Conducting audits and investigations is an inherent component of any effective compliance program. What’s more, given the complexities of healthcare regulations, you need subject-matter experts who can assist you with solving complex coding and compliance issues that may affect your entire organization.
We’re here to help. With over 40 years of compliance experience, we have played an integral role in some of the nation’s largest healthcare fraud and abuse cases, which allows us to bring unique insights to every project.
Extensive experience ensures you get the results you need. We routinely perform documentation, coding, and coverage audits including DRG validation, coverage of AICD and pacemaker implantation, teaching physician services, short stay admissions, hyperbaric oxygen therapy, neonatal intensive care, ambulance services, physical therapy, and evaluation and management services.
We regularly perform audits and investigations in a variety of settings such as:
- Conducting internal investigations into known or suspected compliance violations.
- Investigating for purposes of self-disclosing to Medicare contractors and the Office of the Inspector General (OIG).
- Providing expert defense against government allegations of fraud and abuse from the OIG, Department of Justice, Medicare Administrative Contractors, and Program Integrity Contractors.
To get you the answers you need, we offer a full spectrum of auditing services including data analysis, documentation, coding, coverage and medical necessity reviews, process reviews, and employee interviews to identify necessary corrective actions to help you move forward in full compliance, reduce risk, and ensure best practices. We utilize the same audit tools and approach as the government contractors to ensure consistent, accurate results you can rely on.
We work collaboratively with you to develop the right solutions to help your organization’s precise needs while meeting your budget.
Our main audit services include:
- Coding and Billing Reviews
- Documentation Improvement Reviews
- Payor, Government, and Internal Investigations
- Risk Assessments and Acquisition Due Diligence
- Independent Review Organization (IRO) Services
- Medical Necessity Reviews
- Statistical and Non-Statistical Sampling
- Charge Description Master Reviews
- Revenue Cycle Reviews
- Artificial Intelligence (AI) Assessments and Validation
Coding and Billing Reviews
The accurate assignment of CPT, HCPCS and ICD-10 codes is a critical component in ensuring an organization’s compliance and financial success. We have a team of certified physician and hospital coding experts who perform outpatient and inpatient coding reviews to evaluate the accuracy and completeness of your coding. We work with you to design the scope of the review to ensure meaningful and efficient results based on your needs and risks. We provide you with a detailed report identifying any potential risk areas as well as charge capture and revenue opportunities combined with corrective action recommendations to reduce your compliance risks and improve your financial performance. We offer these services on an as-needed basis or as part of the regular compliance monitoring program. We also perform coding audits as an integral part of risk assessments and due diligence as well as internal and external investigations. We are available to provide assistance in implementing and monitoring the recommended corrective actions and providing customized education and training based upon the findings of the review.
Documentation Improvement Reviews
One of the biggest challenges facing healthcare providers is generating accurate and complete medical record documentation. Medical record documentation is at the forefront of patient care, coding and reimbursement. With the continuing evolution of electronic health records, providers face an increased risk of malpractice, improper coding and financial concerns. Our experts have extensive experience working with electronic health records and templates and are well versed in the current regulatory issues surrounding the known risks and reimbursement implications. We perform reviews of provider documentation for the purpose of identifying potential risks like cloning, inconsistent and/or improbable documentation as well as identifying areas for documentation improvement to increase reimbursement. We provide you with a detailed report identifying any potential risk areas as well as documentation and reimbursement opportunities combined with corrective action recommendations to reduce your quality of care and compliance risks and improve your financial performance. We offer these services on an as-needed basis or as part of the regular compliance monitoring program. We are available to provide assistance in implementing and monitoring the recommended corrective actions and providing customized education and training based upon the findings of the review.
Payor, Government, and Internal Investigations
Our team has played an integral role in some of the nation’s largest healthcare fraud and abuse cases where we have gained exceptional experience; this allows us to bring a unique perspective and insight to each and every project. We work integrally with compliance, general, and external legal counsel to ensure a timely, efficient process that yields the best results for our clients. We have extensive experience working with providers to conduct internal investigations and self-disclosures to multiple Medicare and Medicaid contractors as well as to respond to allegations from the Office of Inspector General and Department of Justice. Our team of experts has a proven track record for identifying accurate, objective, defensible work plans and results that have never been rejected or subjected to further review by a government payor or enforcement contractor.
Risk Assessments and Acquisition Due Diligence
Healthcare compliance enforcement is at an all-time high. There has been an increase in the number of audits by a multitude of agencies including the Department of Justice, Office of Inspector General, Unified Program Integrity Contractors, as well as Medicare and Medicaid claims processing contractors. Identifying and mitigating compliance risks are essential components of an effective compliance program. The process of conducting risk assessments and acquisition due diligence reviews is the best practice for identifying areas of risk and prioritizing the need for policies, procedures, education, and training. Our team of certified healthcare compliance and coding experts will work across your organization to identify areas of risk and work collaboratively with you to address areas of risk to ensure compliance.
Independent Review Organization (IRO) Services
The selection of an IRO is a critical decision for any organization. You need an IRO you can trust to be timely, thoughtful, thorough, objective, knowledgeable, and, above all, accurate. We have over a decade of IRO experience and currently serve as the IRO for both physician group practices and large hospital systems. As an IRO, we have never been removed or had a report rejected by the government. We understand the stress as well as the financial and operational burden of maintaining a corporate integrity agreement (CIA). We work closely with each of our clients to provide efficient and cost-effective IRO services that not only satisfy the government’s requirements, but also provide valuable findings to improve the client’s operational, compliance, and financial performance. We provide comprehensive IRO services including unallowable cost reviews, statistical sampling and extrapolations, documentation, coding and claims reviews, and medical necessity reviews.
Medical Necessity Reviews
We have internal clinical staff as well as a contracted team of board-certified physicians with expertise in a variety of clinical areas including emergency medicine, wound care, internal medicine, cardiology, interventional cardiology, electrophysiology, family practice, and pediatrics. Our physicians review medical record documentation to determine medical necessity for inpatient admissions and procedures as well as outpatient services. Our physicians have vast experience in peer reviews, investigations, testimony, and Corporate Integrity Agreements.
Statistical and Non-Statistical Sampling
We provide statistical sampling services including identification of the relevant population, reviews of population integrity, sample size optimization and risk, and confidence and precision levels. In performing these services, we use masters-level statisticians to assist in all phases of the sampling process. HBE Advisors adheres to both industry and government protocols regarding sample selection, evaluation, and documentation.
Charge Description Master Reviews
In today’s environment, a significant percentage of outpatient, hospital coding, and reimbursement is chargemaster-driven. Having a current and accurate chargemaster, combined with staff education, is critical to ensure compliant reimbursement and optimal charge capture. Due to the volume of coding performed through the chargemaster, an error in a CPT/HCPCS code, description, and/or price will result in repetitive improper claims and/or lost revenue. Our reimbursement and coding experts have developed a proprietary comprehensive chargemaster audit process to identify revenue opportunities and reduce compliance risk. Our unique approach encompasses reviewing the items, codes, and prices within the chargemaster in combination with documentation and claims to ensure that all items and services are accurately included and appropriately priced in the chargemaster and that they are transitioning to the claim in an appropriate manner. We provide you with a detailed, prioritized report outlining our recommendations, by line item, to improve charge capture and financial performance, reduce denials, and limit compliance risk. We are available to provide assistance with monitoring the recommended corrective actions and providing customized education and training based upon the findings of the review.
Revenue Cycle Reviews
The financial success of any organization is dependent on effective, efficient processes from patient registration to claims submission to payment posting. Our healthcare team has decades of experience in evaluating provider revenue cycle processes to ensure optimal performance. We review key financial performance reports including aged accounts receivable, aged credit balance, denial, and bad debt reports. Based on the findings of these reviews, we work with management to establish benchmarks and revise processes to improve days to collection, reduce claim denials, and bad debt write-offs. We offer these services on an as-needed basis or as part of a monthly monitoring program. We are available to provide assistance in implementing and monitoring the recommended corrective actions and providing customized education and training based upon the findings of the review.
Artificial Intelligence (AI) Assessments and Validation
AI is the future of healthcare auditing and coding. Effective, thorough, and accurate, AI begins with a foundation of expert coders and auditors. Our team is available to provide the support you need with AI development, testing, and post-deployment validation. Our documentation and coding experts can assist you with evaluating the quality of the medical record documentation and coding used for AI development, evaluating the accuracy of AI generated coding, as well as conducting post-deployment quality monitoring and auditing. Our comprehensive AI services are performed in collaboration with your team to promote a positive approach to ensure quality and compliance.