Business Expense Recovery Audits California

Document Sample
Business Expense Recovery Audits California Powered By Docstoc
					                                                     GSA Contract GS-23F-0003T

                  GSA SCHEDULE 520-9              RECOVERY AUDITS

                              Federal Supply Service
              Authorized Federal Supply Schedule Price List
                  FSC GROUP 520-9 RECOVERY AUDITS

                     MANAGED RESOURCES INC.
                      11 GOLDEN SHORE, STE. 360
                         LONG BEACH, CA 90802
                          PHONE: 562-499-2190
                           FAX: 562-499-2191
                  WEB ADDRESS:

CONTRACT PERIOD: Our GSA Schedule Contract (GS-23F-0003T) period of performance is
5 years from date of award (10/16/06), with 3 five-year option periods.
GENERAL SERVICES ADMINISTRATION: On-line access to contract ordering
information, terms and conditions, up-to-date pricing, and the option to create an electronic
delivery order are available through GSA Advantage!, a menu-driven database system. The
INTERNET address for GSA Advantage! is For more information on
ordering from Federal Supply Schedules click on the FSS Schedules at http://www
                                                    TABLE OF CONTENTS:

COMPANY OVERVIEW ............................................................................................................ 3

CUSTOMER INFORMATION................................................................................................... 4

PRICING ....................................................................................................................................... 6

SERVICES PROVIDED .............................................................................................................. 7

JOB DESCRIPTION FOR CASE MANAGER ....................................................................... 16
                  SIN 520-9 – RECOVERY AUDITS


Managed Resources, Inc. (MRI) is a national consulting and staffing company with headquarters
in Long Beach, California. Founded in 1994, MRI has been focusing on providing professional
revenue support services to commercial and governmental healthcare organizations.

Our company works with Health Systems and Hospitals nationwide in providing consultancy and
staffing support. Basically, our expertise is focused on revenue. We assure documentation,
coding and billing and contractual compliance so that the healthcare provider is appropriately
compensated for services rendered. Our goal is to enhance revenue for our client, but also to
ensure that both the provider and the payor are in compliance with contractual and regulatory
guidelines. For example, in the Managed Care area, our staff are experts in contract
interpretation and in the recovery of underpayments. In the area of coding audits and claims
analysis, our staff is comprised of coding specialists, billing specialists and collection experts. In
the area of DRGs, our staff are experts in Medicare guidelines, and review for both under and
overpayments in accordance with those guidelines. Overall, our services result in significant
revenue recovery and enhancement for our client, but also in effectively diminishing the risk of
governmental fraud and abuse allegations. Our services are priced mostly on a contingency basis,
except for expert consulting and educational programs, which is priced based on time and

We conduct regular surveillances to ensure compliance with the productivity and quality
standards of our clients. We hold ourselves 100% responsible for client satisfaction.

Our GSA Schedule Contract (GS-23F-0003T) period of performance is 5 years from date of
award (10/16/06), with 3 five-year option periods.

Managed Resources, Inc.                                                                          -3-
                 SIN 520-9 – RECOVERY AUDITS


1.     Authorized Special Item Number (SIN)
       520-9 Recovery Audit

2.     Maximum order: $1,000,000 per SIN

3.     Minimum order: $300.00 per SIN

4.     Geographic coverage (delivery area): Domestic Delivery

5.     Point of production (city, county, and state or foreign country):

       Long Beach, CA and other Managed Resources, Inc. offices in the U.S.

6.     Discount from list prices or statement of net price: Government prices are net.

7.     Quantity discounts: None

8.     Prompt payment terms: Net 30 Days.

9a.    Government Purchase Cards are accepted at or below the micro-purchase threshold

9b.    Government Purchase Cards are accepted above the micro-purchase threshold

10a.   Time of Delivery: As negotiated between Contractor and Ordering Agency.

10b.   Expedited Delivery: Services that can be provided on an expedited schedule will be
       provided in accordance with the terms and conditions negotiated for that delivery and
       specified in the task order, or task order modification.

10c.   Urgent Requirements: As negotiated between Contractor and Ordering Agency.

11.    F.O.B. Point: Destination.

12a.   Ordering Address:

       Managed Resources, Inc. (headquarters)
       Golden Shore, Ste. 360
       Long Beach, CA 90802

12b.   Ordering Procedures: For supplies and services, the ordering procedures, information on
       Blanket Purchase Agreements (BPAs), and a sample BPA can be found at the GSA/FSS
       Schedule homepage (

Managed Resources, Inc.                                                                        -4-
                 SIN 520-9 – RECOVERY AUDITS

13.    Payment Address:

       Managed Resources, Inc. (headquarters)
       Golden Shore, Ste. 360
       Long Beach, CA 90802

14.    Warranty Provision: N/A

15.    Export Packing Charges: N/A

16.    Terms and Conditions of Government Purchase Card Acceptance (any thresholds above
       the micro-purchase level): N/A

17.    Terms and Conditions of Rental, Maintenance, and Repair: N/A

18.    Terms and Conditions of Installation: N/A

19.    Terms and Conditions of Repair Parts: N/A

20.    Terms and Conditions for any Other Services: N/A

21.    List of Service and Distribution Points: N/A

22.    List of Participating Dealers: N/A

23.    Preventive Maintenance: N/A

24a.   Environmental attributes, e.g., recycled content, energy efficiency, and/or reduced
       pollutants: N/A

24b.   Section 508 Compliance Information: NA

25.    Data Universal Number System (DUNS) number: 868712308.

26.    Contractor has registered in Central Contractor Registration (CCR) database. Cage Code:

Managed Resources, Inc.                                                                      -5-
                 SIN 520-9 – RECOVERY AUDITS



 Service Name                           GSA Price with IFF
 Recovery Audits                        20%

Labor           10/16/06-   10/16/07-   10/16/08-   10/16/09-   10/16/10-
Category        10/15/07    10/15/08    10/15/09    10/15/10    10/15/11
Case Manager    $61.75      $63.91      $66.15      $68.46      $70.86

  Managed Resources, Inc.                                              -6-
                 SIN 520-9 – RECOVERY AUDITS


Audits & Recovery  Claims Denial  Coding Validation  DRG  Case Management


MRI has performed defense, concurrent and focused retrospective assessments and evaluations
on patient accounts against national and local medical review policies, and in the light of “Best
Practice” criteria, with the goal of process improvement in the areas of charge accuracy,
contracting, and compliance with regulatory and internal charging policies and procedures.
Through its performance, MRI has assisted the client: 1) in identifying areas of revenue loss and
non-compliance through auditing contracts and claims and reviewing medical documentation,
charging policy and identifying areas of discrepancy and deficiency; 2) in recovering payment
discrepancies identified in the course of the audit; and 3) in training staff through educational
programs and reports, highlighting application of performance measurements, identified
deficiency patterns, corrective action and process improvements.

The following is a sample periodic graphic summary submitted by Managed Resources,
Inc. to a client:

                  Hospital       Hospital      Hospital      Hospital      Hospital         Total
                       A             B             C             D         E               System

                                   Discrepancies- identified

     Amount         $742,778       $843,327    $1,071,087    $2,519,574        $563,952   $5,740,718

     Accounts              162           322           344           451            64         1,343
                      524,355       799,332     1,012,819     2,190,903         210,906    4,738,315
Projected Cash        475,000       700,000       875,000     1,825,000         175,000    4,050,000
Cash Received
                      223,817       162,117       197,340       278,983           7,540     869,797

Managed Resources, Inc.                                                                          -7-
                       SIN 520-9 – RECOVERY AUDITS

Audits & Recovery  Claims Denial  Coding Validation  DRG  Case Management


You can counter the effects of declining payments and increasing cost pressures through
effective claims management. Claims denial management is a critical component of a hospital’s
revenue integrity and strategy. Claims Denial Management can enhance revenue at a time of
declining payment.

Enhance Revenue Through Claims Recovery

Our clinical nurse specialists review claims along with medical records for medical necessity.
They identify the services rendered and validate that the appropriate levels of care are billed
correctly. They address issues regarding documentation, lack of medical necessity and plan of
care. Our staff will provide effective appeal letters to improve claims recovery. They provide
complete follow-through on denials from 1st Level to 2nd Level to achieve the desired results.
Furthermore, we provide comprehensive reports to assist prospective prevention.

Our Claims Denial Appeal Management Program

This program consists of parallel recovery and prevention processes:
         claims recovery process to address claims that have been denied, and
         a prospective prevention process to avoid future claim denials.

                                     Sample Report by Facility
                                     January – December, 2005







                            A              B            C              D            E
           Appealed     536,594.00     446,483.00   157,952.00    120,010.00     62,985.00
           Collected    456,821.00     252,799.00   118,935.00     93,650.00     38,926.00

Managed Resources, Inc.                                                                      -8-
                 SIN 520-9 – RECOVERY AUDITS

Audits & Recovery  Claims Denial  Coding Validation  DRG  Case Management


Review of the accuracy, appropriateness and compliance of health care claims submitted to
commercial insurance companies by VA Medical Centers.

Purpose of Project:

The purpose of the contract is to evaluate the accuracy and consistency of claims prepared for
inpatient, outpatient and pharmacy services at a facility and network level.

Scope of Work:

The intent is to furnish validation of the compliance, appropriateness and accuracy and claims
sent from VA facilities to commercial insurance carriers. Managed Resources will complete all
monthly Corporate Business Integrity (CBI) audits required by VHA. We will review additional
claims over and above the CBI requirements.

A representative sampling of claims will be audited. When auditing, we will review all claims
prepared for an individual patient for the selected date of service. We will review each claim for
compliance, appropriateness and accuracy. The following guidance will be followed when
reviewing claims:

Review of claims will follow Veterans Health Administration (VHA) guidelines. Errors will not
be reported for issues that are not applicable to the VHA.

VA bills health insurance carriers for treatment of non-service connected conditions provided to
veterans. Treatment of service-connected conditions will not be billed. The presence of service-
connected conditions may be found in the medical record documentation.

The VA is not authorized to bill Medicare or Medicaid. Medicare supplemental policies are
required to pay without Medicare Explanation of Benefits.

Recommendations not compatible with VHA guidelines will be identified and discussed with the
Facility Contact/ COTR prior to inclusion in the final results.

Managed Resources, Inc will review findings with the Facility Contact/ COTR during or
following the audit, and prior to preparing the final written report. Upon request, we will
provide VA with the specific resource used to substantiate a reported error. Areas of
disagreement will be referred to the Facility Contact/ COTR for resolution prior to the
completion of the written report. Areas that cannot be resolved at the facility level will be
referred to the VISN COTR for resolution.

Managed Resources, Inc.                                                                      -9-
                SIN 520-9 – RECOVERY AUDITS

1. VA will provide Managed Resources with online access to the applicable claim forms,
   medical record, Chargemaster and patient registration information.

2. We will complete the Corporate Business Integrity (CBI) process as defined by VA. The
   reviews will be done using VA Forms and completed per VA guidelines. The following
   items will be reviewed. Should VA make minor modifications of the CBI audits, we will
   make such changes at no additional cost to VHA.

      a. CBI Data Elements – First Party Co-Payment:

             Medical record documentation exists for service billed

      b. CBI Data Elements – Third Party Billing:

             Diagnosis code matches Patient Care Encounter (PCE) software entry

             Date of service matches PCE

             Place of service matches PCE

             Type of service matches PCE

             Procedure codes matches PCE

             Modifiers match PCE

             Linkage Procedures/DX match PCE

             Number of units match PCE

             Provider credentials match PCE

             Covered service – service which third party carries pay

             In addition to “matches PCE” vendor will provide an error report, which states the
              correct element even though the element matches PCE and is not considered an
              error for the VA CBI audit.

Managed Resources, Inc.                                                                   - 10 -
                 SIN 520-9 – RECOVERY AUDITS

      c. CBI Data Elements - Outpatient Coding Monitor:

            E/M codes, Primary CPT code, Secondary CPT code, Primary Diagnosis code,
             Secondary Diagnosis codes, and Modifiers:

             o   Insufficient documentation
             o   Undercoded
             o   Upcoded
             o   Missing (documented) not coded
             o   Provider can’t use level of E/M code
             o   E/M code bundled into another CPT code
             o   Wrong E/M Type assigned
             o   No documentation for encounter
             o   Incorrect code selected
             o   Unbundled codes
             o   Lack of specificity (4th, 5th digit incorrect)
             o   Incorrect modifier assigned
             o   Modifier assigned to wrong code
             o   Modifier should not be used

      d. CBI Data Elements - Inpatient Coding Monitor:

            DRG monitor

             o   Admit date
             o   Discharge date
             o   DRG correct
             o   Principal Diagnosis not supported by documentation
             o   Complications and Comorbidities (cc) not coded (absent/incorrect)
             o   Incorrect code selected for principal diagnosis
             o   Significant procedure(s) not correct

      e. Additional Third Party Data Elements:

            Managed Resources, Inc. will review any additional cases per month. The
             additional cases will be chosen based on one of the following criteria: UB-92 bill
             type, diagnostic lab including cardiology testing, and radiology. Once the claims
             are selected, all additional claims for the individual patient for the date of service
             selected will be reviewed. . The claims will be reviewed for the following items:
             o Medical record documentation exists that a service of equal or lesser value
                 was performed
             o Duplicate claims – every service is billed only once
             o Missed claim – all services provided are billed
             o Revenue codes – correct revenue codes used on UB-92

Managed Resources, Inc.                                                                      - 11 -
                 SIN 520-9 – RECOVERY AUDITS
             o Expired insurance billed - insurance carrier billed was active at the time of

             o The additional cases per station per month will be selected by the criteria
               provided. Once the claims are selected according to the criteria, we will
               review all other claims and care on the same date of service as the selected

      f. Other Additional Service:

            Telephone Consultation: Managed Resources, Inc. will offer monthly one hour
             telephone coding/billing consultation with each facility falling below 85%
             accuracy rate in any category. Consultation will be at discretion of the facility

      g. Summaries:

            Managed Resources, Inc. will provide monthly summaries for additional data
             elements and yearly summary of telephone consultations (dates of consultation,
             topics discussed and VA personnel involved).
            Results of the claims audit will be provided in written form and will include, but
             are not limited to:

             o   Review Methodology
             o   Findings
             o   Recommendations for improvement
             o   Attachment with a listing of claims reviewed with detailed findings and
                 recommendations for the claims.

      h. Requirements:

            Managed Resources, Inc. will provide all labor, materials, transportation, and
             supervision necessary to perform audit.

            The actual reviewer will have at least three years of experience reviewing claims
             in a large tertiary care hospital and outpatient health care organizations, as well as
             two years of education and training. Experience will include both institutional
             (UB-92) and professional (CMS 1500) claims. In addition, the reviewers who
             will be verifying ICD-9-CM and CPT-4 codes will have one of the following
             current credentials:       Registered Health Information Technician (RHIT),
             Registered Health Information Administrator (RHIA), Certified Coding Specialist
             (CCS), or Certified Professional Coder (CPC). The proposal will include the
             resumes of the actual reviewers, two (2) current client references specific to each
             individual reviewer, and proof of credentials.

Managed Resources, Inc.                                                                      - 12 -
               SIN 520-9 – RECOVERY AUDITS
            All reviews will utilize electronic auditing of the computerized medical record
             system (CPRS), whenever possible. Claims will be reviewed from a hard copy.
             Should the information not be contained in CPRS, Managed Resources, Inc. will
             request a copy from the Facility Contact/ COTR before considering the audit of
             the claim incomplete.

            Managed Resources, Inc. will be responsible for providing for their staff
             computers, reference material, and software/encoder tools for conducting reviews
             and developing training materials. Managed Resources, Inc. will be proficient in
             the use of the laptops, reference materials, and software/encoder tools and provide
             with their proposal evidence of use of an encoder.

            Managed Resources, Inc. will be able to accept an ASCII text file with data fields
             in a fixed width record format. Managed Resources, Inc. will be provided a map
             of the data fields detailing the structure of the file (i.e., the first 30 characters
             contain the patient name, the next 9 characters contain the social security number,
             etc.). Managed Resources, Inc. will be provided with files from which to extract
             the review samples.

            Managed Resources, Inc. will develop a collection tool for additional data
             reviews, and submit it with the proposal.

            Managed Resources, Inc. will submit in the proposal the methodology for
             resolving questions by reviewers and ensuring inter-reviewer consistency and

            Managed Resources, Inc. will be responsible for reviewing each facility’s policy
             and procedures prior to commencement of review.

            Managed Resources, Inc. will document in writing all records reviewed and
             provide such documentation to contact each Facility Contact/COTR at the
             conclusion of the review.

            Managed Resources, Inc. will review findings with the Facility Contact/COTR,
             management, and other designated medical center personnel to review proposed
             changes prior to final written report for mutually agreed upon changes.

            Vendor will provide general company background/composition to include: years
             in coding consultation business, number of employees and their positions and
             number of contracts awarded of this size (to be submitted with the proposal).

Managed Resources, Inc.                                                                     - 13 -
                   SIN 520-9 – RECOVERY AUDITS
 Audits & Recovery  Claims Denial  Coding Validation  DRG  Case Management


Managed Resources, Inc. performs Diagnosis-Related Group (DRG) Code Assignment
Validation Audits.. This project was to support client in its mission to provide and enhance
accessible, comprehensive, cost-effective health care services for its communities. We perform
DRG code-assignment validation audits; review closed/paid Medicare, and other DRG-based
payors; screen all reimbursed remittance invoices for appropriateness of admission necessity and
quality of care; and in conjunction with code assignment changes to indicate pending
reimbursement dollar values.

Project includes: compiling and discussing audit findings with Health System representatives,
particularly results and financial/business implications; making recommendations pertaining to
code assignment changes, enhancement of medical records documentation, trends that negatively
impact coding of diagnoses and procedures, remedies for issues of concern to Health Information
Management, and information/data relevant to program improvement. Also, to provide onsite
education and training classes for clinical, medical and/or support staff; to coordinate and work
with client Corporate Compliance committee to discuss and resolve identified regulatory issues;
to assist client Corporate Director of Business Services in establishing and maintaining
consistency, relative to reimbursement, throughout the Client Hospital System.

Financial impact by hospital and system for a Health System Corporation client from July 2003
to December 2004:

HEALTH CORPORATION                        Increased          Decreased               Net
                                       Reimbursement       Reimbursement        Reimbursement

Medical Center A                              1,034,345             256,223              778,122
Medical Center B                                237,179             129,980              107,199
Medical Center C                                344,711             131,152              213,559
Medical Center D                                110,539                4,169             106,371
TOTAL                                         1,726,744             521,523            1,205,251

Managed Resources, Inc.                                                                    - 14 -
                  SIN 520-9 – RECOVERY AUDITS
Audits & Recovery  Claims Denial  Coding Validation  DRG  Case Management


MRI performs utilization review and case management to evaluate admissions, on a
concurrent/retrospective basis, for severity of illness and/or intensity of service to determine
compliance with InterQual Adult ISD 2000 criteria, or other official criteria; to monitor the
patient record, on an ongoing basis, for the appropriate level of care; to provide concurrent
review to obtain initial and continued-stay authorization; and provide consultation to physicians
and other clinicians in the area of discharge planning; to coordinate interdisciplinary conferences
on complex cases; to facilitate transfer of patients to appropriate level of care; to provide
ongoing education to facility staff regarding medical necessity requirements and admission and
continued–stay criteria and conduct sample retrospective reviews to determine patterns and
trends among providers; to review denial reasons for past claims, to develop appropriate training
tools; and to provide reports, which include findings, observations and recommendations for
improvement of the case management system.

We provide the following services:
    Provide personnel to perform utilization review and case management
    Review admissions, on a concurrent/retrospective basis, for severity of illness and/or
     intensity of service to determine compliance with InterQual Adult ISD 2000 criteria, or other
     relevant criteria.
    Monitor the patient record, on an ongoing basis, for the appropriate level of care
    Provide concurrent review to obtain initial and continued-stay authorization
    Provide consultation to physicians and other clinicians in the area of discharge planning
    Coordinate interdisciplinary conferences on complex cases
    Facilitate transfer of patients to appropriate level of care
    Provide ongoing education to facility staff regarding medical necessity requirements and
     admission and continued–stay criteria
    Conduct sample retrospective reviews to determine patterns and trends among providers
    Review denial reasons for past claims to develop appropriate training tools
    Provide reports, which include findings, observations and recommendations for improvement
     of the case management system

The result of our performance is to lower the average length by better than 10 percent of the
length-of-stay at client facilities. Enable an improvement in turnaround by 5 days in orders
placed by staff and results reported that enabled a more timely discharge of individuals from the
facility. This reduces the use of resources by the client, improves financial performance
consequential to the efforts of our staff and makes available beds for other incoming individuals,
resulting in overall improvement in customer service and quality-of-care.

Managed Resources, Inc.                                                                      - 15 -
                 SIN 520-9 – RECOVERY AUDITS


Job Summary: Assesses, plans, implements and evaluates the needs of patients for discharge
planning and utilization review. Coordinates discharge planning with physicians, Nursing,
Social Services, patient and significant others who have an ongoing caring relationship with the
patient. Reviews patient procedures and DRG status against criteria for Medicare, Medicaid, and
other insurance coverage.


  Responsible for performing initial and concurrent assessments on all patients to determine
   prior level of function and discharge planning needs. Admission assessment is placed into
  Coordinates and documents Interdisciplinary Team Conference that includes ancillary staff.
   Collaborates with team members regarding patient achievement and new goals.
  Able to communicate and collaborate with physician regarding discharge planning needs of
   the patient. Assists the physician to facilitate post-hospital care.
  Is knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage
   and how to seek information about specific benefits information.
  Maintains current knowledge of resources available within the community, maintains
   supply of resource materials to be distributed to patients when needed. Is able to obtain
   other resources as needed.
  Communicates daily with admissions personnel regarding admissions and potential
   discharges to various levels-of-care.
  Initiates ongoing communication with the patient and patient’s family to assess discharge
   needs, educate regarding levels of care, insurance, etc. Participates at family conferences.
  Treats patients and families with respect and dignity.
  Ability to complete TAR (Treatment Authorization Request) accurately and timely for
   prompt Medicaid reimbursement.
  Interacts professionally with patient/family and involves patient/family in the formation of
   the plan of care. Works closely with social services staff.
  Documents discharge planning in the progress notes in an ongoing manner.
  Presents case information to Utilization Review Committee. May also present re-
   admissions or deaths within 30 days of discharge.
  Assures a safe discharge to home by timely delivery of all DME, Home Nursing and other
   care needs are available and in place prior to patient transfer. Assures all caregiver training
   has been completed, prescriptions provided and discharge instructions given. Safe
   transportation is provided.
  Aware of critical length-of-stay guidelines related to Medicare, MediCal and provides
   timely clinical reviews to insurance companies to justify continued acute stay and avoid

Managed Resources, Inc.                                                                     - 16 -
                 SIN 520-9 – RECOVERY AUDITS
Professional Requirements:

    Completes annual education requirements and professional development.
    Maintains regulatory requirements, JCAHO regulations and professional standards.
    Complies with all EOC, infection control and patient safety requirements.
    Follows Hospital/Departmental policy and procedure.
    Complies with organizational policies regarding ethics and confidentiality.
    Attends and participates in committees, meetings, PI and in-services as applicable.
    Demonstrates good judgment and problem-solving skills.
    Demonstrates positive patient relations and/or customer service.

Education and Licensure Required:

  Current Registered Nurse licensure.
  Three years clinical experience working with medically complex patients.
  Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance
  One year of experience in acute hospital UR or discharge planning.

Skills and Abilities Required:

  Basic computer knowledge.
  Ability to communicate effectively with patients, family, physicians and other staff.

Managed Resources, Inc.                                                                    - 17 -
                                                             - 17 -

Description: Business Expense Recovery Audits California document sample