Case Studies: Healthcare Systems
Large Hospital System in Five-Year Corporate Integrity
Agreement
We were retained by one of the largest hospital systems in the Western
United States that had entered into a five-year corporate integrity
agreement (CIA) with the Office of Inspector General as part of a global
settlement agreement with the U.S. Department of Justice resulting
from a qui tam (whistleblower) action for allegedly submitting false
claims for reimbursement to federal healthcare programs. Pursuant to
the terms of its CIA, the health system retained us to serve as its
Independent Review Organization in order to perform certain agreed-upon
procedures to assist the health system evaluate its compliance with
the terms of the CIA. We presented its findings to the health system’s
management who in turn submitted our findings with its annual report
to the OIG pursuant to the terms of the CIA.
Hospital System Emergency Department Investigation
BlickenWolf was engaged by a hospital system’s outside counsel to assist
in the investigation of potential False Claims Act violations. The
U.S. Attorney’s Office subpoenaed patient billing and medical record
documentation in connection with the allegations. We conducted extensive
analyses of the client’s billing and medical record documentation
to assess whether the provider intentionally submitted false claims
to governmental payers. Our analysis provided legal counsel with
strategies to defend against the potential violations.
Radiology Center Risk Assessment
BlickenWolf was engaged by an integrated healthcare provider to perform
an overall risk assessment of their Radiology Department (the Department),
related to departmental operations, the radiology information system
(RIS), and billing/coding compliance.
Our assessment included an overall review of the revenue cycle from scheduling through charge capture and billing as it relates to the Department. We performed a thorough evaluation of the operations of the Department by conducting interviews with the physicians, technicians, and staff and performing on-site observations of the daily functioning of the Department.
Our primary objective was to identify specific areas of risk and vulnerability in their departmental operations, RIS, and billing/coding process. From this evaluation, we made recommendations for improved operational efficiencies and advised on specific process improvement initiatives.
Fetal Diagnostic Center Risk Assessment
BlickenWolf was engaged by a large integrated healthcare delivery network
to assess the status of their outpatient high-risk fetal diagnostic
center as it relates to federal, state and private payer regulatory
compliance. We performed a thorough evaluation of the operations
of the center by conducting interviews with the center physicians,
and staff, performing an on-site observation of the daily functioning
of the center and “shadowing” the medical director in both the outpatient
center and in the adjacent hospital.
Our primary objective was to identify specific areas of compliance risk and vulnerability in their operations, billing and coding, and documentation processes. From this evaluation, we made recommendations for improved operational efficiencies and advised on specific procedural coding initiatives. We further developed a comprehensive, detailed Policy and Procedure Manual that specifically addressed individual medical and diagnostic procedures performed in the medical specialty clinic. Inherent in this process was the establishment of quality standards of practice.
As the outpatient fetal diagnostic serves as the obstetrical resource to a very large population of the medically underserved, the significance and ramifications of this project are of paramount importance to this healthcare network.
Ambulatory Clinic Internal Audit
BlickenWolf was engaged by a health system (the System) to perform
an internal audit of the System’s four outpatient clinics. The audit
consisted of both an operational review of the revenue cycle processes
and procedures in the four clinics and a medical records analysis
for accuracy related to documentation, coding and billing.
We interviewed individuals representing administration, patient service, coding and billing; observed processes; and reviewed documentation. We documented investigative findings and recommendations. We also worked with System management to prioritize recommendations, and developed an implementation and response plan.
Counseling Center Internal Audit
BlickenWolf was engaged by a major healthcare organization to conduct
a review of the provider billing practices for the organization’s
counseling center. We conducted a review of medical records that
revealed problems with practitioner documentation, ICD-9-CM code
assignment, and CPT code assignment. We also discovered that the
organization was conducting a billing practice that could affect
the funding received from a federal program.
Our findings resulted in management implementing standards to improve billing, coding and documentation practices. In addition, management addressed the issue of the billing practice that could affect federal funding by seeking written clarification from a local agency.
Sex Abuse Treatment Center – Revenue Cycle Process Improvement
BlickenWolf was engaged to assist the management of a health system
(the System) in performing a revenue cycle process improvement review
of the System’s emergency department clinic for sex abuse treatment
(the Clinic). We facilitated a cross-functional team in identifying
ways to ensure that charges were captured appropriately so that revenue
is calculated accurately and the Clinic’s funding sources are charged
correctly.
Our team conducted interviews, reviewed documents, and developed workflows of the revenue cycle processes. We drafted policies and procedures and managed the System’s resources in implementing systematic and operational process enhancements.
Large Healthcare Organization – Revenue Cycle Management
Working with a large healthcare organization in the New York area which was experiencing revenue cycle issues, we assessed and made recommendations to multiple departments impacting revenue. BlickenWolf was responsible for the implementation and development of a Revenue Cycle, CDM, and Denials Management Team. As a result of our work, best practices were implemented, policies and procedures developed, cash increased, and denials decreased. Additionally, Point of Service collections increased by more than 50% in less than six months. Within this process we have been able to impact the bottom line by millions of dollars.
