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Today's healthcare providers face a dizzying array of new regulations and increased enforcement actions designed to combat fraud and abuse. As federal and state authorities multiply their efforts to scrutinize payments and recoup money, it has never been more important for providers to identify areas of compliance weakness and develop solutions before these problems multiply. To prevent and address compliance issues Provider Consulting Solutions offers the following services:

Put PCS' experts to work for you:

  • Review medical records, coding, billing and Medicaid Rate Code Compliance
  • Identify and quantify exposure
  • Audit support with Independent Review Organization for Corporate Integrity Agreements and Recovery Audit Contractors (RAC) Response Services
  • SentinelTM Compliance Report Series

PCS has vast experience assisting providers in all aspects of compliance related services, working with large academic medical centers, hospital systems, physician groups, nursing home chains and other providers, as well as significant experience in working with the OIG and the DOJ.

Independent Review Organization

As an Independent Review Organization (IRO), PCS offers an interactive approach. Given the nature of the engagement, it is critical that the IRO be involved during the earliest planning phase of the work and we recommend establishing open communications with a representative from the Office of Inspector General (OIG) to address issues that may arise during the planning and audit process. PCS will keep the client's Compliance Officer fully informed of any issues that arise during the review process and apprised of all communications with the OIG representatives.

Claims Review

The Claims Review must be performed annually for each one-year period of the Corporate Integrity Agreement (CIA), beginning with the effective date of the CIA. Year two of the IRO consists of reviewing the adequacy of billing, coding practices and compliance obligations, based on documentation available at the Hospital pursuant to the specific requirements of the CIA and applicable regulations and guidance under the general requirements of Federal health care programs.

The review involves a "Discovery" sample of 50 paid claims, randomly selected by the IRO. If the Error Rate in the Discovery Sample is less than 5%, no additional sampling is required, nor is the Systems Review required. If the Discovery Sample has an Error Rate of 5% or greater, we perform a Full Sample and a Systems Review. The Full Sample will be designed to 1) estimate actual Overpayments in the population with a 90% confidence level and with a maximum relative precision of 25% of the point estimate, and 2) conform to the Centers for Medicare and Medicaid Services ("CMS") statistical sampling for overpayment estimation guidelines. As permitted by the CIA, the Discovery Sample may serve as the probe sample and Discovery Sample findings may be included as part of the Full Sample.

Systems Review

The Systems Review (if required-depending on the results of the Discovery Sample) requires that for each claim in the Discovery and Full Sample that resulted in an Overpayment, the IRO will perform a "walk through" of the system (s) and process (es) that generated the claim to identify any problems or weaknesses that may have resulted in any identified overpayments. The focus will be on what circumstances might exist which could give rise to a billing error and not being detected by the system.

The objectives and scope of work involved in the Systems Review cannot be determined until the Discovery and Full Claims Review have been completed, but may include the following elements:

  • Review order entry systems/ encounter forms and Charge Description Master for Behavioral Health.

  • Preparation of a Flowchart of registration, order entry, billing, claims submission, payment posting and verification for Behavioral Health services to identify problems or weakness in the accuracy/integrity of information and the internal control structure.

  • Evaluation of the knowledge of Behavioral Health clinical staff and administrative support (registration, billing) staff relative to documentation, coverage, coding and billing requirements and regulations.

  • Develop observations and recommendations to improve the systems and processes involved in coding and billing.

PCS will prepare a report based on findings of the Discovery Sample, Full Sample and Systems Reviews, as applicable. The information included in the report will be based on the requirements listed in Appendix A of the CIA.


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