Clinical Compliance & Reimbursement

Strict enforcement of coding and documentation requirements has forced many healthcare providers to evaluate their current coding and documentation patterns to ensure regulatory compliance. PYA provides assessment services that supply our clients with the information needed to determine overall risk of compliance exposure. Our assessment services are very comprehensive in nature and typically incorporate a comparison of initial encounter data, medical record(s) documentation and claims data including the original claim form and Explanation of Benefits (EOB)/Remittance Advice (RA). We provide these services to a wide range of healthcare providers such as hospitals, physicians, physician extenders, teaching physicians and residents, and home health agencies. Through a recent engagement, we assisted a large regional health system in assessing their quality of coding across patient types and analyzing DRG trends in comparison to national benchmarks. Our work on their behalf mitigated the risk of inappropriate coding/billing and identified areas for internal monitoring according to state and national focus.

In addition to assessment services, PYA provides extensive education and training on coding, documentation and billing topics. These sessions may be conducted in several formats ranging from large group presentations to one-on-one customized training based on the provider’s actual documentation. We have found that our customized education sessions have been very effective and valuable in preparing providers and coding/billing staff in compliance related issues. In addition, we have developed training tools that may be utilized during each session. At the completion of each session the provider(s) receives a set of training tools to use as a future reference.

PYA provides assistance and guidance in the area of billing compliance to virtually all healthcare providers including hospitals, physicians, and third party billing companies. Our billing compliance assessments help to ensure the organization’s billing processes are efficient, effective and comply with regulatory and private payer requirements. Our billing compliance assessments can entail an assessment and review of the billing process from an operational and technical standpoint. We are also available to assist in ongoing billing coverage related research and support.

Services Offered:

• Charge Process Assessments
• Chargemaster Assessments
• OPPS Assessments
• APC Assessments
• Chargemaster Development
• DRG Validation
• Inpatient/Outpatient Compliance Assessments
• Pre-admission & Registration Process Reviews
• Observation Bed and Denials Management
• Assessments and Program Development
• Utilization Management & Case Management Assessments and Program Development