Risk Mitigation

With nearly 40 years of experience in applied and computational statistics, DoctorsManagement, LLC can significantly increase your odds of successfully defending against an extrapolation audit. And when it’s time for you to conduct your own internal repayment review, self-disclosure analysis, or risk management plan, we can provide you with the expert statistical assistance you need from A to Z.

Services

• Real-time Analytics
• Documentation and Tracking
• Robust Reporting
• Audit Workflow
• True Predictive Analytics
• Risk Mitigation
• Risk Based Auditing – For coding and billing Risk Assessment and Management
• Statistical Sampling and Overpayment – Extrapolation Defense Self-Disclosure
• Advanced Healthcare Analytics – Litigation Support Data Mining Statistical Analysis

Compliance Risk Analyzer

CRA OVERVIEW

HOW IT WORKS

CRA TOUR

Effective Programs

Effective risk management programs tie together all key business functions to help the risk team protect the organization. If your business has multiple business owners and multiple healthcare organizations over various locations, collecting and analyzing that data can be overwhelming. DoctorsManagement, LLC Analytics can help by

• Enabling risk managers to view all of their risks on one platform
• Provide data-driven recommendation initiatives
• Focus resources on the risks and controls

Healthcare Risk Management

Healthcare practices are under increased scrutiny from government agencies – CMS, RAC, MAC, and others – as well as from private payers who are increasingly using sophisticated auditing algorithms to uncover improper claims that can lead to them clawing back reimbursements you’ve received. Many providers are not leveraging the technological firepower necessary to assess their compliance risks to prevent these expensive takebacks.

DoctorsManagement, LLC’s Data Analytics division will help protect your healthcare facility and ultimately patient safety by connecting healthcare risk management to incidents and warnings.  Our experts assess what could happen and link that to what did actually happen utilizing real data and even determine low-risk vs. high-risk situations. By utilizing our compliance risk analysis dashboard, you will identify where your risk mitigation plan has gaps,  conduct actionable risk assessments to hedge against emerging risks, and quantify the impact of your risk mitigation plans. Risk management strategies and a solid risk management action plan are crucial to healthcare providers to manage risk for healthcare practices and healthcare systems.  Properly managed, your healthcare risk management program will protect your facility, but also patient safety, patient care, and patient health. 

The Most Common Approaches to Audit Risk Management

Organizations understand the need to monitor their compliance risk. However, there is a wide range of approaches being used – each with varying levels of sophistication and success.

• Homegrown systems. Smaller practices sometimes take a basic approach which employs a system of excel spreadsheets and other APC audit worksheets.
• Vendor-developed workflow automation audit-based software. Implementing compliance audit-focused software from a vendor is clearly a step up from the homegrown solution above, but there can still be issues that prevent gaining true visibility into overall compliance audit risk.
• RAC tracking solutions. A Recovery Audit Contractor (RAC)-based process is only a slight upgrade from a home grown system. The RAC technology was developed to provide access to your claims data with no sophisticated method for selecting which claims you should review. 
• Artificial Intelligence/Machine Learning. This solution, based on the power of artificial intelligence/machine learning (AI/ML), is a major leap forward from the other audit-risk detection approaches.
• DoctorsManagement, LLC – Compliance Risk Analyzer (CRA) SolutionCRA, developed by the Frank Cohen Group, a division of DoctorsManagement, LLC, is an AI/ML solution that augments any of the existing systems or approaches that practices may be using. CRA is a true risk-based auditing tool that delivers an effective, efficient, accurate, and rapid identification of potential risk for every single provider in your healthcare organization. Learn more on our CRA page here.

Post-Audit Extrapolation

Chapter 8 of the CMS Program Integrity Manual (PIM) sets the standards for the use of sampling and extrapolation for Medicare audits. While it may be “good enough for government work;’ it often represents a blatant violation of the standards of statistical practice. This explains why there are so many extrapolations thrown out on appeal. 

Section 8.4.1.2 states: “By law, the determination that a sustained or high level of payment error exists is not subject to administrative or judicial review;’ which means that the only recourse is to successfully challenge the sampling and extrapolation methodologies, both of which require a qualified and experienced statistician. 

Frank Cohen, our expert statistician, has engaged as a statistical expert in over 350 post-audit extrapolation appeals and more than 30 years of risk management and managing risk. He has testified on numerous occasions. Having been both a clinician and practice administrator, his focus is to translate statistical findings into practical results that an independent arbitrar can use to render a fair and honest opinion.

Contact DoctorsManagement, LLC for a no-cost opinion on the likelihood of successfully challenging an extrapolation 800-635-4040.

Problems with Extrapolation

Because the purpose of this type of audit is to extrapolate findings to a larger universe of data, we work within the realm of inferential statistics, which is different from descriptive statistics. In inferential statistics, when we attempt to “infer” the results of a sample to a larger universe, we have to be very careful how the sample is selected and very certain as to how our calculations are made. Because we are going outside of the sample itself, it is critically important that the sample is representative of the applicable universe – or in this case, the sampling frame. In pretty much every case I have worked on, government auditors worry about one thing and one thing only: is the samplerandom? This is great if all you are doing is trying to describe certain characteristics of the sample, such as some point estimate or tendency towards some location of data, but it is simply not enough when the goal is to infer the results of the findings in the sample to some data set that is larger than the sample. Just because you stratify a sample doesn’t mean that it was stratified properly.

Expert Witness Service

When it comes to an expert witness, it’s important to remember that their testimony is not about them. It’s about the client. Our team trains others to communicate complex issues to a jury of lay people. The best approach to win over a jury is honesty, humility, and politeness. We know this because we have a proven track record as expert witnesses ourselves. The success that training participants experience also confirms that this approach works. Attorney Yanes says it better than we can …

DM Expert Frank Cohen

Frank Cohen’s areas of expertise in his role of risk management including data mining, applied statistics, and predictive analytics. In addition, he provides compliance risk analysis and meaningful assistance to healthcare organizations in the areas of process improvement, compliance, quality, and profitability. The author of several risk management and analytical books, including his latest, “Evidence-based Thinking.” Frank is a sought-after speaker. He has participated in and published numerous articles and studies and trained thousands of physicians, administrators, CPAs and other healthcare professionals in all areas of healthcare analytics.

It’s Time to Think About Predictive Analytics for Coding Compliance

There are some responsibilities of running your healthcare industry business that you cannot afford to get wrong. Among them: healthcare risk management, risk management strategies and risk mitigation, regulatory compliance, audit preparation, and setting up solid practices for documentation, coding and billing. These efforts require validation – and often assistance – from outside experts because of their complexity, the potential risks involved, and the sheer magnitude of what a single oversight can cost you.

Don’t Risk Your Financial Stability

Let the consultants at DoctorsManagement, LLC improve the effectiveness of your operations, increase the revenue you receive for the services you provide, and minimize your compliance risk with a rock-solid plan.

And if you’re planning or implementing a merger with another healthcare business, DoctorsManagement, LLC consultants will help you craft a winning deal and realize the full synergies available to the newly-integrated organization.

Since 1956, DoctorsManagement, LLC has been a trusted adviser to thousands of physician practices, home health agencies, hospitals, acute-care facilities, ambulatory surgery centers and integrated delivery systems nationwide.

Because of this experience, our consultants thoroughly understand the practical implications of the trends shaping your business, and will prepare you to act rather than react to what’s coming down the road tomorrow while optimizing your operations and results today. We work collaboratively with you to develop solutions that best fit your individual circumstances, regardless of specialty, size or location.

Learn more about healthcare risk management by visiting the American Society for Healthcare Risk Management (ASHRM) at www.ashrm.org.

How DoctorsManagement, LLC Healthcare Risk Mitigation Experts can help

DoctorsManagement helps compliance professionals reduce the cost of identifying and mitigating coding and billing risk. With a team of in-house experts and our audit risk mitigation tool, Compliance Risk Analyzer (developed by Frank Cohen), we help thousands of clients reduce risk, improve practice profit and reduce stress for providers and staff.

Compliance Risk Analyzer (CRA™) creates fast and accurate assessments of potential risk for healthcare organizations. This web-based application produces a comprehensive report that instantly identifies potential coding and billing compliance risks for each of your providers.

Risk is assessed for the five most important categories — those that the auditors consider when deciding whether or not to audit your practice:

• Frequency utilization of E&M and non-E&M procedure codes
• RVU consumption of all procedure codes
• Frequency utilization of modifier codes
• Provider’s hours per year versus OIG’s FTE guidelines
• Accurately assess risk in key areas
• Efficiently select codes for internal review
• Validate training and remediation programs

DoctorsManagement is a full-service medical practice consulting firm comprised of in-house experts to support your practice goals. Our consultants work alongside administrators and providers of large and small healthcare organizations to help reduce compliance risks, increase practice profits, improve patient satisfaction and employee morale as well as reduce stress for physicians, managers and staff.

Our firm’s strategies are sound, having been proven over five decades of experience, and our clients gain access to a team of nationally-recognized industry experts in practically every area of medical practice management, including compliance, healthcare analytics, coding, auditing, financial services, patient retention, human resources and more. Call us at 800-635-4040 or contact us online.