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Internal Audits of Your Home Infusion and DME Processes

Written by: Mediware Bloggers on Monday, April 3, 2017 Posted in: HME/DME, Home Infusion

By: Kathy Wright, Reimbursement Manager, Mediware Reimbursement Services

Meeting requirements for each payer is critical to reimbursement. Therefore, you have to be sure that your billing teams know the requirements and are collecting documents and creating claims in accordance with each payer’s rules and contracts. To protect your business and monitor staff performance, consider conducting regular internal audits of your billing processes, so small errors can be corrected before they become big problems for your business.

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The first step in conducting internal audits is to be fully aware of payer requirements and what is necessary for billing, including detailed written orders, refill documentation, coverage criteria guidelines, local coverage determinations (LCDs), etc.  In addition, because payer requirements can change, sign up for your payers’ email updates, so you and your team can be notified whenever there are changes to policies or coverage.

Here are 5 different areas you may want to conduct internal audits on to ensure your business is compliant and getting paid appropriately.

  1. System Set-Up
    Go back to your contracts to double check what should be billed and how it should be billed, and audit the information on the delivery slip. When delivery tickets list all supplies and services provided, errors are more likely to occur. For example, your staff might include too many items in the per diem header, or they could end up missing items for which you should be billing. Either way, these errors will cost you money.
  2. Employee Processes
    Whatever the size of your infusion pharmacy, it is vital that you spot check patient files and staff member functions from time to time. Start with the intake processes because errors and missing documentation at the beginning will create problems throughout the system. In addition, ensure that your billing team members include complete notations regarding claim status, contacts made with payers, patient payment statuses, etc. and that they aggressively monitor and follow up on claims under review. These details are critical for keeping claims moving forward. Detailed documentation regarding follow up done will also help to avoid or fight any timely filing related denials. If there are gaps or errors in the processes, provide training to help your team improve.
  3. Financial Metrics
    Monitoring your business metrics helps you quickly spot issues, so you can react and make corrections. Each week, check the status of your A/R over 120 days, cash-to-net revenue, and changes in positive or negative adjustments. If you have a system that allows you to set threshold alerts, you can be notified immediately when serious issues arise. You can also monitor trends in these areas to spot ongoing issues that need to be addressed. Changes could indicate issues with your intake department—perhaps not gathering all necessary documentation to support clean claim submission—or changes could indicate trouble with billing falling behind, or even unexpected denials from a particular payer. With these metrics on your radar, you can be forewarned of underlying issues that need your attention.
  4. Copayment and Waivers Policies
    Because you care about your patients, many of whom are struggling with challenging illnesses, collecting copayments and balances due can be uncomfortable. However, it is important that providers follow stated policies for managing copayments, waiving fees, and applying discounts. If your staff routinely waives copayments without following policies that clarify the terms, these actions could be brought into question during a payer audit.
  5. Booking and Billing Revenue
    Payers make mistakes, too, and occasionally, they pay more than they should. Because providers have a limited amount of time to return excess funds without penalties or fines, you have to respond promptly. If you are booking revenue based on your contracted rates, you should be able to quickly identify if you’ve been overpaid. Also, more importantly than being over paid, often times you are underpaid, thus if you are booking and billing revenue correctly, you will know and be able to appeal the claim timely for the additional payment due.

If you feel overwhelmed by all the details that need to be regularly monitored, you may want to seek assistance from an outside billing specialist who can help you get paid for your home infusion and durable medical equipment services. Contact Mediware Reimbursement Services today.