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Case Study: Grassi Healthcare Advisors Helps a MSO Get to the Bottom of Reimbursement Issues

February 25, 2020
All healthcare organizations face compliance and reimbursement challenges. But when you’re a management services organization (MSO) comprised of many different practices, these challenges are compounded by the number of providers and practices involved.
Even with the best faith efforts to maintain high levels of revenue integrity and performance, problems within an individual practice can arise and threaten the reputation and wellbeing of the entire MSO.

For one of Grassi Healthcare Advisors’ clients, a MSO with more than 70 providers, this scenario became an alarming reality in one of the last places they ever expected to find it.

The Challenge

The MSO supported its providers and practices with education, billing resources, a strong referral network and annual compliance reviews. Among the areas that the practices were tasked with monitoring themselves were claims management, coding compliance, staff performance and other practice management basics.

When it came time for the annual review of the group’s busiest practice, it would have been rational to assume that its success was the result of a well-run, compliance-focused environment. After the retirement of a key physician, however, the MSO found out how quickly that environment had deteriorated.

The new lead physician had not adjusted well to having additional business responsibilities and did not help the MSO enforce any policies or workflows that were recommended to mitigate known issues. The medical coding review uncovered a high rate of billing errors, claim denials and questionable coding practices.

The errors were frequent and serious enough to put the entire MSO at risk. A Medicare audit of just that one practice could have resulted in refunds and penalties for the practice and disqualification from Medicare for all members of the MSO.

At the same time, the MSO was exploring a possible merger with another healthcare organization, and these findings put that transaction in jeopardy, as the due diligence process was already underway by the acquiring company.

Until a solution could be found, all claims were put on hold, resulting in a significant drop in revenues. The MSO needed to find a way to get these claims out the door quickly and not only get paid but stay paid.

The Solution

The physician practice’s attorney recommended Grassi Healthcare Advisors (GHA) to assess the situation and provide a timely, effective solution. GHA was able to implement a variety of remedies that addressed issues far beyond coding errors:

• Coding Review – GHA’s team of coding specialists reviewed all open and denied claims quickly and recoded them accurately based on their extensive experience and knowledge of high-risk coding areas. GHA immediately initiated a workflow that let the practice’s staff make the first attempt at a clean claim, with GHA’s review and the MSO’s consensus required to move the claim forward.

• Education – Discovering that there were fundamental flaws in the way the practice was coding, GHA professionals became intimately familiar with the practice’s Electronic Health Records (EHR) software and trained the internal staff on proper coding processes and recommendations specific to their EHR platform.

• Relationship Management – The initial audit that originally revealed these deficiencies formed an adversarial relationship between the practice and MSO. GHA stepped in as a neutral party, found common goals for both sides to work toward and helped to repair that relationship. As a liaison and advisor to both parties, GHA could provide objectivity that made the whole recovery process more amicable and productive.

• Disclosures – GHA supported the client’s legal counsel in helping the client voluntarily disclose overpayments, self-report errors to Medicare and successfully avoid penalties and a larger Medicare audit.

• Review Assessment – GHA provided a second opinion on the most recent medical coding review provided by the prior firm to ensure there were no other overlooked areas of deficiency within the practice.

The Results

Under GHA’s direction, the MSO was able to clear up the backlog of claims, restart that stream of revenue and make permanent changes to its policies and procedures across all practices to help prevent the situation from reoccurring. The MSO adopted the education and training programs that GHA introduced and added annual coding training for all physicians and staff.

GHA’s analysis of the situation also helped the MSO uncover underlying issues that caused much of the trouble in the first place, including physician burnout that wasn’t being addressed, lack of performance management over the worst offenders, lack of accountability and inadequate internal controls.

Armed with these key opportunities for performance improvement and bolstered by improved revenue integrity measures, the MSO was able to complete its acquisition, maintain their good standing with Medicare and emerge stronger than ever.

For more information on how Grassi Healthcare Advisors can help your organization reach its revenue integrity and performance goals, please contact:Joseph Tomaino, CEO, at 212.223.5020 or jtomaino@grassihealthcareadvisors.com.