We provide professional services for the healthcare industry including but not limited to Blue Cross Blue Shield plans, insurance companies, medical groups, hospitals, home health agencies, independent laboratories, academic medical centers and independent research entities. Our professional services range from inpatient/outpatient reimbursement strategies to compliance regulatory solutions. We are focused on value and a return on investments for all of our engagements while complying with third party regulatory requirements.
Medical Records Documentation
Medical Record Documentation Services
The objective of Bay Area Healthcare Advisors Medical Records Documentation services is to ensure that physician practices are in compliance with Federal, State and local regulations and third-party requirements for proper billing of services.
Medical Record documentation audits are used to review a medical record for compliance of a physician's documentation for third-party billing requirements. This service identifies risk areas for compliance within physician billing, coding and documentation.
Bay Area provides a comprehensive process involving staff experienced in all phases of physician practice operations and improvement. Our audit process involves these key elements:
A statistical sample of patient records chosen for audit. These samples also reflect the current federal and state diagnostic categories reported in their annual work plans.
20 records are selected for each group (1-5 providers) representing all payers. These individual records are examined for documentation of date of services, forms and tests related to service, billing forms and EOB related to service.
An audit of the information collected for each encounter is performed to determine the validity of the codes billed and the sufficiency of the medical records documentation.
A draft report is prepared for discussion with physicians and staff.
On-site education and training sessions based on reports are scheduled and delivered. A final report will be provided at the completion of the engagement. The report will identify specific areas for improvement, areas of non compliance, and corrective actions required. A detailed listing of all findings within each medical record will be included.
Follow up telephone consulting services are available at a discounted hourly rate.
The professionals at Bay Area have years of experience working for national/regional consulting firms. Our alliances throughout the country provide our clients with the most appropriate resources for their immediate needs. Our professionals and alliance networks are comprised of doctors, nurses, certified coders, pharmacists, and financial experts with decades of clinical and consulting experience. Additionally our professionals have worked with major law firms throughout the United States in representation of their client's third party disclosure purposes.
We provide professional services for the healthcare industry including but not limited to, BlueCross/Blue Shield plans, insurance companies medical groups, hospitals, home health agencies, independent laboratories, academic medical centers and independent research entities. Our professional services range from inpatient/outpatient reimbursement strategies to compliance regulatory solutions.
Non-compliance with third party billing requirements can result in serious financial penalties and, in extreme cases of false claims, incarceration for offenders. Medicare Fraud enforcement is a major priority of the department of Health and Human Services Office of the Inspector General OIG the Federal Department which administers the Medicare program. The OIG has published major risk areas for physician practices and their fraud investigations have uncovered millions of dollars annually. Paper documentation of medical billing is at the core of their investigations. More recently, individual states have organized Medicaid fraud task forces to address erroneous fraudulent provider billing practices within that reimbursement program. At the same time all major insurers have strengthened their audit processer's to capture billing irregularities. Given this enforcement environment, physician practices need to periodically assess their compliance with third party billing requirements to avoid future penalties and sanctions.
PHS Research Grant, Compliance, and Adminstration Consulting Services for Academic Research Institutions, Medical Schools, Research Programs
Bay Area Healthcare Advisors, LLC's ("Bay Area") professional staff has provided research consulting oversight and management services to academic medical centers and community hospitals throughout the United States. More recently, James Cesare President, and CEO of Bay Area served as the lead consultant for a 500 bed Southern California Hospital and associated regional cooperative hospitals, providing clinical research management/expertise in the areas of Cardiology, Diabetes, Cancer, Lung and Respiratory studies. The engagement primarily focused on restructuring and reorganization of the entire research department due to inadequacies and substandard cooperative audit results. The research cooperatives involved in this project include ACOSOG, NSABP, RTOG, and SWOG. The hospitals main research component was cancer related trials in association with Duke University Hospital. There were in excess of 100 different clinical studies being performed within the listed coops involving over 400 subjects. The studies included both preventive and treatment regimens by design.
The Bay Area team has provided similar projects to hospitals throughout the country. Hospital financial management and compliance departments rely on our engagement and leadership expertise to provide appropriate Corrective Action Plans ("CAP") resulting from our analysis. We also provide process improvement which insures that our recommendations are carried forward and implemented in the existing corporate compliance plan. Our professionals have worked with national children's hospitals, academic medical center, free standing research centers, and acute care hospitals. Bay Area professionals have served as interim management in research positions that has required the entire restructuring of the research department at a hospital. The project involved but was not limited to: IRB reporting requirements, adverse events reporting, COOP (NSABP and ACOSOG) audit reporting requirements, reimbursement audits, clinical trial medical records review, and formulation of CAP for approval by the National Cancer Research Institute and the Office of Inspector General.
Recipients of PHS biomedical and behavioral research awards need to identify and track all clinical trial revenue in order to ensure that program costs are accurately allocated and billed to the correct funding source. The conduct of sponsored clinical research is overseen by the DHHS Office of the Inspector General, ("OIG"). Compliance guidelines are designed to eliminate erroneous and improper expenditures of Federal funds. An institution's implementation of a serious , meaningful and effective research compliance program requires a significant commitment of time and resources which should be supplemented by a periodic independent, external consulting support to insure the highest level of due diligence.
Physician Practice Management Advisory Services
Bay Area Healthcare Advisors, LLC ("Bay Area") recognizes that each practice is unique therefore we begin our engagement with an assessment of the practice involving physicians and staff. This information is used as a basis for interviews with physician's leaders and key management to further determine the issues that are of concern.
The next step involves a review of the practice to include:
Staffing , organization, policies and procedures
Office physical layout, patient flows
Education/Information transfer
Charge master, coding, billing
Medical record coding analysis
Analysis of accounts receivable and denials
Financial reports
Utilizing the information gained through the review process, Bay Area will prepare a draft report of recommendations for discussion with the practice management team. These recommendations will cover critical areas for practice improvement including:
Recommendations for coding
Identification of billing delays and improvements
Improper billing
Documentation improvement
Practice metrics, financial, statistical, payer specific analysis
Staff training and monitoring of compliance plan and educational requirements
The professionals at Bay Area have in excess of 20 years of experience working for national and regional consulting firms. Our experience in clinical, financial and governmental settings provide our clients with the best solutions for any issues that they may be facing in the industry. Our professionals are comprised of doctors, nurses, certified coders, pharmacists, and financial experts with decades of clinical and consulting experience. Additionally our professionals have worked with major law firms throughout the United States in representation of their client's third party disclosure purposes.
We welcome further correspondence on how Bay Area can provide reimbursement and regulatory solutions for your practice.
The day- to- day pace of free standing physician practices does not allow time for analysis of operational and financial processes critical to the success of the business.
The continuing stream of regulatory changes governing reimbursement has added to the complexity of assuring an accurate, compliant bill for services rendered.
To succeed in today's environment physicians and their staffs are engaging the support of expert professionals who specialize in improving practice management, operations reimbursement and regulatory compliance.
Independent Review Organization Audits
Bay Area Healthcare Advisors, LLC ("Bay Area") professionals can provide independent reviews for your organization in fulfillment of your Corporate Integrity Agreement. Standard compliance program requirements of Corporate Integrity Agreements ("CIA") include review procedures to be performed by an Independent Review Organization ("IRO"). The provider is required to retain an entity, that has the industry expertise to perform procedures to assist the provider in assessing their compliance/program requirements and provisions specific to the CIA. Our review process encompasses the following:
Facility review of the compliance program
Reviews of claim issues identified in the settlement agreement
Review conducted in accordance with an IRO workplan incorporated within the settlement agreement
The review process is performed over 30 days in coordination with a designated project manager to insure minimal disruption. A final draft report is presented and discussed with organizational leaders. A final written summary report is given. Follow up consulting services are available at a discounted hourly rate.
The professionals at Bay Area have years of experience working for national accounting and consulting and firms. Our alliances throughout the country provide our clients with the most appropriate resources for their immediate needs. Our professionals and alliance networks are comprised of doctors, nurses, certified coders, pharmacists, and financial experts with decades of clinical and consulting experience.
We provide professional services for the healthcare industry including but not limited to, BlueCross/Blue Shield plans, insurance companies medical groups, hospitals, home health agencies, independent laboratories, academic medical centers and independent research entities. Our professional services range from inpatient/outpatient reimbursement strategies to regulatory compliance solutions.
Is your organization in need of an Independent review organization to comply with your Corporate Integrity Agreement?
Most Corporate Integrity Agreements require outside independent organizations to assess compliance.
Our staff of certified coders and documentation specialist is equipped to provide the technically specialized analysis necessary. Accurate coding and documentation are key to compliance. Achieving and maintaining a high level of proficiency I coding. Billing and revenue capture require access to expert services from experienced professionals who specialize in improving practice management, operations, coding reimbursement and regulatory compliance.
Outpatient Charge Capture Analysis
Bay Area Healthcare Advisors, LLC ("Bay Area") has the expertise to perform a comprehensive Outpatient Charge Capture Analysis on your outpatient claims utilizing our proprietary software. Our proprietary software and professional expertise will determine where reimbursement or charges have been lost affecting Medicare and Commercial Payer Reimbursement. We are successful at identifying and recovering net reimbursement for our healthcare clients through the correction and resubmission of claims. The focus of a Bay Area Outpatient Charge Capture Analysis is to identify reimbursement opportunities for all major payers while insuring accurate and compliant claim submission. The success of our project is accomplished through resubmission of claims that have been accurately recoded based upon examination of medical record documentation. Our recommendations strictly adhere to the coding and billing policies of Medicare and/or commercial payers.
Our professional fee structure is based upon value identified through our analysis. We are confident that we can identify lost charges in addition to systemic billing issues that are negatively impacting your financial goals. Our professional fees can be provided on a no risk model to your organization and the services performed on a contingency basis. Bay Area, will only be paid for professional services based upon the net reimbursement produced for your organization. This arrangement allows for the hospital to enter into a risk-free arrangement that will economically benefit the hospital. Additionally, our process will provide a transfer of technical/billing knowledge to the end user that will insure the financial benefits remain upon our completion of the project within your organization.
Our analysis has included but is not limited to the following payers:
Medicare
Highmark Blue Cross\Blue Shield
Independence Blue Cross\Blue Shield
Aetna
Geisinger
United Healthcare
Blue Cross of Northeastern Pennsylvania
Our analysis will identify issues such as:
Missing CPT/HCPCS codes
Missing charges
Use of incorrect or invalid codes
Incorrect or missing modifiers
Incorrect number of units billed
Based upon our expertise, we focus on but are not limited to review the following clinical areas:
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The professionals at Bay Area look forward to providing our Outpatient Charge Capture Analysis to your organization. Our deliverables will include an executive summary providing recommendations per department on future billing practices. The recommendations identified through our analysis will serve as departmental guidelines for future billing practices. Our process allows for a seamless transition of knowledge from our experts to your departmental managers. Additionally, our report will provide a Return on Investment (ROI) illustrating the value of our analysis. As previously stated, these recommendations will provide future economic benefit to the hospital that extends well beyond the completion of the project.
Are you being fully reimbursed for all services performed?
Based upon our experience, hospitals are not capturing hundreds of thousands of dollars of net reimbursement that they are entitled to under third party payers.
Our process will identify the issues resulting in lower than expected reimbursement.
As healthcare costs continue to increase and reimbursement continues to diminish, the ability to determine opportunities for additional revenue and the recovery of lost reimbursement are increasingly vital to all healthcare providers.
Clinical Research Compensation Consulting Services
Compensation for the personal services of Professional Investigators, both direct salary and fringe benefits, are typically a major cost of a research project. Compensation planning for research project's Principal Investigators and Medical Directors require a salary compensation model be based upon fair market value. The development of a compensation model should include an independent professional appraisal of the market place to establish comparability. Several factors need to be evaluated for the compensation analysis that are typically not identified or measured with other healthcare related disciplines. It is essential that the model for participating physicians demonstrate a reasonable market comparison for structuring the compensation. Bay Area Healthcare Advisors, LLC provides our clients, comprehensive studies and written opinions as to the market comparability of salaries and reasonableness of all salaries related to research. Our professionals have the necessary experience to perform these services within any research setting.
The development of the compensation model itself must take into account all aspects of the services performed by the participating principal investigators and associate investigators including:
Compensation on a per subject basis
Compensation for providing strategic planning or advisory services
Compensation for physicians who serve as medical directors or other administrative positions
Additional metrics such as hours, stipends, Medical Director requirements, and Internal Review Board ("IRB") responsibilities.
Bay Area Healthcare Advisors, LLC's professional staff has provided research consulting services to academic medical centers and community hospitals throughout the United States. More recently, James M. Cesare, President and CEO of Bay Area Healthcare Advisors, LLC, has served as lead consultant and interim Vice President for a Comprehensive Research cooperative involving a 500 bed southern California hospital and associated regional hospitals. The engagement involved restructuring and reorganization of the entire research department ranging from compensation restructuring to a Corrective Action Plan. (CAP) due to a federal investigation.
According to OIG guidelines for PHS research recipients, the most critical compliance issue is the accurate reporting of research time and effort because the compensation for the personal services of researchers, both direct salary and fringe benefits are typically the major cost of a project. It is essential the portion of the researcher's compensation for particular projects be carefully structured and accurately reported. Also, all compensation must be justified based on reasonable fair-market compensation. An institution's implementation of a serious , meaningful and effective research compliance program requires a significant commitment of time and resources which should be supplemented by a periodic independent, external consulting review to insure the highest level of due diligence and compliance.
Coding, Billing and Revenue Capture Services for Physician Practices
Bay Area's consulting process is tailored to meet your individual practice specialty. Our project scope is determined based on our initial discussion with practice leaders. The project fee is a fixed fee to meet your practice budget requirements. Our review process encompasses the following sample categories:
Selected Interviews
Chargemaster
Coding, Billing Process and Procedures
Physician Coding
Reimbursement Review – Inpatient and Outpatient
Compliance Plans and Process
Practice Educational Needs
The review process is performed over 30 days in coordination with a designated project manager to insure minimal disruption. A final draft report is presented and discussed with practice leaders. A final written summary report is given. Follow up consulting services are available at a discounted hourly rate.
The professionals at Bay Area have years of experience working for national/regional consulting firms. Our alliances throughout the country provide our clients with the most appropriate resources for their immediate needs. Our professionals and alliance networks are comprised of doctors, nurses, certified coders, pharmacists, and financial experts with decades of clinical and consulting experience. Additionally our professionals have worked with major law firms throughout the United States in representation of their client's third party disclosure purposes.
We provide professional services for the healthcare industry including but not limited to, BlueCross/Blue Shield plans, insurance companies medical groups, hospitals, home health agencies, independent laboratories, academic medical centers and independent research entities. Our professional services range from inpatient/outpatient reimbursement strategies to compliance regulatory solutions.
Is your practice being fully reimbursed for all services performed? Based upon our experience, physician practices are not capturing thousands of dollars of net reimbursement that they are entitled. The business operations of a physician's office are critical to the financial success of the practice. Accurate coding and documentation are key to proper reimbursement. Keeping current with the continuing stream of regulatory requirements is essential to proper billing, maintaining compliance and avoiding federal sanctions. Achieving and maintaining a high level of proficiency in coding, billing, and revenue capture require access to expert services from experienced professionals who specialize in improving practice management, operations, coding reimbursement and regulatory compliance.
Urology Management Advisory Services
Bay Area Healthcare Advisors, LLC (“Bay Area”) understands the dynamics and complexities of Urology Professional Practices. Our experience has provided urology groups additional reimbursement while insuring third party compliance guidelines requirements. We begin our engagements with an assessment of your practice to insure that your needs are met and that your practice fits our client profile. We recognize that each practice is unique therefore we begin our engagement with an assessment of the practice involving physicians and staff. This information is used as a basis for interviews with physician’s leaders and staff to further determine the issues that are of concern.
The initial step of our project will include a review of the following components of your urology practice:
Staffing , organization, policies and procedures
Medical records review (Focus areas: Consultations, Transfer of Care, Scheduling, Surgery)
Education/Information transfer
Charge master, coding, billing, charge analysis
Analysis of accounts receivable and denials
Contract analysis
Financial reports
Utilizing the information gained through the review process, Bay Area will prepare a draft report of recommendations for discussion with the practice management team. These recommendations will cover critical areas for practice improvement including:
Coding recommendations
Documentation recommendations
Identification of billing delays and improvements
Denial management
Comparative analysis with other urology practices including productivity, revenue, profit margins, PA ratios, etc.
Staff communications, training and monitoring of protocols.
The professionals at Bay Area have years of experience working for national and regional consulting firms. Our alliances throughout the country provide our clients with the most appropriate resources for their immediate needs. Our professionals are comprised of doctors, nurses, certified coders, pharmacists, and financial experts with decades of clinical and consulting experience. Additionally our professionals have worked with major law firms throughout the United States in representation of their client’s third party disclosure purposes.
We provide professional services for the healthcare industry including but not limited to, BlueCross/Blue Shield plans, insurance companies medical groups, hospitals, physician practices, home health agencies, independent laboratories, academic medical centers and independent research entities. Our professional services range from inpatient/outpatient reimbursement strategies to compliance regulatory solutions.
The day- to- day pace of free standing physician practices does not allow time for analysis of operational and financial processes critical to the financial success of the business.
The continuing stream of regulatory changes governing reimbursement has added to the complexity of assuring an accurate, compliant bill for services rendered.
To succeed in today’s environment physicians and their staffs are engaging the support of expert professionals who specialize in improving practice management, operations reimbursement and regulatory compliance.