The Practice Checkup

The Practice Checkup

The analysis is broken down into major service categories and individual supplemental service components. In this manner, the practice can build the analyses based upon both their needs and their resources. The Basic package consist of the following services:

The Practice Checkup, which includes:

· Fee Analysis

· Procedure Code Compliance Analysis

· Correct Coding Policy Edit Analysis

· Relative Value Scale Analysis

The data used for this process is aggregate data, that is, not specific for any location or physician. We use aggregate or cumulative data for the entire organization and do not break out the analyses by location and/or physician.

Charge Master Analysis

For the purposes of this analysis, the charge master is defined as a concise listing of the procedure code/modifier groups (code groups) that are integral to the practice’s fee schedule. It includes, for each code group, the annual frequency for which the service is performed and the commercial fee that is charged. A full charge master analysis consists of the following elements:

Fee Analysis

The fee schedule is the most important financial tool within the medical practice. It is from here that the entire billing and collection process begin. And while EOBs are required in order to validate reimbursement, much can be done in their absence to establish a fee schedule that is quiet, consistent and passes muster in relation to several important internal and external benchmarks. This process of balancing the fee schedule is referred to profiling and it is designed to assist the practice with the development and maintenance of a fee schedule that optimizes revenue and minimizes exposure. First and most importantly, fees are compared against the Medicare Fee Schedule amount to insure that no procedures are being charged below that benchmark. Next, fees are compared against the Minimum Charge Threshold (MinCT), a factor established by the practice as a relational minimum amount above which the procedure should be billed, and the Maximum charge Threshold (MaxCT), a value above which might be considered as overpriced. Then, further profiling is conducted to insure that the fees identified for modifier relationships are appropriate with their non-modified counterparts and that fees are within defined minimum and maximum charge thresholds.

Procedure Code Compliance Analysis

In this process, each procedure code is checked to insure it is valid for the current year and represented by the correct description. Then, it is compared with Medicare and other government regulations to insure that it is being used properly. The RPA identifies codes subject to the National Correct Coding Policy, fraud exclusionary areas and reasonableness of use. This report will include such important regulations as those covering the use of assistants at surgery, co-surgeons, multiple surgeons, multiple procedures, etc. These types of details are often overlooked, particularly by academic institutions, because of the difficulty in obtaining all of the data from one source. Other reports show such specifics as the financial impact and deletion dates for codes that are no longer valid for the current year and also for codes that have never been valid HCPCS codes.

In addition to the above, we do a specific examination of the use of modifiers in relation to their counterpart codes. For example, we will identify code/modifier combinations that are inappropriate and that may result in denials and even violations of the law. We look at all E/M codes to insure that they are used only with appropriate E/M modifiers and then exam the rest of the codes to insure that they are not used with E/M-only modifiers. We will compare your use of modifiers with that of the national statistics for the same specialty to identify potential lost revenue opportunities and possible compliance issues.

Correct Code Initiative Compliance Analysis

The Correct Coding Initiative (CCI) was developed for the purpose of eliminating the practice of unbundling procedures by establishing an exhaustive set of restricted coding pairs. Currently, the database contains over 165,000 records, each containing a pair of procedure codes that if billed together will either be rejected outright or paid at an amount equal to the lowest reimbursement of the two codes in the edit pair. If a practice has noticed a seemingly unexplained increase in Medicare rejections over the past year or so, they can be relatively certain that it is due to the CCI restrictions.

We use the only integrated system that will produce a set of cross referenced reports for the practice that are filtered by the practice’s fee schedule. By making the reports far more user-friendly and manageable, it all but guarantees the practice will use this as a reference to increase Medicare collections and cash flow.

Relative Value Scale Studies

Relative value scales (RVS), particularly the RBRVS, have been embraced for years by the health care industry as a way to statistically benchmark the medical practice and the individual physician. Relative value scales are used in almost every aspect of costing, revenue, compensation, utilization and resource allocation studies performed. As part of the total package, we will perform a complete Relative Value Scale analysis to prepare the practice for further, more complex analyses. Information obtained includes component RVU data, conversion factors and GAF adjusted value broken out by major HCPCS coding categories.