As part of compliance requirements, a team of Pinnacol auditors reviews a subset of provider bills to identify errors. The provider audit program of the Quality Department identifies billing trends and overpayments and works with providers to clarify the Division of Workers' Compensation rules and encourage correct coding. The auditors also provide offices with information to correctly bill Pinnacol. Supporting their efforts are complex bill processors.

Auditors have a custodial role for Pinnacol policyholders, who pay premiums and deductibles, by managing medical costs and ensuring providers are paid accurately for reasonable and necessary charges. The audits for bill coding include those for high-level evaluation and management (E&M) visits, costly procedures and surgeries, and durable medical equipment, as well as for codes frequently billed incorrectly and Division Z codes.

Bundled codes are also reviewed, as these can inflate costs when a provider incorrectly bills for two procedures instead of one. As an example, in an eye exam, vision screening is part of the E&M visit and should not be coded separately.

Coding education  

The educational component of the provider audit program is essential to auditors' roles. The auditors assist providers by comparing providers' billing patterns to their peers' and also by identifying missing elements in their documentation. In some cases, providers may be using the wrong guidelines for E&M coding. Colorado workers' compensation follows the guidelines from 1997, not 1995.

Pinnacol auditors serve as a resource for workers' compensation billing and assist with coding and documentation requirements. For the past two years, providers have been given the benefit of the doubt and numerous opportunities to amend records and submit bills for reprocessing. Payment denials will follow if the missing components are not included in subsequent documentation.

Quality Assurance Manager Kelly Bowland wants providers to know the audit program is not merely for compliance and cost savings. "The goal is more efficient bill processing. Accurate bills are paid quickly and correctly, which optimizes provider satisfaction and enhances service to Pinnacol's policyholders and injured workers," he says.

For billing and coding assistance, please email billingsuccess@pinnacol.com or call 303.361.4940.

References

Division of Workers' Compensation – Evaluation and Management (E&M) Audit Form

Centers for Medicare & Medicaid Services – 1997 Documentation Guidelines for E&M Services

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