

onnel. We cprocess to en

Page 9

ocuments ded. Any tation are

ed before ews, and and not

views, the mission of e original

ion that a State for ot submit

ed.

extensive ment and commend nsure the


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Thereregar


No. 1018

ed Resugement

ctive #2: Evacomplete billi


Obtained a dubmitted frovaluation of t

Conducted walinics, to valind MBU.

Evaluated proReviews for M

Obtained an efore Medi-C

Obtained andesults, and st

Obtained an uhe Medical R

Medical Billing

clusion audit found tent impropermined by HC

ctive included

. Automatic(MRT Holerrors, omMedi-Cal adequatel

. A quality ahave beenYouth Serand Clinic

. Post-paymsupportedbasis for areviews re

e are no firding efficienc

ealth Care Agency

ults, FinRespo

aluate the adngs.

e following to

detailed undm Behaviorathe frequenc

alkthroughs, idate the pre

ocesses for cMedi-Cal claim

understandinCal and Medi

d reviewed statistical data

understandinReview Teag Unit Coders

that pre-billinr or incomplCA based ond:

c billing holdsds) and code

missions, impbillings andy supported.

assurance pn passed. Frvices), there

c Technical R

ment reviewsd. Also, postadditional traeflect an erro

ndings andcy and effect

y

ndingsonses

dequacy of p

o accomplish

erstanding oal Health Sy of reviews

interviews, ae-billing revie

conducting Cms to determ

ng of work qcare claims a

system repora or metrics.

ng of the tecms in Quals to conduct

ng and post-lete billings. n the progra

s in IRIS thater reviews (Cproper codind claims for.

rocess that rFor certain He are pre-billReviews at th

s are done ot-payment re

aining to prevor rate below

d recommentiveness of p

, Recom

re-billing and

our audit obj

of the pre-bervices andand sample

and reviews ews and pos

Clinic Technicmine if they ar

queues and are submitted

rts that docu

chnical requirity Improvempre-billing an

-payment rev The level

am and reimb

t prompt for Coder Holds)g, and non-

r payment.

re-verifies paHCA programing reviews ue clinic sites

on selected eviews analyvent similar e5% (the indu

ndations forre-billing and

mmend

d post-billing

jective:

illing review Public Hea

sizes.

of related dost-billing paym

cal Reviews are valid and s

holds in IRISd for paymen

ument the m

rements, cerment and Prnd post-billin

views are ad of pre-billinbursing entity

various pre-b)]. These revcomplianceThe review

atients’ Medicms where Musing Medi-C.

paid claims yze claim erroerrors from ocustry standar

r this objecd post-payme

dations

reviews that

process foalth Services

ocumentationment reviews

and Medical supported in

S that requirnt.

medical billin

rtifications anrogram Comg payment re

dequate in hng and posty. Key cont

billing reviewviews are vitprior to sub

ws also help

care eligibilitedi-Cal is bi

Cal Review t

to ensure thors and use ccurring. Curd acceptable

ctive. See ent reviews.

and

t help detect

r billings ans. This inc

n at a samples performed

Review Teaclinic docum

res reviews/a

g process w

nd training nempliance, aneviews.

helping to det-payment retrols noted u

ws [e.g., charal in helping mitting Medip ensure cla

y and that plled (e.g., C

teams (MRT)

hey are accuthis informa

urrently, post-e error rate is

Audit Obje

Page 10

improper

nd claims luded an

e of HCA by QIPC

ms Chart ments.

approvals

work-flow,

eeded by d by the

etect and eviews is under this

rt reviews to detect care and aims are

rior holds hildren & ) in QIPC

urate and ation as a -payment s 5%).

ective #5


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No. 1018

ed Resugement

ctive #3: EvaPractice Expegation of duransactional


Gained an undwhether: onuthorization uthorizations

Gained an unermination to with written fomployee's laeactivates or

Obtained appwhether they orces systemmay be reuseefore the acppropriate ind

Obtained a lisuties (data erocess.

Conducted walinics, the Quo obtain a d

Health Serviisits/encounteviews. Theiagnostic anate/time, aceviews/appro

clusion audit found ms are ade

egation of du Key contro

Based on discccess to the o add or modmail authoriz

ealth Care Agency

ults, FinRespo

aluate the adpert systems uties, systemaudit trails.

e following to

derstanding oly departmeis in written

s are filed.

nderstanding determine w

ollow-up whenst day of em

r removes the

plication accomeet best p password c

ed; number ocount is lockdividual to re

sting of applentry versus r

alkthroughs, uality Improvdetailed undeces and Pters, pre-billie purpose wnd procedurections takenovals, etc.).

IT applicatioequate in tuties, systemls noted were

cussions withapplications

dify access rzations or wri

y

ndingsonses

dequacy of IT in the area

m edit checks

o accomplish

of procedureent managem

form or com

of procedurwhether: secn an employ

mployment; ane user accoun

ount and paspractices: mhange; numbof concurrentked; length omove accoun

lication usersreview/releas

interviews, avement and Perstanding o

Public Healthng reviews,

was to docume codes, et

n, data valu

on controls ohe areas o

m edit checkse:

h relevant HCincluded the

rights; authoitten authoriz

, Recom

T applicationas of user acs (e.g., data

our audit obj

s for grantingment has themmunicated

res for remourity adminis

yee gives notnd upon notint or user pro

ssword settinminimum pasber of times pt connectionsof lock out pent lock), and

s and reviewse) and acce

and reviews Program Comof medical bh Services,

submissionment applicattc.) and tranues before/a

over the billiof user acces, system en

CA staff and e following: orization is in zations are fil

mmend

controls oveccess (passw

a validations)

jective:

g users accee authority via email; an

oving user acstration is nottice or is to bfication, the

ofile from the

ngs for the fossword lengthpassword mus allowed; nueriod (users length of time

wed access fess to confide

of related dompliance Divbilling proces

starting wn of claims tion edit chensactional aafter and e

ing process ess (passwonforced holds

review of fornly departmewritten form

led.

dations

er the billing word and ac), system en

ss to the appto add or mnd email aut

ccess upon tified promptlybe terminatedsecurity admsystem.

ollowing parah; number oust be changumber of incshould be re

e incorrect lo

for an approential data as

ocumentationvision, and thsses and cowith patient

to the Stateecks (e.g., daudit trails (devents logge

in the IRIS ord and acs/queues, an

rms, proceduent managem

m or commun

and

processes inccount mananforced holds

plications to dmodify accesthorizations o

employee try in writing od; notification

ministrator im

ameters to df days befored before a

correct logon equired to co

ogon count is

opriate segres related to t

n at a samplehe Medical Bontrols for B

registratione, and post-uplicate claidata loggeded - data

and Practiccount manand transactio

ures for grantment has the nicated via e

Page 11

n the IRIS agement), s/queues,

determine ss rights; or written

ransfer or or verbally n includes mediately

determine re system password attempts

ontact an retained.

egation of the billing

e of HCA illing Unit

Behavioral , patient -payment ms, valid

d – user, changes,

ce Expert agement), onal audit

ting users authority mail; and


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No. 1018

ed Resugement

Based on discccess upon otified in wrierminated; noecurity admin

HCA uses thehe applicatiohose settingsonnections a

ock out periodock), and lenwe reviewed aumber of da

must be chang

RIS and Pracdequate segata.

RIS applicaticcess and caystem enforciagnosis andiagnosis/proc

dentifier) requ

RIS applicatiystem generadata change

modified by th

Practice Expemiting their alculated by

Practice Expentries (user n

e are no find

ealth Care Agency

ults, FinRespo

cussions withemployee trating or verbaotification incnistrator will d

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Page 12

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Page 13

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to transitionmanaging theentation inclue Business C

Page 14

ng a new ss due to ws similar CA uses a

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the entire

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No. 1018

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Page 15

Continuity

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Page 16

(e.g., no e whether gs.

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No. 1018

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ating the termoach by cons (e.g. MRT use of the fis

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he industry st

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ment ended, HCA sho

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ssing Medi-Mssess the ris

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y a MBU Com Complianiews are diffor not the bews. Since tof the MRT ho

and Post Payee Certified Cor to submittiwas less thanignated samicare claims,

2 lling review pcess which rbilling and poonsideration tandard in th

anagement urse of this ahave alreadybeen modifi

nt reviews onthe conserva

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formed pre-bs on all Medthe errors r

di-Cal claimseral governm

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ment had endepost paymenAudit Reviewrs on the Cou

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e, HCA estas, and adop within the inQuality Revier from Officed. Howevent reviews ofw, MBU Codunty.

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w, known as eview, knowoted that th

be submittedeview supersclaims.

ws on a Samucting pre-bilr billing. Becry standard. consider conform both rev

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st payment ree enhanced pld assess coer a pre-billinsame claim.

determine thePC. In additvioral Health he reviews g

e review proreview procer review. Que to review

Page 17

icare and roper and Office of Integrity

mpliance, ve billing

use of the rate was officially

nservative t different

C Review)

and post nt review

i Claims. i. These

Behavioral all claims ed by the

Medi-Medi a Quality ough the the final

conflicts CA should

eviews on pre-billing onducting ng or post

e need to tion, HCA Services iven they

cess was ess for all

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No. 1018

ed Resugement

The post-bilerror rate. Hhappen in Jis found thabe modifiedabove 2%, error rate reabout 10%.

ing No. 3 –

mary Medical Billiram ~ FamilyFPACT claimonsible for pe

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n No. 3 evaluate thed to limit theost-payment

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3, 100% of Mate is consise size of abosize for thatbelow 2% fo

ent Review

BU) performam (FPACT)y, there are ese reviews

hedule. The 1 through Ma

ed that the e paid report,the selected eview percen

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BU responsibd a sample ovaluation of

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ement Respoeview procesmple size fore error rate sh

accordingly.sponsible for This has elities allowing

, Recom

also been anr critical cha

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mple size is co

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st-payment reze at a reaso

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g for all revie

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ss for PHS cunt to enhan

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ms

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ram to selecReport, from

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t-payment rehey are accuocess for PHsize at a reduring our f

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Page 18

ct the low ch as will When it ocess will increases on, if the reased to

h Service on 20% of

primarily the post- payments

ct a 20% m Practice e multiple k that the

affect the hat Coder imeliness e.

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No. 1018

ed Resugement

ing No. 4 –

mary audit noted ted billings, annformation isagement repo

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