Legal Support Services - Advize...

Legal Support

Services

May 2019

Copyright © 2019 Advize Health

Advize Health Capabilities

Program Integrity

FWA TrainingClaims Analysis

and AuditCompliance

Program Management

Project Management and

Education

User Requirements

Analysis

Research/Evaluation: Health Policy, Program, Market

Legal Support

Review Expert Testimony Reporting

Government Programs Private

Payers

Health Systems Law Firms

Private Practices

✓ 16+ Years of Positive Track Record ✓ Cost Effective Solutions

✓ 65+ Employees; Responsive and Flexible SMEs ✓ Reliable and Compliant; Secure Processes

✓ Variety of Payer/Provider Clients ✓ Fast Implementation

2Copyright © 2019 Advize Health


Daily Advize Questions: How could we…

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Our Obsession: Cost vs. Care

…Innovate and deploy

better best practices?

…Save more

money?

…Increase the quality of

healthcare?

https://www.bloomberg.com/graphics/2017-health-care-spending/



After 16 years of auditing larger data sets and performing extrapolation for increased ROI for

payers, we have shifted to focus on more of a relationship with the provider based on data and

best practices.

▪ Advize has pushed to:

– Simplify the process of receiving data and sending results to providers

– Flexibly leverage the data in more real life contexts

– Focus on changing the ecosystem by positively impacting ongoing provider behaviors

– Increase the engagement between provider and payer by serving as the helpful third party

▪ Advize takes a multifaceted approach which extends beyond normal data analytics

– Our team has expanded our model of coding and billing audits focused on waste and abuse to also

examine fraud through Data Analytics and OIG best practices.

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Introductions



▪ Data Analytics – Peter Armstrong

– Founder of Sunera, 300+ employee consultancy focused on analytics, regulatory compliance, internal audit, information security & technology services

– Former Partner with KPMG and led risk-based services initially in Calgary and subsequently in the North Florida region

– ACL Certified Data Analyst (ACDA)

• Worked with many healthcare systems in implementing data analytics and continuous controls solutions.

▪ Investigations – Eric Rubenstein

– 25 years of federal law enforcement experience; focused in healthcare fraud, waste and abuse

– 22 years as an OIG Special Agent; Close to ten trials and many opportunities to successfully testify

• Over 150 convictions and civil settlements

• Aided in recovery of $500 million in restitution, forfeiture, damages, penalties, and fines to government programs

▪ Client/Project Management – Jeanmarie Loria

– Owner of Advize Health; 10+ years of experience supporting trials involving FWA, clinical coding, and more

– Created and manages medium to large programs with various payer SIUs

– Manage teams of nurses, providers, CPCs, project managers and project support staff

– Former KPMG focus on IT Security; PMP, CPC

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Introductions



▪ Type of Services

– Audit and Advisory around Program Integrity, including Data Analytics and Payment Audits

– Arbitration and Litigation Support

– Education: Providers, Coders, Compliance Teams, Payer SIUs, Law Firms

• Lunch and Learns, Webinars and Bootcamps

– Record Collection

▪ Value of Services

– Savings, impact, case studies

▪ Focus

– Reducing the cost of healthcare

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Support Services


Copyright © 2019 Advize Health 7

CPTE/M Professional Services; Facility; Emergency Department; Mental Health; Substance Abuse; Pain

Management; Modifiers 24, 25, & 57

Procedure Lab; Pharmacy; Radiology; Surgery; Modifier 59

DME DME and Home Healthcare Audits

ICD-9/10 HCC and Risk Adjusted Rating and Payment

UPIC State and CMS

DRG DRG Inpatient Hospital Audits

HCPCS Products; Special Procedures; Pharmacy Audits

Teaching Teaching Hospital Reviews; Educational Reviews

Consulting

Corporate Integrity Agreements, SME Utilization, Expert Testimony, Reporting, Policy and Procedure

Reviews; Risk Adjusted Rating Reviews; Dental Reviews

Medical Necessity Reviews; Over-Utilization Reviews; Clinical Documentation Improvement

High-Demand Services



▪ Advize synthesizes audit best practices across all clients to provide advisory services with the quality found within larger consulting firms without the associated cost.

▪ Best Practices include:

– Leverage Technology

• Robust, Faster, More Cost effective audits

– Reduce IT Risk

• Cybersecurity

– Education

• Provider community and members

– Partner with SIU more

• Determine audit strategy

• Targeted onsite record retrieval (look for billed equipment)

– Staff Augmentation

• Statistician

• Peer-to-Peer

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Implementing Industry Best Practices



▪ Innovation within Current Context

– Healthcare is large and slow to move

– Utility and healthcare industries

▪ Compliance and Education

– Provider Education

– Medical Coder/Biller/Auditor Training

– Highly Credentialed Compliance & Education Staff

– Group Trainings

• Onsite, live virtual, on demand

▪ Arbitration & Litigation Services

– Federal, Commercial, Private clients

– Data Abstraction, Analysis, Reporting

– Credentialed & Qualified SMEs

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Fraud, Waste and Abuse Support Services



▪ Sample of Services to support the audit lifecycle

– Record Retrieval, Storage, Purge

• Onsite record retrieval

• Send request letters and other communications with providers

• Secure file upload (SFU)

• Records are stored securely

• Minimum necessary PHI accessed

• Record files are securely returned with audit result delivery

– Corporate Integrity Agreements

• Statistically valid sampling

• Medical necessity and proper coding/documentation review

– Audit Management and Quality Assurance Support

– Reporting and Results Delivery

– Overpayment Recovery and Overpayment Support

– Legal Support

• Case building, expert witness, audit, reporting and testimony

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Audit Support Services



▪ Claims Data

− Cleaning the data will remove inconsistency

− Transforming or consolidating the data into an appropriate form for performing summary or

aggregation

− Analyze the relevant data retrieved from the database

− Pattern evaluation

▪ Selection Process

− Determine the parameters of the claims selection

− Random Sampling

− Statistically-valid sample size - RAT-STATS

− Extrapolation

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Planning, Claim Selection Methods



▪ Audit notification

– Composition, shipment, transference correspondence notifying providers of impending review.

▪ Facilitate the secure collection and transfer for claims documentation, medical records,

and more

▪ Dispatch SMEs, reviewers, or MRTs to onsite locations to abstract clinical data for

review and reporting

▪ Assess HIPAA compliance and identify areas of improvement within practice

– Access control

– Privacy

– Security

– Penalties for infringements, non-compliance

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Collection and Fieldwork



▪ Reviews performed by highly experienced and credentialed auditors

– Audit personnel work with a variety of healthcare personnel and patients. They should always conduct themselves in an acceptable, professional manner and adhere to ethical standards, confidentiality requirements, and objectivity. Auditors trained to completely document their findings and problems.

▪ Perform verification of charges

– What citations are important, and what policies are important?

– Citation guidebook creation

– Review of claims

▪ QA Review

▪ Generation of preliminary audit results

▪ Results delivery and collaboration with client

▪ Report generation

▪ Final Audit Results:

– Contain final audit reporting, this reporting will have included the overpayment amount.

– Review the next steps for the provider who was audited.

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Review and Reporting



▪ Comprehensive reports are created and delivered to clients and are fully customizable.

▪ Standard Reports include:

– Staffing/Provider Structure and Organization

– Audit Scope

– Audit Methodology

– Audit Sample Information

– Individual Practitioner Billing Review and Trends

– Key Audit Findings and Reporting

– Quality of Clinical Documentation and Practices

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Compelling Reporting



▪ Results delivery

– Provide physicians and staff clinical

summary prior to training meeting

• The clinical summary will include both

their error rates and their educational

feedback in an easy to understand

format

• Word or PDF format vs Excel

spreadsheet

• Increase provider engagement – more

likely to come to the meeting prepared

with questions and other feedback

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Compelling Reporting



The Need

▪ A Provider review of dental services, identified as excessive and outlier, which warranted a review of the services.

▪ A State Medicaid program required this project to conduct a complete through review of the dental services.

The Solution

▪ Advize Health conducted an in-depth, comprehensive review of the dental services. The goal being to reduce excessive

services and not medically necessary service expense to the State and Federally Funded program.

▪ Advize Health played an active role in the effort to reduce potential overpayments. Advize Health’s auditors were available to

explain the audit results to the State and CMS.

The Outcome

▪ Advize Health provided supported to the State during ALJ hearing process.

▪ Advize Health identified close to $200 thousand in overpayments.

▪ During the conclusion of the ALJ hearing the provider paid the full amount of the overpayment.

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Dental Review – Case Study



The Need

▪ Chiropractic services has been continually reviewed by and included in the Office of Inspector General’s (OIG) annual work plans.

The expectation, in the identification of trends was to mitigate the potential risk of overpayments by educating providers in best

documentation and coding practices.

The Solution

▪ Advize Health conducted an in-depth, comprehensive review and identified multiple inaccuracies within the chiropractic records

billed . The goal being to reduce overall risk and control payer expenditures

▪ Advize Health played an active role in the review in collaboration with the State Agency to provide a comprehensive reports of

all findings to each licensed professional social workers and/or professional counselor

▪ The healthcare payer organization as a result of the study was able to deliver valuable education to their network of providers.

This education was instrumental in mitigating the risk of any potential future overpayments to be made by the plan. Additionally,

communication was improved between all of the parties involved.

The Outcome

▪ Advize Health identified 34 providers (1680 medical records) with multiple billing discrepancies which resulted in overpayments

and recoupment by the health plan.

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Chiropractic – Case Study



Past Performance

▪ Legal Support Services

– Independent medical reviews of arbitrated cases

– Variety of Specialties

• Acupuncturist: issues with licensing, and false claims being submitted for payment

• Nutritionist: billing for higher level services than actually provided

» Identified alteration of charts post-audit and arbitration reviews

• Oral surgeon: billing both medical and dental insurance for the same patient/services

» Claim information changed in attempt to have both claims paid

• Cardiologist: one provider of a group practice was participating with the carrier

» Claims billed as though one participating provider performed them, when in reality other

providers were completing care

» High volume of upcoded claim lines



▪ Large BCBS Plan enlisted our subject matter expertise to conduct medical review and data

analytics services to attest and testify in multi-clinic, multi-specialty cases from 2017 through

late 2018. Specialties/Cases included:

– Pain Management Clinic with overutilization of high-level E/M codes.

• SVRS performed

• Identified overpayments of over $100,000

– Sports Medicine/Experimental Treatment

• ImPACT testing

• Identified 100% error rate

– Emergency Room – E/M

• Upcoding and insufficient documentation

• Identified 52% error rate

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Medical Review & Testimony



▪ Litigation Support

− Worked on various third party reviews and provided reporting and testimony in several arbitration files within the past 10

years. Some cases have settled due to our effective reporting of the audit results and a case summary. We have worked on a

variety of cases and provider specialties which include government and commercial carriers. A leading global provider of

insurance, annuities and employee benefit programs

− Retrieve medical records, perform data analytics and analyze physician pre- and post- disability claims

▪ 2 Multi-Specialty Clinics with close to 40 locations and 35 specialties combined

− Performing proactive audits and deliver education and training for providers to improve coding

▪ Self Funded Insurance Plan with 300 employees in 2 Companies

− Analyzes claims data and targeted largest dollar claims to audit. Delivered a savings of $5 to every $1 spent

▪ Northeast Regional Health Plan operating in several states with 1M+ members

− Created an E/M Audit Program and audited 50 Physicians using 100-150 records per physician

▪ Hospital offering healthcare to people in an indigent county; 1,000 Employees

− Auditing 70-bed Acute Care Hospital with a 6-bed Critical Care Unit, 8-bed Pediatric Unit, and 25-bed

Medical/Surgical Unit

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Sample of Representative Clients



Durable Medical Equipment (DME) – Case Study

The Need

▪ DME services have quickly grown into a multi-billion dollar industry. When costs are so great, it’s critical that healthcare Payer organizations pay only for the products and services that are supported and rendered.

▪ Home health services / DME activity has been continually reviewed by, and included in, the OIG’s work plans. Advize Health was engaged to assist a national Home Health Benefits Management Services Provider to assist in reviewing these types of claims.

The Solution

▪ Advize Health’s (DME) audit program involved the verification of specifically selected DME claims. It targeted not only high dollar claims but those prone to up-coding, miscoding, and potential abuse.

▪ Advize Health received and audited a total of 812 medical records. All transaction lines on each claim were reviewed, not just the DME line item code.

The Outcome

▪ Each physician received a 1-2 page audit trail for every medical record audited. Advize Health identified the overpayments and error rates shown to the right:

Total paid amount - eligible claims $300,705

Identified overpayments – eligible claims $178,298

Identified error rate 52%

Total paid amount – eligible claims $82,141

Identified overpayments – eligible claims $73,712

Identified error rate 87%

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Heavy Duty Beds

CPAP Rentals



The Need

▪ The behavior health services conformed to all State guidelines as required along with verification of all license social workers and professional counselors

▪ A State Medicaid agency requested a Third Party review of all licensed social workers and professional counselors

The Solution

▪ Advize Health conducted an in-depth, comprehensive review and identified multiple inappropriate billed behavioral health services. The goal being to reduce overall risk and control payer expenditures

▪ Advize Health played an active role in the review in collaboration with the State Agency to provide a comprehensive reports of all findings to each licensed professional social workers and/or professional counselor

▪ The review detailed multiple billing discrepancy, provided awareness and assisted in proper edit implementation to reduce future overpayments

The Outcome

▪ Advize Health identified close to 88 licensed professional social workers and/or professional counselors with multiple billing discrepancies which resulted in overpayments and recoupment by the State Medicaid Agency

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Behavioral Health – Case Study



What Current Clients are Saying

Advize Health has a voluminous pipeline of contracts with health plans, providers and the government. Due to confidentiality

agreements we are unable to provide a full list of the active contracts, but have included customer quotes and representative

clients below.

– “We cannot determine which is better: Advize Health’s responsive team or their auditing tool, which we use daily.”

– “Our staff has received a wealth of information through the educational offerings of Advize Health. Your detailed

reports, your knowledgeable staff, your monthly newsletters and your ongoing communications with our staff has

increased our ability to do our jobs much more efficiently and effectively. As a CFO I am tempted to question if you truly

know your value as we have paid more for less in the past...but I won't as we are happy with the value proposition as

it currently exists.”

– “Advize Health has provided tremendous ROI and very detailed results, which serve as a great tool for our team.”

– “Advize Health’s audit findings sheet will be our standard going forward.”

– “Outside of the actual work product that you produce, I value most importantly the level of communication,

explanation, and availability of your staff to us when questions arise that we need to get answers to. Your ability to

be available on-call is invaluable to us allowing for prompt turn-around as we move each of these to resolution.”



▪ Cost-effective and efficient services to enable Providers and Payers to focus on providing

quality healthcare.


Vision/Mission/Values

Cheapest. Booth. Ever., 2016

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