Rehab

Article of the week: Internal reviews can offer a revealing reflection

Rehab Regs, November 9, 2007

Two of the biggest complaints rehab providers have are that they don't understand why a payer denied a claim or why they are losing money. Often, these financial problems stem from a lack of knowledge about the claims process.

 

"Too many providers have the approach of, 'Let's submit our claims and see what gets paid,' " says Ken Mailly, PT, of Mailly and Inglett Consulting, LLC, in Wayne, NJ. "Providers need to have a strategy for coding and billing and need to know more about their practice than the outside world does."

 

One way of discovering financial mistakes or process variances is through an internal claims review. Providers should set up a process for constantly checking their claims, either by having their therapists check each other's work or by hiring an outside consultant. "If you aren't checking your claims, you're taking huge risks," Mailly says.

 

Claiming ignorance

 

The claims process is a culmination of caring for the patient, documenting that care, and billing for reimbursement, according to Mailly. The process also involves everything from the patient referral to the therapist's findings and interventions to patient outcomes.

 

"If you start looking at your practice solely on the basis of making more money, you might start turning more of a profit," says Stuart H. Platt, PT, MSPT, a principal at Appropriate Utilization Group, LLC, in Atlanta.

 

However, a high profit margin won't mean much to payers and patients if it isn't backed up by effective, quality care.

 

Mailly gives the example of a rehab company and a managed care contractor attempting to negotiate a contract. The rehab provider spouts off numerous facts and figures about getting great outcomes and deserving top dollar because of the services it offers. But when the managed care representatives pull out files of cases in which the provider's treatment didn't help the patient and lacked documentation to show why, the entire sales pitch is shot.

 

High expectations

 

To create an evaluation tool, determine which aspects of your claims process you want to examine. What legal, ethical, and reimbursement standards must you keep in mind during the review?

 

"People associate quality with good outcomes and rightly so," Mailly says, "but that's not the entire picture if you're getting those outcomes illegally or immorally."

 

Use the following guidelines to establish your practice's expectations:

 

  • State laws
  • The guidelines of professional associations' (e.g., the American Occupational Therapy Association)
  • Medicare reimbursement regulations
  • Other payer standards

 

Expectations will invariably differ by state, practice size, specialties, and individual therapists, but facilities can customize their own claims checklist.

 

According to Platt, several types of tools exist to evaluate either an individual therapist or the facility as a whole, including

 

  • chart audit. Does the "technical" chart contain all of the right items (e.g., referrals, signatures, dates)?
  • peer review. This review assesses the quality of therapy provided using accepted practice standards and guidelines. For example, do you have realistic patient goals and a plan to reach those goals?
  • utilization review. This process considers medical necessity, appropriateness, and reasonableness of services provided (e.g., the appropriate frequency and duration of care given the patient's diagnosis).

 

Look in the mirror

 

Once you establish ways to judge and critique your facility's claims, either self-audit your practice or hire someone to do it for you.

 

If you opt for an internal review, you'll have to establish baseline cases and have therapists spend time reviewing cases and not treating patients. However, the review process can serve as valuable learning experience for those taking part.

 

To establish baseline cases, Mailly recommends taking your most common treatments and collecting data about them. Determine what the typical plan of action for that treatment is and then pull out any cases that fall outside the norm. Use those cases to evaluate what went right or wrong. Review with your therapists the entire treatment to see what you can do differently.

 

Obviously, the more detailed your baseline cases are, the better, but the most important aspect is to actually sit down and reexamine past cases.

 

Going outside to look within

 

Although the thought of having an external agency review internal actions be scary, hiring someone to conduct your claims review process can be beneficial.

 

The contracted agency isn't connected with Medicare or any other regulatory commission and is under no obligation to report any wrongdoings. Instead, it can serve as a watchdog and perform the critiques that colleagues often don't want to make of each other. A contracted auditor will also have more established baselines with which to judge you and can perform inservice training in any area you are lacking. No matter what type of claims review process you perform, some therapists will feel as though they're being watched or singled out. Assure them that, at least in the initial phases, findings won't negatively affect them and are meant as constructive criticism.

 

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