Audit & Review Services

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Part Number: AUDrvw.sod

Audit Service Offerings: *

Select the number of physicians or providers per 10 encounter or case review (+$995.00) Each encounter encounter per physician or provider, in addition to the 10 above (selecting this option adds additional encounters to the audit above) (+$25.00)

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Description

NAMAS Audit Review Services & Scope of Work

NAMAS is here to support our members and Clients who might be in need of an internal audit review.

Any approach needed, we can accommodate: target, probe, retrospective, prospective, risk-based, or compliance.

We also have a team of experts that can support all adult and pediatric specialties and subspecialties.

While our team can provide services for any sized organization and assist with sample plan, this particular audit scope is designed for providers in practices of less than 5 providers who are looking to review 10-20 encounters or cases per provider.

If you need assistance with an audit of any size or scope, email Shannon DeConda at [email protected] for more information.

Below is our outlined scope and approach for each audit review performed:

Scope of Work

Review specifications include:
1. All reviews are performed based on CMS National Guidelines along with scrutiny of the medical necessity of each service reviewed from the coding and documentation aspect
2. A review to include 10-20 encounters and/or services per physician and/or provider
3. Review may include E/M and/or procedural based services
4. Audit reviews that include procedures and present with the associated E/M service, will include an evaluation for the medical appropriateness for the medical decision for the procedure based on LCD and/or medical policy
Review sample specifications:
1. The Client is responsible for identifying the sample selection for this project based on this scope
2. DM will provide access to secure access site, ShareFile upon contract execution for secure data exchange
3. Documents such as samples, records for review, and/or audit deliverables will be housed in Sharefile within password protected, organization specific, dedicated files per project
Project Specifications:
1. Projects that require turnaround time of less than 20-30 business days may be subject to an expedited fee
2. Projects that require deliverables identified as Draft or Attorney Client Privilege work product are available upon request by the Client until a finalized draft is agreed.
The review will be performed, and a claim line level findings report will be provided for each provider. The claim line level report of findings will include an analysis of the following, as appropriate to the claim:
1. Evaluation and management (E/M) coding accuracy to include validation of medical policy and medical appropriateness for E/M services leading to the decision to perform a procedure;
2. Charges documented in the medical record but not billed (missed charges);
3. Missing or deficient documentation (billed but not documented);
4. Accuracy of ICD-10 coding based on medical record documentation;
5. Procedural CPT codes selected and their appropriate use or the consideration of other service codes as required, LCD and medical policy adherence to include medical appropriateness and medical necessity;
6. Accuracy of modifier assignment;
7. Code bundling issues;
8. Validation of ancillary services (if applicable);
9. Potential electronic medical record issues (e.g., templates that may be causing documentation deficiencies).
A report, via spreadsheet or PDF, will be provided to include these detailed findings can be customized to the the Client.
A formal Provider/Summary Report of Findings will be provided to include the following:
1. Coding and compliance recommendations with reference to the underlying authoritative source(s);
2. Recommendations (if any) for EMR development;
3. Assessment of the auditor's analysis, and appropriate feedback of their findings and rationale;
4. Recommendations for provider education, documentation improvements including documentation to support the medical necessity of services, and corrective action plans as appropriate
Audit Feedback Sessions are provided upon project completion to review of the audit findings in either individual or group sessions. All training sessions as part of this scope of work should be scheduled and performed within 30 days of audit completion. Failure to do so may forfeit the training session
1. Individual sessions are held to appropriate lengths to include coverage of all findings and recommendations, typically scheduled for 15-20 minutes.
2. Group sessions generally last approximately 30-45 minutes based on questions and interaction.

Additional Services Beyond the Scope Above:

If at any time services are performed outside or in addition to the Scope of Work including but not exclusive to additional consulting services, administrative work in conjunction with audit projects, rebuttal work in excess of outlined above, additional audit reviews beyond outlined scope, carrier audit support/appeal work, or additional education/training will be billed at the NAMAS hourly standard rate.

Terms of Payment:

Audits paid in full at the time of booking are provided a 10% discount

Otherwise, 25% down is required, upon document upload for review and additional 25% is due, and the remaining balance is due upon audit review completion

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