Updated on: May 26, 2016

Exposing Investigatory Audits

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Original story posted on: May 25, 2016

I don’t think anyone would argue that we have made significant strides in technology over the past several decades. In fact, advancements in technology are emerging at exponentially faster speeds.  

Just think about the relatively new ability to track our every move. Credit cards, toll-taking devices, bar code scanners, license plate readers, GPS systems, smart phones, tablets … the list goes on.  

Virtually every one of us can be geo-located and our expenditures tracked by someone, somewhere, at pretty much any time, day or night.  And most of the time, it happens without our knowledge or direct consent. I used to think that I was just paranoid, but now I think I’m not paranoid enough!

This is also true for healthcare providers, and in more areas than one.  Electronic health records (EHRs) were touted to be a silver bullet with regard to consolidating and organizing patient data to improve communication and efficiency. Instead, they have proven to be one of the greatest contributors ever to inefficiency and productivity loss.  

And this is also true when it comes to compliance.  

In 2011, the Centers for Medicare & Medicaid Services (CMS) introduced providers to its fraud prevention system, a complex statistical system that uses a series of predictive analytics algorithms to review 100 percent of all fee-for-service claims. 

In general, the field of statistics is nearly always involved in technology enhancements in one way or another. Sometimes it leads the way, and sometimes it’s just in a support role. When it comes to compliance and audits, this holds particularly true. I recently attended the Compliance Officers Forum for the Association of American Medical Colleges, and at least in the sessions I attended, there emerged a clear, consistent, and loud message about the need to move toward risk-based auditing. The term “risk” is heavily dependent upon statistics in general, and more specifically, in predictive analytics. It’s clear, at least to this forum of chief compliance officers from some of the most prestigious academic institutions in the country, that audits are here to stay. We, as a provider industry, need to better understand the audit process and be more prepared to support what we bill and defend against as it pertains to audits. 

In the upcoming June 2 documentary broadcast “Audit Nation, The Documentary: Exposing Investigatory Audits” we will present a team of healthcare experts in every critical field. It will include healthcare attorney David Glaser, who will speak to the legal challenges that audits create. Ronald Hirsch, MD will give you the physicians’ perspective. Sean Weiss, who oversees hundreds of thousands of audits a year at DoctorsManagement, will report on the hard costs of being unprepared for an audit versus the relatively lesser cost of when facilities and providers are prepared. Pat Marion, formerly of the U.S. Department of Health and Human Services (HHS) Office of  Inspector General (OIG), along with a chief compliance officer from a major academic institution, will also be part of the 60-minute broadcast. I will speak to the introduction of advanced statistics and predictive analytics use by all payors seeking to identify high-risk providers.  

The bottom line is this: everyone who contracts with a third-party payor, whether government or private, agrees to have every move, every claim, and every dollar questioned – and if we don’t do something to prepare up front, we will have to do much more to defend ourselves in the end. If ever “an ounce of prevention is worth a pound of cure” made sense, this is the time. 

In the infamous words of Chinese military strategist and philosopher Sun Tzu, “the more you sweat in peace, the less you bleed in war.”

And that’s the world according to Frank. 

About the Author

Frank Cohen is the director of analytics and business intelligence for DoctorsManagement, a Knoxville, Tenn. consulting firm. Mr. Cohen’s specializes in data mining, applied statistics, practice analytics, decision support, and process improvement. 

Contact the Author 

fcohen@drsmgmt.com

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Frank D. Cohen, MPA, MBB

Frank Cohen is the director of analytics and business Intelligence for DoctorsManagement, a Knoxville, Tenn. consulting firm. He specializes in data mining, applied statistics, practice analytics, decision support, and process improvement. He is a member of the RACmonitor editorial board and a popular contributor on Monitor Monday.

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