DSS / Medicaid AuditsClosed – June 2017

CONNECTICUT MULTISPECIALTY GROUP, PC (2014)

GROVE HILL MEDICAL CENTERS, PC (2015)

DSS / Medicaid AuditServices from 01/01/2011-12/31/2013

CONNECTICUT MULTISPECIALTY GROUP, PC

Audit Conducted at Corporate OfficeSeptember 2014

u Original Sample: 100 Records

u Included: Office, In-Patient, SNF and Dialysis Services

u Medicaid Group: Internal Medicine 004170833u Allergy, Endocrinology, Geriatrics, Hematology/Oncology,

Hospitalists, Infectious Disease, Internal Medicine, Nephrology, Pulmonology, Rheumatology

Audit Findings Returned October 2015

u Errors Found in Sample: 19 (out of 100 Records)

u Amount of Overpayments Found: $709

u Extrapolated Overpayment Amount: $246,013

Exit InterviewDecember 2015

Each record was reviewed and discussed.Each record was individually disputed with the DSS Representatives.

In Attendance:u Michael Deshaies, DOu Jarrod Post, MDu Mark Vye, CEOu Cindy Kisselburgh

DSS Final Report January 2016

u Remaining Errors Found in Sample: 16 (from 17)u Amount of Overpayments Found: $573u Extrapolated Overpayment Amount: $198,831

u Request for hearing by Starling Legal Counselu Challenging findings on individual recordsu Challenging method of extrapolation and requesting

data files for statistician review

DSS FindingsSpecific Errors Identified

u E&M Servicesu 14 of 16 Errorsu 88% of Errors

• 6 Office • 6 In-Patient Hospital• 2 Skilled Nursing Facility

Place of Service

• 1 Up-coded• 11 Down-coded• 2 Disallowed

Level of Service

• Denial for 2nd administration code during same visit• Claim processing issue with Medicaid paying primary

in error

Other than E&M

What did we learn?

u E&M Coding can be SUBJECTIVE – don’t leave it up to the auditors!u Clearly document the medical necessity for all of your encountersu A comprehensive history requires at least 4 HPI elements, at least 10

systems reviewed, and a medical, family and social historyu A comprehensive examination requires 8 organ systems (no credit for

body areas)u High level medical decision making requires 2 out of 3 of the following:

u At least 4 diagnosis points; at least 4 data points; or a high risk for morbidity/mortality

DSS / Medicaid AuditServices from 07/30/2012 – 07/29/2015

GROVE HILL MEDICAL CENTERS, PC

Audit Conducted at 300 Kensington OfficeAugust 2015

u Original Sample: 100 Records

u Included: Office and In-Patient Services

u Medicaid Group: Pediatrics 004195930u Included six physicians

Audit Findings Returned August 2016

u Errors Found in Sample: 35 (out of 100 Records)

u Amount of Overpayments Found: $1,592

u Extrapolated Overpayment Amount: $825,665

Exit InterviewJanuary 2017

Each record was reviewed and discussed.Each record was individually disputed with the DSS Representatives.

In Attendance:u Michael Genovesi, MDu Marc Ramirez, MDu Mark Vye, CAOu Mindy Tompkins, Esqu Cindy Kisselburgh

DSS Final Report April 2017

u Remaining Errors Found in Sample: 21 (from 23)u Amount of Overpayments Found: $708u Extrapolated Overpayment Amount: $233,786u Request for hearing by Starling Legal Counsel

u Challenging findings on individual recordsu Challenging method of extrapolation and requesting

data files for statistician review

DSS FindingsSpecific Errors Identified

u E&M Servicesu 11 of 21 Errorsu 52% of Errors

• 10 Down-coded• 1 Disallowed

Level of Service

• Vaccine/administration not documented• Developmental screening not documented

Other than E&M

• Incorrect vaccine billed• Duplicate billing

Billing Errors

What have we learned?

u Department of Pediatrics now on AllScriptsu Custom templates created for developmental screening interpretation and

discussion

u Custom templates created for vaccine counseling and immunization orders recorded in chart with administration date

u Custom templates created for oral evaluations and documentation of fluoride administration

u Documentation of time spent counseling and coordinating care more easily captured with built-in statement option

DSS / Medicaid AuditsClosed – June 2017

CONNECTICUT MULTISPECIALTY GROUP, PC (2014)

GROVE HILL MEDICAL CENTERS, PC (2015)