By Anthony W. Minge, EdD
The word “audit” strikes fear in the hearts of most healthcare leaders. As managers, you’ve heard the stories, been to the conferences, read articles like this, and may have even been through an audit yourself. The mere utterance of the word causes your palms to sweat. Add the word “surprise” and your anxiety level peaks!
However, there is a contingent of the EMS population that remains blissfully ignorant to the fact that they will someday be audited. Perhaps they haven’t heard the news or otherwise just don’t believe that it will happen to them. And if it does, they actually believe it will be someone else’s problem. In a word: wrong!
The truth of the matter is, there are no surprise audits. Compliance audits have become so commonplace in EMS that the catchphrase is “not if, but when.” That’s not to say that a letter or, heaven forbid, a subpoena won’t show up unannounced, advising you of your responsibility to produce records. But when it does, the shock factor should be minimal.
The Office of Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), and the Department of Justice (DOJ) have all made their commitment to combating fraud and abuse in healthcare, including EMS, quite clear. The OIG even publishes an annual workplan giving very specific detail as to what they will be focusing on in the coming year.
Repeatedly, EMS has shown up in this document. There are a multitude of programs, contractors and agencies dedicated to sniffing out improper payments and questioning compliance practices. One only needs to mix the letters in your alphabet soup to come up with an entity that is monitoring and assessing the accuracy of bills submitted. A short list includes:
- CERTs
- HEAT
- MACs
- MICs
- MIPs
- RACs
- MFCUs
- OMIGs
- PERMs
- ZPICs
So, I say again, no one should be surprised when they are audited.
The best way to deal with a surprise audit is to not be surprised when you get the call. This calls for adequate preparation, the first step of which is to ensure that your agency has a robust compliance plan and is actively following it. You remember the compliance plan. It’s that thing you had done by those people that they put in that book that now sits on that shelf in your office ... collecting dust.
Maintaining an active compliance program is the best preparation for an audit. This can be accomplished in four steps:
- Develop
- Communicate
- Monitor
- Improve
1. Develop
As the story goes, in a time long ago, guidance was provided for developing compliance programs for ambulance suppliers (which is easily applied to providers as well). In 2003, the OIG published this guidance in the Federal Register at 68 FR 14245. This document provides a roadmap for creating the ambulance compliance program. Seven basic elements are outlined:
- Develop policies and procedures
- Designate a compliance officer
- Education and training programs
- Internal monitoring and reviews
- Respond appropriately to misconduct
- Develop open lines of communication
- Enforce disciplinary standards through well-publicized guidelines
This step is a heavy lift initially. It requires commitment from the organization to develop written standards for operation, educate staff, and regularly monitor to ensure they are appropriately being followed.
2. Communicate
An organization’s commitment to compliance is without meaning unless it is effectively, and regularly, communicated. Initial and annual training is simply not enough. Compliance should be an ongoing dialogue with employees, business associates and the patients and customers served. They need to know the rules, what they mean, and how to report issues, in person or confidentially. Robust knowledge of – and easy access to – the compliance plan are critical elements. A single copy of the compliance plan sitting on a shelf in an administrator’s office is most likely not going to be effectively communicated to the masses and is even less likely to be effective. Ambulance services are far more likely to have favorable audit outcomes if policies, procedures, updates and expectations are communicated frequently and clearly.
3. Monitor
Monitoring is a two-fold approach. Knowing what is happening in the industry is important, as this will give you a roadmap for what to be reviewing within your own agency. Rules and regulations evolve and update regularly. Compliance officers must be reviewing policies and procedures constantly, to ensure that they are up to date and in line with current regulations, and that these are being appropriately followed.
The OIG and state EMS websites report ambulance service violations giving you important information as to what to be watching for within your own agency. Continual review of these websites and of CMS, MAC, Medicaid and other governmental publications will keep your service abreast of new rules and revisions. Signing up for e-mail updates brings a wealth of compliance information into your mailbox at regular intervals.
Now that you know what to look for: look for it. Compliance is everyone’s responsibility and as the old saying goes, people will respect what you inspect. A good way to monitor the plan adherence and effectiveness is to make it a part of the QA/QI process.
Using both internal and external resources to review charts and billing practices is advisable. An external claims review can provide a perspective similar to what is reviewed in an actual audit, identify areas of best practices, and make recommendations where there is need for improvement. These regular reviews should be designed to identify appropriate level of charge and payment for services.
Refund over or inappropriate payments in a timely manner, consistent with the 60-day rule when necessary. Voluntary identification and refunding can help the service avoid penalties that often accompany a government audit. Finally, in some instances, claims are found to be billed at a lower level than allowed, providing the opportunity to actually improve accounts receivable performance.
4. Improve
Maintaining the highest levels of clinical competency is an expectation and continual development of charting, billing and records maintenance must be as well. Striving for zero errors all the time may not be reasonable expectation. To err is human and mistakes will happen. Not looking for these errors and identifying ways to correct and prevent them is where organizations fail.
Services should seek to maintain low error rates and regular improvement in all areas prone to mistakes and non-compliance such as mileage, coding and obtaining appropriate signatures. Keeping compliance error rates below 5% should be a goal of all ambulance services. If this is not happening, it may be time for additional training.
What to do when your EMS agency is audited
Depending on how the information is delivered may have bearing on your response. Many audits come in the form of a mailed written request to provide information for claims that have been billed to Medicare or Medicaid. Other may be delivered in person by a contractor or government agent. In any event, professional and timely response and provision of the requested information is imperative.
The first step is informing the appropriate management, compliance and legal representatives when necessary. Next, review the documents thoroughly to understand what is being requested. Oftentimes, this may just be records, such as copies of charts, signature forms or supporting documentation, such as physician certification statements. Having high-quality records maintenance and advanced familiarity with the process of accessing or requesting documents is recommended.
Compile and provide all documents in the manner requested and in the most expedient manner possible. Waiting to the last minute to respond is not advisable. Prior to sending, ensure all documents being delivered are thoroughly examined. This will provide you with an understanding of what is being looked at and possibly why.
Upon completion of their review, the requestor will provide secondary communication. This may be a request for additional documents, refund of payments or, hopefully, notification that no further action is necessary at this time. Once again, review and, if necessary, respond promptly.
This may require a written rebuttal including additional records from the sending/receiving facility and even an interpretation or explanation of the need for transport from the medical director.
Make a copy of the entire packet and keep it readily available for reference when and if the auditors contact you with follow-up questions. They may ask to review your compliance plan and activities. Records of regular staff compliance education, plan review/updates and claims review reports should be included. Adherence to the processes discussed above will be beneficial.
Finally, always be respectful and professional in your communication, whether written or verbal. A good attitude and pleasant demeanor can pay dividends.
Remember, your audit is coming. Will you be surprised or prepared when it arrives?
About the author
Anthony Minge, EdD, is a senior partner at Fitch & Associates. He has extensive experience in public safety and healthcare finance. Prior to joining the firm, Anthony was the business manager for Northwest MedStar in Spokane, Wash., one of the largest air medical programs in the Pacific Northwest. He holds a Doctor of Education degree in organizational leadership. Contact him at aminge@emprize.net.
