Case Study: Triple Check Observations - Billing Audits

Triple Check

A long term care (LTC) operator had outsourced rehabilitation services for three LTC facilities to a therapy company that later was investigated by the Office of Inspector General (OIG) and Department of Justice (DOJ) for overutilization of therapy services and overpayment of Medicare funds.  While the outsourced provider’s therapists prescribed services for residents, the LTC facilities were responsible for billing.  As a result, the OIG found the LTC facilities also at fault for the overutilization and overpayment.  After settling with the OIG, the LTC operator called Compliagent to determine how the overutilization and its subsequent overbilling happened, and ways to mitigate the risk of recurrence. 

Compliagent’s Actions: We conducted on-site billing audits, reviewing documentation from various disciplines to ascertain consistency and the accuracy of MDS assessments and UB-04 claims.  Documentation reviewed included:  MDS assessments, therapy logs, UB04 claims, and Medicare Part A residents’ medical records.  We also evaluated each facility’s compliance with federal and state billing guidelines.  Through on-site observations of Medicare Triple Check processes, we determined whether each facility’s interdisciplinary team members were following the operational procedures necessary for accurate and appropriate billing. 

Outcomes: Through our billing audits, we discovered deficiencies that inhibited the facilities’ ability to bill for services rendered.  UB-04 claims generally were missing critical ancillary services (e.g. wound care, pharmaceuticals, medical equipment) provided to residents, thereby failing to capture all of the facilities’ revenues.  Our Triple Check observations identified vital procedures missing from operational processes, particularly a failure to consistently cross-validate various disciplines’ documentation in the verification process. We provided a sample Triple Check process for Medicare Parts A and B.  After our client customized them, we reviewed their work for accuracy.  Educational training was provided at one facility, and validation audits were conducted at the three LTC facilities approximately 3-6 months later. 


“Compliagent’s team was easy to work with and went above and beyond our expectations in scheduling and response time.  They were very knowledgeable, bringing valuable insight in assisting our organization with improving compliance knowledge and identifying areas of opportunity.”  


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