SOW - OCAO Coding and Billing Audit Services.docx

SCOPE OF WORK

PURPOSE OF PROJECT

The purpose of this contract is to evaluate the accuracy and consistency of clinical documentation as well as the coding and billing of claims prepared for inpatient and outpatient services throughout the Oklahoma City Area Indian Health Service. This service shall be performed on a quarterly basis and shall include a written report documenting finding and recommendations for improvement as well as staff education/training.

BACKGROUND

The Oklahoma City Area federal facilities has a quarterly coding and billing compliance audit requirement under the Indian Health Services Office of Resource Access and Partnership (ORAP). These services are necessary to ensure optimal reimbursement is achieved ethically and legally. Optimal reimbursement through coding and billing of appropriate services is necessary to provide safe and effective care to our patients. The facilities include the following:

· Hospital and Ambulatory Care Setting o Claremore Indian Hospital

· Annual Visits:391,831; Number of Coders, 11; Number of Providers 53 Lawton Service Unit/Lawton Indian Hospital

· Annual Visits: 379,914; Number of Coders, 13; Number of Providers 93

· Ambulatory Care Setting Only

· Anadarko Indian Health Center

· Is a facility of the Lawton Service Unit through a multi-divisional database. Figures are included as a whole under Lawton above.

· Carnegie Indian Health Center

· Is a facility of the Lawton Service Unit through a multi-divisional database. Figures are included as a whole under Lawton above.

· Clinton Service Unit

· Clinton Indian Health Center

· Annual Visits: 222,851; Number of Coders, 6.5; Number of Providers, 35 Providers

· El Reno Indian Health Center

· Is a facility of the Clinton Service Unit through a multi-divisional database. Figures are included as a whole under Clinton above.

· Watonga Indian Health Center

· Is a facility of the Clinton Service Unit through a multi-divisional database. Figures are included as a whole under Clinton above.

· Haskell Indian Health Center

· Annual Visits, 42,224; Number of Coders, 2; Number of Providers, 14

· Pawnee Indian Health Center

· Annual Visits, 137,817; Number of Coders, 4; Number of Providers, 14

· Wewoka Indian Health Center

· Annual Visits, 136,048; Number of Coders, 4; Number of Providers, 18

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The ambulatory services include: Audiology, Behavioral Health, Chiropractic Services, Dental, Endodontics, Endocrinology, Laboratory, Medical, Nursing, Nutrition, Optometry, Orthopedics, Pharmacy, Physical Therapy, Podiatry, Public Health Nursing, Radiology Services, Rheumatology, Tele-Psychology, and Wound Care.

The hospital services include: All services noted under ambulatory services and Surgery, Day Surgery, Cardiology, Ophthalmology, Otolaryngology, Pain Management, Respiratory Therapy, Infusion clinic and inpatient services that include Medical, Surgical, ICU, Pediatrics, OB, GYN, ER/ED, Urgent Care and Newborn.

The provider types include: Provider types include: MD, DO, PA, ARNP, CNM, PT, AuD, Chiropractor, Optometrist, Dentist, Dental Hygienist, Psychiatrist, Psychiatric Nurse Practitioner, Psychologist, LCSW, Wound Care Specialist, Massage Therapist, Pharmacist, RN, LPN and Nurse Aides. The government reserves the right to add a provider(s) if such provider is added at a respective facility during the period of performance of this contract.

SCOPE OF WORK:

1. The Coding and Billing Audit shall be conducted on a quarterly basis for the previous quarter during the period of performance.

2. Services shall be rendered on-site at each facility or remotely (VPN access shall be granted if desired).

3. The Contractor shall conduct the following deliverables/tasks:

a. · Coding Audits

b. Billing Audits

c. Training/Education

4. The Quarterly Reviews shall include but not limited to the following:

a. Coding/Data Entry: Each facility must have an independent or peer certified coder perform a quarterly review (by random sampling) of all coding/data entries. The sampling must be conducted by someone who did not do the original coding/data entry.

b. Timely Process Reviews. Using random sampling methodology, perform an independent/peer review of documents from check in to reconciliation (check in, registration, coding/data entry, billing, posting, adjustments/write-offs, and reconciliation) to verify accuracy, compliance, and timeliness of preparation and submission.

c. Aged Receivable Review. Perform an independent/peer review (random sampling) of AIR that is older than 120 days to verify accuracy, compliance, completeness, and proper submission and follow-up. Accounts in this category should not exceed 20% of total AIR for the entire facility/location.

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5. The coding and billing audits shall include but not be limited to: coding/data entry, provider documentation, billing, charge capture, adjustments/write-offs, aged account follow-up, compliance, and timeliness of preparation and submission (throughout revenue cycle).

6. Contractor shall audit the coding and billing of all medical providers, coders and billers for each site.

7. The coding and billing audits shall be on randomized visit encounters but may include specific service categories if requested by the service unit. The government reserves the right to add providers if a new service is added during the term of the contract.

8. Under the Medicare Part A CMS Claremore/Lawton Shared Contract, ambulatory centers are allowed to bill for some of the procedures which are submitted on institutional claims; therefore, the Contractor shall review UB-04 and CMS-1500 professional claims.

9. The Contractor shall review findings with the Facility Contract/ COR during or following the audit, and prior to preparing the final written report. All areas of disagreement shall be referred to the Facility Contract/ COR for resolution prior to the completion of the written report.

10. Due to the fluidity of the number of providers at each site, costs for services shall be submitted on a cost per provider basis for completion of tasks noted below rather than a cost per site. Therefore, the costs per quarter at each site shall be determined on the number of active providers during that quarter.

11.Tasks

11.1 Task 1-The contractor shall provide quarterly coding audit functions:

a. Contractor shall conduct coding and data capture audit for 10 random visits for each medical providers and associated clinic (all provider/clinic types as noted in background section of this SOW) for each facility. ·

b. The Contractor shall conduct a coding audit on each coding staff member at each site.

c. The Contractor shall provide an Exit Conference at the completion of the audit and provide preliminary electronic data tables and narrative documentation of findings and recommendations to HIM Administrator, Business Office Manager, Executive Leadership Team and COR.

d. The Contractor shall provide the Coding department report within 15 business days; the report shall be in-depth and individualized in electronic format (i.e. Word, Excel or equivalent) that includes extensive analysis of identified strengths, weaknesses, and suggested improvements for the coders to include but not limited to education training.

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e. The Contractor shall provide onsite Post-audit in-service within 30 business days of exit conference to share findings with coding staff.

f. Clinical Documentation Improvement Data Elements

Outpatient Monitor Data Elements:

· Insufficient documentation

· Medical record documentation exists for service billed

· Under coded

· Up coded

· Missing (documented) not coded

· Provider Credentials

· Provider correct use level of E/M code

· E/M code bundled into another CPT code

· Wrong E/M Type assigned

· No documentation for encounter

· Incorrect code selected

· Unbundled/bundled codes

· Lack of specificity (3rd 4th, 5th, 6th, 7th character),

· Incorrect modifier assigned

11.2.1 Task 2 - The contractor shall provide quarterly Billing/Revenue audit functions:

a. The Contractor shall conduct claim filing audits on:

1. Private Insurance and Workers' Compensation

2. Medicare Part A and Part B

3. Institutional Claims

4. Professional Claims

5. Medicaid (including State Children's Health Insurance Program if applicable)

6. Beneficiary Medical Program

7. Non-beneficiary

8. Veterans Administration

b. Contractor shall conduct billing and data capture audit for 10 random visits for each medical providers and associated clinic (all provider/clinic types as noted in background section of this SOW) for each facility.

c. Contractor shall conduct a trend analysis for collections, deposits, amounts billed, point of sale rejections, denials, and adjustments by allowance category, age, or payer. All analysis should be based on past or current operations to allow managers to see potential or actual problems and where improvements can be made to increase revenues and decrease losses.

d. The Contractor shall provide an Exit Conference at the completion of the audit and provide preliminary electronic data tables and narrative documentation of findings and recommendations to HIM Administrator, Business Office Manager, Executive Leadership Team and COR.

e. The Contractor shall provide the Business Department report within 15 business days; the report shall be in-depth and individualized in electronic format (i.e. Word, Excel or equivalent) that includes but not limited to extensive analysis of identified strengths, weaknesses, billing aberrancies, double billing, bundling or unbundling, missed claims, unnecessary billing, outliers and financial impact and suggested, and any improvements for the identified for the business office staff.

f. The Contractor shall provide onsite Post-audit in-service within 30 business days of exit conference to share findings with business office staff.

11.3 Task 3 - The Contractor shall provide Training/Education:

a. The Contractor shall provide post-audit in-service for provider staff on the both the coding and billing outcome findings within 30 business days of the exit conference. This in-service shall consist of an extensive analysis of identified strengths, weaknesses, and any improvements for the identified for clinical documentation.

b. The Contractor shall conduct onsite bi-annual departmental training for patient care providers, nursing, ancillary, coders, billers, and administrative staff in coding/billing documentation requirements/changes, appropriate documentation requirements under ICD-10-CM, ICD-10 PCS, E/M codes, Primary CPT code, Secondary CPT Code, and Primary Diagnosis codes, Secondary Diagnosis codes, and Modifiers for clinical documentation improvement and clinical documentation improvement to enhance revenue recovery. This in-service may be combined with a quarterly post-audit in service noted above.

c. The Contractor will conduct onsite bi-annual training on use of management audit reports for administrative staff, coding managers and billing staff.

Services shall be provided on a quarterly basis for the previous quarter during the period of performance. The quarters are January- March, April - June, July- September, and October - December.

SCHEDULE OF WORK

Auditing of records to be provided. The contractor shall be responsible for all inclusive labor, travel, mileage, materials, and expenses for supplies, copies and final recommendations of findings.

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QUALIFICATIONS

The actual reviewer shall have at least three years of experience reviewing claims in an ambulatory and hospital health care organizations, as well as two years of education and training. Experience shall include professional (CMS 1500) claims. In addition, the reviewers who shall be verifying ICD-10-CM, ICD-10-PCS, CPT codes, and HCPCS codes shall have one or more of the following current credentials: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P), or Certified Professional Coder (CPC). In addition, highly preferred individuals with credentials as a Certified Professional Biller- CPB, Certified Professional Medical Auditor- CPMA, or Certified Professional Compliance Officer - CPCO.

The proposal shall include the resumes of the actual reviewers, two (2) current client references specific to each individual reviewer, proof of credentials samples of completed audit reports.

Prefer contractor with 3M encoder experience.

SPECIAL CONDITIONS

In accordance with HHSAR 304.1300(b) non-routine contractor employees shall comply with OPDIV DHHS/SE Region - Human Resources, Security Clearance Guidance - Visitors (3/29/12) policy for contract performance period.

1. Contractor shall report to the front desk upon arrival and upon completion of work daily.

a. Contractor is required to sign-in on the contractor's log book located in at the front desk, obtain and wear a ID badge prior to starting the job each day and return the badge and sign out at the end of the day.

2. Contractor shall comply and complete all training requirements as related to IHS HIPAA and IT security policies.

GOVERNMENT PROPERTY/SPECIALITY STAFF/SUPPORT STAFF

The Government shall provide the facilities and audio/visual equipment for conducting onsite reviews and in-service trainings as well as VPN access if required.

OVERSIGHT CONTROLS

The Contractor services shall be coordinated and approved by Contracting Representative Officer (COR) and shall be in coordination with facility HIM Administrator & Business Office Managers. No work shall be conducted without full authorization of COR and shall not exceed scope noted in SOW. The government reserves the right to modify the contract if required and is in the best interest of the government.

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