To reduce the risk of a government audit and as part of the ophthalmology group’s internal compliance plan, they asked for their annual utilization analysis, chart audit, and custom training to be performed.
Situation
The objective was to enhance compliance by identifying potential billing outliers and associated risks through a utilization analysis and comprehensive chart audits, and to deliver targeted training to address vulnerabilities and improve overall compliance. As part of compliance, the ophthalmology group included new providers in their review to ensure a smooth onboarding process, and to ensure that billing, coding, and documentation was in alignment with regulatory expectations.
Solution
VMG Health conducted a comprehensive analysis of a full year’s billing data, benchmarking it against the Centers for Medicare & Medicaid Services’ (CMS) standards. The report provided an in-depth evaluation of the distribution between new and established patient visits, with a focus on E/M and Eye code usage, as well as diagnostic testing and surgical coding for both MDs and ODs. Beyond CMS benchmarks, VMG Health compared each provider’s data to their peers within the same specialty and across different practice locations to assess their relative standing and identify potential areas for improvement.
Based on the results, VMG Health conducted a detailed chart audit to further analyze claim accuracy, ensure compliance, and identify areas of risk, opportunities for improvement, and potential undercoding.
Leveraging the findings from the chart audit, VMG Health developed and delivered custom training focused on addressing compliance risks, optimizing coding accuracy, and mitigating potential under-coding issues.
Success
By aligning their billing practices with feedback provided by our ophthalmology experts, they successfully reduced areas of risk and enhanced overall compliance. The combination of data-driven insights, an in-depth chart review, and customized education enabled the client to proactively correct discrepancies, ensuring more accurate billing and a stronger compliance framework.
The client’s internal compliance plan required this project to be repeated every two years. VMG Health provided ongoing support and shared process improvements with the client. The client shared with VMG Health that there was an increase in supportive claims, demonstrating that the practice providers successfully integrated the training and compliance insights into their daily workflows.
