Grady Health System created a corporate subsidiary, One Grady, LLC to serve asthe professional services billing entity for the health system and all billing eligible providers working within the health system. As Grady Health System is staffed by providers employed by Grady Health System, Emory School of Medicine and Morehouse School of Medicine, One Grady serves as the billing party for all three (3) entities. Vendor will provide the requested services to One Grady, LLC, through Grady Health System’s Corporate Compliance Department. This is a completely outsourced audit program, which includes the following program requirements: • Vendor will audit the professional component for services which will include evaluating the accuracy of standard E/M, CPT, HCPCS, and up to the first 4 diagnosis codes associated with provider pro-fee billing. • The audit review shall done pursuant to a risk-based model and shall include providers who are deemed outliers in their respective medical specialty. Annually, Vendor will conduct a bell-curve analysis to identify outliers by comparing current provider specialties with data gathered with our current and past engagements. Vendor will conduct an initial analysis and identify outliers in executive summary reports as requested by Client. • Vendor shall develop Audit Schedules annually based on the results of the bell-curve analysis (i.e., identified outlier providers) and other providers/specialties, as requested by Client. The Audit Schedules, one for each entity listed above, will be shared with Client on a monthly basis. Vendor will update each Audit Schedule, when necessary, throughout the year. Revised reports will be shared with Client. • Providers on the Audit Schedule will be audited during their designated month. Each provider identified shall have 10 encounters reviewed and audited. Additional providers and encounters may be added at the discretion of the Client. • Unless otherwise specified by Client, Vendor will conduct all pro-fee audits using local CMS carrier guidelines for applicable services. Where CMS guidelines are not pertinent or do not apply, Vendor will audit using industry standards from ICD-CM, CPT®4, HCPCS. The audits will also be conducted using any specific billing criteria provided by Client, including but not limited to the One Grady Standard Operating Procedure (SOP), policies and procedures.
