Optimize Revenue and Reduce Risk with Medical Coding and Healthcare Regulatory Compliance Services
Comprehensive Medical Coding Portfolio and Robust Healthcare Compliance Program Extends Across Healthcare Continuum
For hospitals, physician practices and other providers, two objectives matter most when it comes to billing for clinical services: maximizing revenues and reducing regulatory risk. Faced with an increasingly complex regulatory environment and aggressive federal and state audit initiatives, hospitals and physicians must ensure that medical billing and coding operations comply with all applicable healthcare laws and regulations to help ensure compliance.
Additionally, lost revenue from poor medical coding practices can significantly impact financial performance. And now with ICD-10 coding firmly in place, the industry is experiencing some troubling healthcare reimbursement trends: Payer system inaccuracies, denials due to unspecified codes and other non-standard submissions, an increase in medical necessity denials, slower payments, underpayments and likewise, healthcare organizations are at risk.
The solution, just one part of a robust healthcare regulatory compliance program, is to review, monitor and track each medical claim, identify disconnects, bring errors to the payers’ attention, and identify where further education and assessments are needed to improve performance across the organization.
Optimize medical coding for improved revenue with certified and experienced coders and coding management
Correct coding for your services requires well-trained and experienced specialty-specific medical coders. To address the nuances of specialty-specific coding, McKesson developed Specialty Coding Certifications (SCCs). Following intensive training, coders must pass the SCC exam and accurately code selected charts with the correct CPT, modifier and ICD-10 codes for both facility and non-facility charts. McKesson currently has over 600 specialty-specific certified coders and doesn’t use autocoding software due to their troubling inconsistent results.
In addition to receiving SCCs, all employees issuing coding guidance internally or externally, including coding managers, supervisors and team leads, are also nationally certified as a Certified Professional Coder (CPC) or CPC-Hospital (CPC-H) and work one-on-one with their coding staff.
Help improve clinical documentation and reduce denials with medical coding services
McKesson can help you improve accuracy with ongoing, periodic or one-time coding assistance in all specialties or with hospital charge capture assessments. Additionally, we can conduct periodic audits of your internal operations by department and by provider to help ensure coding and documentation are being performed at optimal levels. We offer coding services across inpatient, outpatient, emergency department, urgent care facilities and medical group care settings.
We can provide on-site or virtual training to address deficiencies if, after an assessment, it is determined that your current coding and documentation processes need enhancement. Our clinical documentation improvement programs, physician education sessions and medical records services will help set your staff up to document more effectively, code more accurately and in turn, receive the reimbursements you are due for services rendered. From full outsourcing to episodic project work, we'll address both sides of coding by identifying missed revenue opportunities, as well as potential compliance risks due to inaccurate coding.
Improve medical coding accuracy with regularly audited coders
All production coders undergo a quarterly coding Quality Assurance (QA) audit in their specialty-specific area. In an effort to drive ever-increasing accuracy and quality, coders receive ongoing feedback and education as part of each quarterly review.
Approximately 40,000+ items are reviewed as part of the quarterly coding QA process. Auditors performing QA audits of diagnosis and procedure coding are certified medical coders who have completed the mandatory QA audits of diagnosis and procedure coding, and are certified medical coders who have completed the mandatory QA auditor training, the specialty CPT skills assessment and ICD-10 skills assessment. Coding performance is measured based on quality of work and resolution rates.
To affirm that McKesson’s oversight and direction are objective and in agreement with industry standards, each year an external auditing firm reviews a sample of the claims that McKesson Corporate Compliance has audited.
Help reduce regulatory risk and commit to the highest standards of conduct with compliance services
McKesson can help mitigate medical coding compliance risks and improve accuracy with our assistance in: compliance plan development or redesign, auditing and evaluations, compliance monitoring, standards and procedures, employee integrity, program oversight, training and education, monitoring, auditing and confidential reporting, enforcement and response and prevention. The standards we implement meet or exceed federal and state requirements.
Following implementation, McKesson’s provider education services are designed to optimize front-end and back-end billing processes. These services, which are integral to the McKesson standard billing process, are offered on an annual and ad hoc basis as necessary or mutually agreed to by both parties. They include but are not limited to:
- Provider documentation training
- Annual CPT and ICD-10 coding updates/changes
- National coverage determination and local coverage determination update for CPT/ICD-10 coding acceptance
- Updates on regulatory guidance affecting coding/documentation (e.g. PQRS, IDTF policy changes Stark Law, etc.)
As one of the industry’s leading revenue cycle management provider for hospitals and physicians, McKesson has the expertise to deliver in these coding and compliance critical areas. Put it all together and enhancing your team with specialized coding expertise emerges as an astute investment to make as you shift your team's focus to delivering value-based care.
Key features of McKesson medical coding and compliance services
- Medical coding services for inpatient and outpatient facilities, emergency departments and urgent care centers, emergency medical services agencies and professional fee and provider-based billing
- Clinical documentation assessments
- Physician and back office staff training and education
- ICD-10 deep domain expertise
- Compliance plan assessments
- Compliance plan development and monitoring
Key benefits of McKesson coding and compliance services
McKesson's services can help you more effectively manage your denials and increase payment velocity, all with experienced coders that exceed industry standards of excellence. Our Coding and Compliance Services help you to:
- Identify missed revenue opportunities
- Minimize risk of non-compliance
- Improve clinical and financial staff productivity
- Prepare for RAC audits and other regulatory audits
Integrated Healthcare Regulatory Compliance and Auditing
McKesson Business Performance Services Compliance Program
Integrated into everything we do, the McKesson Business Performance Services (BPS) Compliance Program also offers in addition to coding oversight, a central coordinating mechanism for furnishing and disseminating information and guidance on applicable federal and state statutes, regulations, and other payer requirements.
McKesson has made a formal commitment to be compliant in all aspects of its business. With an annual compliance budget of over $7 million, our compliance efforts are designed to establish a culture that promotes prevention, detection, and resolution of conduct that conforms to federal and state law, and federal, state, and private payer healthcare program requirements, as well as McKesson’s ethical and business policies.
Our healthcare regulatory compliance program elements
The elements of the McKesson BPS Compliance Program are designed around the Office of Inspector General’s Model Guidance for Third-Party Medical Billing Companies, which was issued in 1998. Key areas of our program include:
- Standards and Procedures addressing general business ethics as well as specific areas of potential violations are widely distributed and employees are expected to serve McKesson in accordance with these standards. The standards are reviewed annually and updated as needed.
- Employee Integrity is fostered by educating employees about the Standards when initially hired and annually thereafter. Through the standards, the values of compliance and integrity are engrained into McKesson’s culture. Each employee has an obligation to uphold the Standards and ensure that fellow employees do the same.
- Program Oversight begins at the top. The McKesson BPS Compliance program is championed by a chief compliance officer who serves as the focal point for all compliance activities. The chief compliance officer reports to the Senior Management Compliance Committee. Each specialty unit within McKesson BPS has its own compliance director and national coding manager to help ensure that regulatory nuances are understood and that coding expertise is fine tuned. McKesson has over twenty full time compliance professionals.
- Training and Education falls into three major categories: 1) the Standards of Conduct and general compliance; 2) billing process compliance; and 3) medical coding. All training is tracked in a corporate database by employee and by course. McKesson BPS completes approximately 30,000 hours of compliance training annually.
- Monitoring and Auditing are accomplished through a range of programs, policies and tools. All production coders undergo a quarterly coding QA review in each specialty coded, for the duration of their employment at McKesson. In an effort to drive ever increasing accuracy and quality, coders receive ongoing feedback and education as a part of each quarterly review. Every quarter, approximately 65,000+ items are reviewed as part of the quarterly coding QA process. Our goal is to submit claims that are 100% compliant with industry standards; our efforts to improve never stop.
- Confidential Reporting - McKesson maintains an anonymous compliance hotline through an external vendor to ensure that employees have a way to report concerns about compliance issues in a confidential manner and without fear of retribution. Employees are encouraged to call the hotline whenever they suspect a violation of law or regulation. Issues reported via the hotline are thoroughly investigated and corrective action is taken when necessary.
- Enforcement is fostered through both disciplinary action and incentives. Violations of billing compliance policies are punishable by disciplinary action up to and including termination. Each employee’s performance review includes a significant component on integrity.
- Response and Prevention is conducted in a rigorous and comprehensive manner. Investigations focus on a myriad of compliance issues reported by either employees, clients or other sources. Compliance audits and technology-based monitoring programs are reviewed to determine areas of exposure and identify and correct risks. For overpayments, our regular monitoring helps ensure that refunds are timely and appropriately documented.
- Background Checks - Company policy prohibits the employment of any individual who has been convicted of a criminal offense related to healthcare or who is listed as debarred, excluded, or otherwise ineligible for participation in any federal healthcare program. As a matter of practice, the names of all prospective and current McKesson employees are run against the OIG Cumulative Sanction Report and GSA (General Services Administration) Federal Exclusion databases for exclusions before hiring and on an annual basis thereafter.
Taken together, the interlocking components of McKesson’s healthcare regulatory compliance program create a comprehensive ethical, regulatory and philosophical framework. The end result is a corporate commitment to the highest standards of conduct, behavior and performance.
We take compliance seriously. We have to. Because in the final analysis, integrity and a commitment to doing the right thing is one of the products we sell and a vital part of service we provide.