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Surviving a Billing and Payment Review: QA is KEY!
For the typical IDD Service Provider, the thought of strangers picking apart documentation to find ways to take back money that’s already been spent is terrifying! Billing and Payment Reviews don’t have to be scary events – maintaining accurate, compliant documentation at all times can alleviate your fears so you can face Auditors with confidence. This review will cover billing and payment reviews as occur in Texas. All providers are expected to verify billing and payment guidelines for themselves. Please ensure that you use the most current guidelines as provided by your state regulatory body.
Billing and Payment Reviews go much easier when your documentation is safely stored and easily retrieved.
What’s a Billing and Payment Review, and how is it different from a regular program survey?
A billing and payment review is a review of written Service Delivery documentation that has been billed. This review process is not meant to measure the quality of services provided, the satisfaction of people served, or adherence to program-related principles. The purpose of a review is to ensure that documentation is in compliance with the Program Billing Guidelines. Billing and payment staff typically request a sample of documentation for review, then go over it with a fine-toothed comb to verify that all elements of the Service Delivery Logs meet the requirements in the Billing Guidelines. Any service claim that is not supported by written documentation in strict accordance with the Billing Guidelines may result in monetary recoupment and/or may require corrective action.
There are two types of Billing & Payment Reviews: Routine and Special.
A routine review is conducted at least once every 2 years for every provider.
This usually consists of three months of documentation for all services of a representative sample of individuals. The number of individual records included depends on the organization’s past performance and the total number of people served by the organization.
- For new providers who serve fewer than 10 individuals that haven’t yet experienced a billing and payment review, the records of all individuals served will be reviewed, up to 5. For organizations serving more than 10 individuals, an additional 10% of those individuals will be added.
- For providers who have experienced routine review resulting in a recoupment amount that is 10% or less of the total amount of the claims reviewed, the sample will include five individuals plus 5% of the total number of individuals provided services during the review period.
- For providers for which a routine review resulted in a recoupment amount that is more than 10% of the total amount of the claims reviewed:
- if services were provided to 10 or fewer individuals during the review period, all of the individuals; or
- if services were provided to more than 10 individuals during the review period, 10 individuals plus 10 % of the total number of individuals provided services during the review period.
Routine reviews can be conducted on-site by a team of Billing and Payment reviewers or remotely through a desk review process. Telephone notification is provided for on-site reviews at least 14 days in advance and by fax at least one day before the review is scheduled. A list of individuals and the time period to be reviewed will be provided on-site at the beginning of the review (for providers who serve additional people outside the contract area of the on-site review, a list will be provided 2 days prior to the visit). Telephone and certified mail notification is provided for desk reviews. Providers must submit all requested documentation via Certified Mail (Request a Return Receipt!) to be received within 14 calendar days of receiving the notice.
A special review is a billing and payment review as a result of a billing anomaly identified by HHSC staff or as a result of information related to billing issues received from another source (typically complaints). During a special review, documentation may be reviewed for any length of time, any number of individuals, and any type of service.
Review of the sampled records results in claims being verified or unverified by Billing and Payment Reviewers. Payments resulting from any claims that are unverified may be recouped from the provider’s future billed services (your pay will be reduced by the total of all payments you received for unverified claims). Additional sanctions are also possible, such as vendor holds and contract terminations.
Complete details of the Texas HCS Billing and Payment Review Protocol are here.
Complete details of the Texas TxHmL Billing and Payment Review Protocol are here.
What should I do to be ready for a Billing and Payment Review?
1. Maintain Quality Assurance efforts ALL the time! Review all documentation for accuracy and compliance BEFORE billing to avoid problems. It also doesn’t hurt to invest in a system that makes QA easier, like Focused Software!
2. If you haven’t already, develop and implement Policies/Procedures to address all requirements. Read Focused Software’s SPI blog series detailing Privacy & Security policy requirements (SPI – Section A, SPI – Section B1, SPI – Section B2, and SPI – Section C), download the sample Policies and Procedures included in the Offline Documents section of Client Tools (Exclusively for FS Customers), and contact us – we can assist!
3. It’s important that billing staff are well-versed in the Billing Guidelines: (https://hhs.texas.gov/laws-regulations/handbooks/home-community-based-services-hcs-program-billing-guidelines OR
https://hhs.texas.gov/laws-regulations/handbooks/texas-home-living-txhml-program-billing-guidelines
4. Pay attention to the records requirements listed in Chapter 49, Subchapter C, RULE §49.305.
5. Remember (and avoid) these common elements often responsible for recoupments: Service provided by unqualified service provider (Chap 49, Sub C, RULE §49.305 (f,g) Non-specific statements such as “had a good day,” “did ok,” or “no problem today;” Photocopied Service Delivery Logs (or portions of SDLs like initials and signatures) Ditto ” marks rather than written descriptions of services provided Service Delivery that is not supported by justification in a Person Directed Plan (PDP), Individual Plan of Care (IPC) or Implementation Plan (IP) Failure of a provider to develop and implement required procedures (like those required for Electronic Documentation in Chap 49, Sub C, RULE §49.305 (j))I’ve been notified – now what?
Re-review the Billing Guidelines, take another look at service documentation, policies and procedures. If you’re a Focused Software customer and you have questions, CALL US (sooner rather than later)! We’ll be standing by to answer questions and provide support during the review.
This short but critical blog might save you a ton of your hard earned money during your next audit review.
No matter how hard you work keeping up with the increasingly complex regulatory demands in long term care cannot be efficiently achieved with archaic paper charts or rudimentary Excel sheet or Access-based desktop-bound documentation. The value proposition of an EHR or practice management software system is undeniable! They are cheaper than adding new personnel and never need benefits, sick time or rest! Implementing Focused EHR is much easier than you think and we’ll guide you every step of the way! Let your software do the heavy lifting for you – that’s what it’s designed to do! Automation helps you work smarter and is the most efficient and affordable answer! Call FOCUSED SOFTWARE TODAY!
Remember: QA success begins at the grassroots…….have your direct care staff document with Focused Software.
Call NOW – (281) 884 3537 ext. 117
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