08.25.2022

Use data to reduce audit risk

Is your home health or hospice agency effectively monitoring its own data to determine the risk of a Medicare or Medicaid payment-related audit?

Data can help home health and hospice providers identify trends and patterns that trigger program integrity or payment related audits by Medicare contractors, SimiTree compliance experts say, giving providers the opportunity to correct issues before the provider is audited for improper payments.

But many facilities either don’t know how to use data for this purpose or don’t have data tracking built into their operation.

“Most of the organizations we work with lack the ability to effectively track and trend data,” said SimiTree Senior Manager Laurie Newlun, Compliance and Regulatory. “They don’t have the right organizational processes in place.”

Newlun and other compliance and regulatory experts at SimiTree work with providers to help them unlock the means to monitor how and where they are incurring risk, and show them how to make corrections.

Data analytics identifies risk by showing where a provider is operating outside state or national averages, a red flag which often triggers Medicare audits. Correcting aberrancies can reduce audit risk.

Although most providers audited are simply making mistakes instead of perpetrating intentional fraud, the audit experience can be unpleasant, and most providers are eager to learn how to use data to identify and mitigate the risk.

“It can be a harrowing, time-consuming and costly experience to go through an audit, and most providers would prefer to avoid it,” said Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.

OIG calls for more audits

Identifying areas of risk is becoming increasingly important due to a rising number of Medicare audits. Skehan said Medicare program integrity and payment-related audits are ramping up in response to a recent directive by the Office of Inspector General (OIG), the federal agency in charge of investigating fraud and abuse.

“In its most recent work plan, the OIG recommended more investigation, auditing and inspection of all healthcare providers,” Skehan said.

SimiTree consultants are seeing an increase in requests for help from providers who have been selected for Targeted, Probe and Educate (TPE) audits, contacted by Recovery Audit Contractors (RACs) and notified by other Medicare contractors that they are being investigated for suspected overpayments.

When auditors find overpayments were made, they reclaim funds paid to the agency in error. In some instances, penalties may be levied, or criminal prosecution may occur.

Start with PEPPER reports

One of the best sources of data to help a home health or hospice provider identify potential audit risk is Medicare’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), a free educational tool.

PEPPER summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support their internal auditing and monitoring activities. PEPPER summaries, a user guide, recorded training sessions and other resources are available here.

SimiTree compliance experts can help facilities understand how to interpret PEPPER reports and use the information in these reports as well as EMR reports and other data sources to mitigate compliance risk.

Financial Monitor offers benchmarking

Agencies interested in benchmarking and data monitoring may be interested in subscribing to The SimiTree Financial Monitor, an in-depth financial report offering industry-leading analytics and benchmarking.

The SimiTree Financial Monitor helps agencies identify their vulnerabilities and compare their performance with other agencies across the nation and in their state, said Brian Martin, Vice President of The Financial Monitor.

More information about The SimiTree Financial Monitor is available here.

Schedule a compliance assessment

From benchmarking data to prebill audits and full compliance assessments, SimiTree offers the tools and services providers need to better insulate themselves against audits and non-compliance.

The SimiTree team is made up of clinical experts who are certified in healthcare compliance with extensive experience in government audits and appeals at all levels, including ALJ expert witness.

In addition, current, former, and certified surveyors provide best-in-the-industry comprehensive compliance and regulatory support to meet an organization’s needs.

Schedule a full compliance assessment today to evaluate how well your facility is meeting billing and payment requirements, as well as HIPAA requirements and Medicare’s Conditions of Participation (CoPs). Each assessment includes corrective plan recommendations with additional compliance and regulatory implementation support.

Use the form below to ask us how SimiTree can help your organization better understand its risk, and shore up compliance.

Contact Us

Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 800.949.0388 or complete the form below.

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