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Hello,
I am looking for an auditor/consultant who can conduct the following activities, outlined below. The health care provider to be audited has two small clinics that provide primary care services and conduct CLIA waived tests (1 MD, 3 mid-levels, 1 nurse, 1 MA/CNA). I want someone local in the Grand Rapids or near by area. If you have expertise in these areas, we can schedule a time to discuss the project in more detail - email me at Catherine@i1Consulting.com. I would then need from you a proposal for the work that includes an estimated quote for services and professional experience.
Summary of Needed Review – There are 3 separate requests being made as part of the review – 1) documentation/claims review; 2) review of sampling of unbilled claims/services over 3 month period; and 3) review of current query process:
1. Review of 80 encounters (4 providers: 20 encounters / provider). Encounter dates can be randomly selected by us or you. Review would be done virtually since they use an electronic record. For each patient encounter:
a. Audit of documentation – is documentation adequate ? Does documentation support code selection/medical necessity/services performed
b. Audit of code selection – is code accurate /appropriate (E/M level selection, diagnosis code, and CPT codes)?
c. Was encounter billed, and if so was reimbursement appropriate; if it was not billed, was it billable?
d. Audit of compliance against applicable organization policies
2. Over a 3 month period, review of sampling of those claims that were not billed for services that are covered under Medicare/Medicaid….should they have been billed? If not, why was the service un-billable?
3. Review one month's worth of queries to audit query process – is it in compliance with organization's policy and industry standards -- queries should not be leading, etc. (ex. AHIMAs recommendation for query process).
Recommendations for improving the current process such as new or revised policy standards; documentation practices, changes to job descriptions, responsibilities, etc. will be requested as part of the outcome of the project.
Thank you,
I am looking for an auditor/consultant who can conduct the following activities, outlined below. The health care provider to be audited has two small clinics that provide primary care services and conduct CLIA waived tests (1 MD, 3 mid-levels, 1 nurse, 1 MA/CNA). I want someone local in the Grand Rapids or near by area. If you have expertise in these areas, we can schedule a time to discuss the project in more detail - email me at Catherine@i1Consulting.com. I would then need from you a proposal for the work that includes an estimated quote for services and professional experience.
Summary of Needed Review – There are 3 separate requests being made as part of the review – 1) documentation/claims review; 2) review of sampling of unbilled claims/services over 3 month period; and 3) review of current query process:
1. Review of 80 encounters (4 providers: 20 encounters / provider). Encounter dates can be randomly selected by us or you. Review would be done virtually since they use an electronic record. For each patient encounter:
a. Audit of documentation – is documentation adequate ? Does documentation support code selection/medical necessity/services performed
b. Audit of code selection – is code accurate /appropriate (E/M level selection, diagnosis code, and CPT codes)?
c. Was encounter billed, and if so was reimbursement appropriate; if it was not billed, was it billable?
d. Audit of compliance against applicable organization policies
2. Over a 3 month period, review of sampling of those claims that were not billed for services that are covered under Medicare/Medicaid….should they have been billed? If not, why was the service un-billable?
3. Review one month's worth of queries to audit query process – is it in compliance with organization's policy and industry standards -- queries should not be leading, etc. (ex. AHIMAs recommendation for query process).
Recommendations for improving the current process such as new or revised policy standards; documentation practices, changes to job descriptions, responsibilities, etc. will be requested as part of the outcome of the project.
Thank you,