What to expect when HCFA comes knocking
Certain areas will warrant close evaluation
Even if the number of audits increase and the way they’re conducted doesn’t change, you need to be on your best behavior in case auditors come knocking. Here are areas that Tim Redmon, director of regulatory affairs for the National Home Infusion Association in Alexandria, VA, and Kevin O’Donnell, president of Healthcare Resources of America in Lewisville, TX, say your agency should go over now with a fine-tooth comb . . . just in case.
1. Utilization.
"They are going to be looking more at utilization and collecting utilization data in the process," notes O’Donnell. "I think part of this is for data collection, too. They’re going to look at utilization patterns as well, but right now, from what we can tell, that does not appear to be a criteria target."
Redmon notes that a sudden spike in your utilization or a higher utilization than other agencies in your area, although it may trigger an audit, does not mean you’re doing anything wrong. And with proper documentation, you should easily be able to prove that.
"If referrals are coming from a giant physician office complex whose physicians are primarily treating chemo and oncology patients, you might have a rise in utilization," Redmon notes. "If that’s the case, you probably would have to show a couple of things."
First, have data available that show the patients you are treating are sicker than the "average" home care patient. Then, be able to show that these patients require more care, thus the higher utilization.
2. Documentation.
"Auditors are also comparing field behavior to the documentation," notes O’Donnell. "For example, they’re comparing the physician’s orders with what was actually done. They look at the original order and intermittent order and make sure that was done. There should not be a gap between the plan of treatment and what was actually done for the patient."
Redmon says the best way to make sure you don’t run into this problem is to be proactive rather than reactive. When it comes to the physician’s plan of care and its contents, don’t deviate. And if it’s necessary, get the necessary approval and documentation to cover yourself before the auditors are reviewing patient files.
"If you feel the need to do something for a patient, you’ve got to make sure the doctor puts it on there," he says. "Otherwise, there’s no documentation to show that the patient needed it."
3. Credentials.
O’Donnell notes many of his clients have reported a concentration by auditors during recent audits on training and credentials of personnel, such as consistent inservicing, proper managing of personnel, and checking references.
Off on the right foot
A final tip from Redmon is how to start the audit. He says first and foremost you should remain calm and act rationally, something he’s seen too many agencies fail to do.
"If I were an honest agency and someone came in flashing a badge and guns and wouldn’t let anyone go to the restrooms or make phone calls, I’d get a little nervous, even if everything was clean," he says.
First, ask if the auditors have a search warrant. Then, regardless of the answer, step two is to get on the phone with your attorney for immediate legal advice. From there, it’s mostly common sense, says Redmon.
"One thing you should not do is if someone comes in and shows a badge, automatically open your file cabinets for them and let them rummage through," he says. "There were some people letting agents have original copies, but if you let the FBI or somebody have originals, you have absolutely nothing."
Redmon says the obvious steps to take are: Ask what information the investigators need, and then make copies as necessary. From there, make sure a single spokesperson deals with the auditors so there is never an opportunity for confusion regarding what you’ve been told and what you’ve provided to the auditors.
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