Billing and Coding Auditing Services

The vendor is required to provide billing and coding auditing services for include:
•    Conducting periodic risk assessments in collaboration with the office, using comprehensive data analysis to evaluate utilization and coding trends across providers and identify risks, threats, and opportunities related to documentation, coding accuracy, charge capture, and billing practices for services provided by the system.
•    Develop annual audit plans based on completed risk assessments, detailing a schedule for regular reviews and audits (including chart reviews and data analysis), while specifying the recommended sample size, frequency, and target areas for focused reviews based on identified risk areas.
•    Conduct, or assist in conducting, audits of risk areas identified in the annual audit plans
•    Provide prospective and retrospective coding and billing audit services, as appropriate, as outlined below, including, but not limited to:
o    Comprehensive review of medical records to verify that all assigned codes are supported by appropriate documentation and current coding guidelines, ensuring that all charges are captured for billing and that required regulatory documentation (e.g., consent to treat) is completed
o    comprehensive audit of inpatient accounts encompassing verification of present on admission (POA) conditions, precise documentation of primary diagnoses, accurate assignment of secondary codes, review of major and complication and comorbidity codes (mcc and cc), validation of procedure codes, diagnostic related group (DRG) verification both with and without queries, and confirmation of discharge disposition 
o    Comprehensive audit of outpatient, emergency department (ED), ambulatory surgery, and centers accounts, including verification of assigned levels of service for outpatient and professional claims when applicable, accurate capture of all valid procedure codes, international classification of diseases (ICD) diagnosis code assignments, appropriate modifier usage, wrap-around centers billing where relevant, and validation of coding to ensure medical necessity
o    Comprehensive audit of home care services, including verification of all required signed documentation (consent forms, financial agreements, plan of care, face-to-face encounter, physician orders), accuracy of office of addiction services and supports (OASAS) assessments and ICD code assignments (primary and secondary diagnoses), evaluation of medical necessity and homebound status per payer requirements, and confirmation of electronic visit verification and visit documentation 
o    Comprehensive audits of health home services, including verifying member eligibility (Medicaid and managed care organization (MCO) coverage and qualifying chronic conditions), compliance with monthly encounter and assessment requirements, timely responses to inpatient and emergency department alerts, and accurate encounter documentation and verification 
o    Comprehensive audits of skilled nursing facility accounts, including validation of level of care and skilled needs requirements, timely physician orders, certifications and recertifications, and confirmation of timely minimum data set (MDS) assessments 
o    Develop and monitor corrective action plans as needed, including but not limited to advising on modifying applicable policies and procedures, modifying documentation templates, or recommending electronic health record (EHR) enhancements.
•    Assist with disclosures and refunds to third party payers, including Medicaid and medicare, if warranted.
•    Assist with responses to external agency audits of billing and coding issues for services provided.
- Education and training
•    Provide education around findings, including one-on-one and group trainings, as necessary. 
•    Conduct follow-up audits to assess the effectiveness of remedial training following the identification of billing or coding issues. 
•    Provide informal verbal feedback throughout the audits to discuss specific areas of concern or cases. 
•    Provide ongoing consultative support, including research and guidance on documentation, coding, and billing inquiries, as well as recommendations for resolving identified compliance issues.
•    Provide billing and coding auditing training to system staff. 
•    Conduct bi-weekly meetings with appropriate system staff.
- Reporting
•    Provide reports detailing audit results and findings supported by official coding guidelines, incorporating feedback from appropriate billing and coding staff, and tracking corrective action plans as required. 
•    Provide comprehensive monthly statistical reports aimed at identifying outliers, detecting patterns, highlighting additional areas of focus, and determining where retrospective reviews may be warranted, including, but not limited to:
o    Accuracy rates for each audited element and unit, with individual and aggregated statistics 
o    Trending reports by month, quarter, and year 
o    Audit productivity metrics, including the total number of items audited and the total number of errors identified each month
- Advanced analytics
•    Provide continuous dynamic advanced analytics of audit results that include the ability to filter data, drill down within the data, and produce reports.

- Contract Period/Term: 3 years
- Mandatory Pre-Proposal Conference Date: October 29, 20285
- Questions/Inquires Deadline: November 05, 2025