Post on 26-Jun-2020
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Compliance Guidance for Physicians:
Keeping Your Practice Safe
AAPC
2013 Regional Conference
Presented by
Jean Acevedo, LHRM, CPC, CHC, CENTC
All rights reserved
Agenda
The 7 Elements
The new climate
Effectiveness
CMS demonstration
Grading your compliance program
Internal auditing and monitoring
Reporting
Education
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The OIG’s Seven Elements
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1. Conducting internal monitoring and auditing through the performance of periodic audits
2. Implementing compliance and practice standards through the development of written standards and procedures.
3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards.
4. Conducting appropriate training and education on practice standards and procedures.
5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities.
6. Developing open lines of communication to keep practice employees updated regarding compliance activities. Non-retaliation policy.
7. Enforcing disciplinary standards through well-publicized guidelines.
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Identified Risk Areas
for Physicians
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Proper coding and billing
Ensuring that services are reasonable and necessary
Proper documentation
Medical record
CMS-1500
Avoiding improper inducements, kickbacks and self-referrals
Coding and Billing
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Upcoding, unbundling and improper use of modifiers
Misuse of provider’s identification numbers
Q6 (locum tenens) is not to be used to bill for services while you are waiting for Medicare to process the new doctor’s enrollment application.
Billing for:
Items/services not provided
Equipment, supplies and services not medically necessary
Non-covered services as covered
CBC, CMP, EKG as part of an “annual physical”
MAC’s LCD does not cover 76942; billed 76881 instead
Reasonable and Necessary Services
Local coverage determinations
Advanced beneficiary notice
Certificate of medical necessity
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Medical Record Documentation
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If it is not written - it did not occur
Document medical necessity
Complete, legible and signed!
Do you use scribes? How is that fact
documented?
If on an EMR
Copy & paste
Cloning
CMS 1500 Documentation
Match diagnosis to
documentation in
medical record
Match diagnosis with
procedure code
Identify secondary
insurance coverage
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Inducements, Kickbacks and
Self-Referrals
Knowledge of or
willfully providing or
receiving anything of
value that can alter
medical decision
making resulting in
increased referrals or
utilization of services is
not permitted
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Inducements, Kickbacks and
Self-Referrals
Claim induced by a kickback is a false claim
How does your State define an inducement, kickback or
self-referral?
Stark and self-referrals
Florida’s Patient Self Referral Act of 1992
FS 456.053
What does your state say?
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All rights reserved
The New Climate
The New Climate: Whistleblowers
Support and encouragement of whistleblower cases
by leading prosecutors
Whistleblower web sites
Whistleblower support organizations
How-to books, checklists, advice
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The New Climate: Whistleblowers
As of the end of 2012, there were more than 1200
federal qui tam cases under investigation, with no
decision as to whether the DOJ will intervene
Of these cases, over 800 involve healthcare fraud,
many against multiple defendants.
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The New Climate: Whistleblowers
1/4/2013: $4.4M settlement – EMH Regional
Medical Center, Ohio
Unnecessary angioplasty and stent procedures
Former catheterization lab manager accused
hospital of doing procedures on patients with
insufficient blockage.
Received $661,000 award
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The New Climate: ACA
Mandatory reporting, repayment, and explanation of
overpayments by “persons”
“Knowing” retention of overpayment beyond 60 days
is a false claim
With all its fines, penalties and whistleblower provisions
Mandatory Compliance Plans
First, nursing homes, later other providers
Mandatory reporting of overpayments
Mandatory review and follow-up
State requirements
NY Medicaid
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All rights reserved
The New Climate:
Enforcement
Recent Cases – 2013
Salesman Admits Role In Bribes-For-Test-Referrals Scheme
Involving New Jersey Clinical Laboratory
Planned Parenthood Pays $4.3 Million To Settle Allegations Of
Unnecessary Medical Care, TX
Long Island Physician to Pay U.S. $388,000 to Settle False
Claims Act Allegations Related to Overbilling Medicare, NY
Seven Oncologists Charged With Importing Unapproved Drugs,
Ohio
Johnson City Physician Sentenced To Serve Two Years In Prison
For Unapproved Foreign Drugs, TN
Doctor Convicted in Kickback Scheme Involving a Philadelphia
Hospice, PA
Medical Clinic Director, CEO Plead Guilty To Health Care
Fraud, False Tax Return, Kansas
All rights reserved
Medical Clinic Director, CEO Plead Guilty To
Health Care Fraud
By pleading guilty, the Rysers admitted that they engaged in
fraudulent billing by “upcoding” and falsifying claims submitted to
insurers (including Blue Cross Blue Shield, Cigna, United Healthcare
and others, as well as government programs such as Medicare and
Tricare) in an effort to be paid more than the amount to which HCA
was entitled.
The Ryser’s scheme included: (a) billing for physician office visits
when Carol Ryser was out of town; (b) billing for physician office
visits when Carole Ryser had little or no involvement with the patient;
(c) billing for physician office visits when the patient contact was by
telephone call; (d) billing for physician supervised services when no
physician was on duty at the clinic; and (e) improperly billing for
consultation services.
The federal indictment describes six variations of billing fraud and
includes tables of claims demonstrating each type of billing fraud. For
those claims specifically included in the indictment, the total amount
billed on those claims was $359,168. The total amount that was
actually paid on those claims by health care benefit programs was
$51,789.
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Medical Clinic Director, CEO Plead Guilty To
Health Care Fraud
Carol Ann Ryser, 76, and Michael Earl Ryser, 68, both of Mission
Hills, Kan., pleaded guilty before U.S. District Judge Greg Kays to
the charges contained in a June 26, 2012 federal indictment.
Carol Ryser owned Health Centers of America-Kansas City, LLC
(HCA), a medical clinic in Kansas City, Mo.. HCA purported to
specialize in the diagnosis and treatment of chronic diseases such
as Lyme disease, chronic fatigue syndrome, fibromyalgia, and other
auto immune diseases.
Carol Ryser, who was a medical doctor and the clinic’s medical
director, surrendered her medical license today as a condition of her
plea agreement. Carol Ryser may never again seek licensing to
practice medicine in the United States and she may never be
involved as an owner or employee (or in any other capacity) with any
medical clinic, hospital or other health care provider. Michael Ryser
was the CEO, chief administrator and vice-president.
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Medical Clinic Director, CEO Plead
Guilty To Health Care Fraud
Under the terms of the 3/22/2013 plea agreements,
Michael Ryser will be sentenced within a range of 24
to 30 months in federal prison without parole.
Carol Ryser will receive a sentence of three years of
probation, including six months of home detention.
The Rysers must pay $51,789 in restitution to the
health care benefit programs that were defrauded.
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Measuring Effectiveness……
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CMS Compliance Effectiveness Pilot
3 year pilot
Ended early 2007
16 hospitals in the NE participated
84 hospitals applied
#1 Element: Communication
Communication across the organization re: auditing results and training
“Communication makes a difference.” Kimberly Brandt, Director, Medicare Program Integrity, HCCA Compliance Institute, April 2007
The more these 3 elements interfaced, the more there was an increase in the accuracy of claims 1. Communication
2. Auditing
3. Education
Outcomes of Raw Claims Data
When the contractor initiated action it was already
too late
Much less resources/$$ when the provider found an
issue & acted
Based on audit results
Based on the OIG work plan
Etc.
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Outcomes of Raw Data
CMS would like contractors to provide semi-annual
data to providers very similar to what the pilot
participants received
CBRs in 2013
Little changes in the compliance program made big
differences.
Bottom line for the hospitals: Denied and rejected
claims decreased
Outcome: Education
Problem with documentation?
Web-based training does not work
1-on-1 training does work
Can decrease claims denial rate
Coding/Medical Necessity
Small groups work
1-on-1 intensive sessions work
By people who speak the same language
Physicians training physicians works best
Outcome: Auditing & Monitoring
All auditing results need to be communicated
throughout the organization
Then, training & staff education
Makes a difference if the organization makes a
commitment and emphasis on compliance
A culture of compliance
Commitment from the top people must be seen in
meetings/training.
Are your doctors/executive management present at annual
training? Compliance. OSHA. HIPAA
Important that the compliance officer “gets out there.”
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Measuring Effectiveness
OIG’s Supplemental Compliance Program Guidance:
“Every effective compliance program necessarily begins
with a formal commitment to compliance by the hospital’s
governing body and senior management. Evidence of
that commitment should include:
Active involvement of the organizational leadership
Allocation of adequate resources
A reasonable timetable for implementation of the compliance
measures; and
The identification of a compliance officer and compliance
committee vested with sufficient autonomy, authority and
accountability to implement and enforce appropriate compliance
measures.”
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Measuring Effectiveness – Policies &
Procedures
Documentation all employees have received Code of
Conduct, P&P?
Attestations
P&P are clearly written and relevant to day-to-day
responsibilities
Documentation of training at orientation
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Measuring Effectiveness – Training
The OIG Guidance clarifies that education and training and
continual retraining of all personnel at all levels are
significant elements of an effective compliance program.
Updated compliance training materials used and maintained
Training is documented
Sign-in sheets with agenda
Specialized training
Coding and billing training
Coding rules
LCDs
Manager/Supervisor training
Treating each question/report confidentially
Non-retaliation against any employee asking a question/making a
report
Documenting and tracking questions and reports
When to report to Compliance Officer
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Measuring Effectiveness – Monitoring
and Auditing
The OIG Guidance clarifies that the organization
should develop detailed annual audit plans
designed to minimize the risks associated with
improper claims and billing practices.
Conduct a risk assessment
Develop a tool
Keep it simple and practical
Determining your risk universe
OIG Work Plan
ADRs, Denials
Payer audits
Alerts, Bulletins received
AAPC Coding Edge!
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Measuring Effectiveness – Monitoring
and Auditing
The OIG Guidance clarifies that the organization
should develop detailed annual audit plans
designed to minimize the risks associated with
improper claims and billing practices.
Audits
Determine parameters
Baseline, focused, ongoing
What to do with results
Education
Follow up audit
Repayment?
Let’s talk about this a bit….
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Physician Compliance: Refunds
Medicare refunds should be made w/in 60 days of
discovery
Revised FCA – any $ not refunded become false claims!
But how to determine the full extent of the overpayment?
When does that 60-day clock start ticking?
How far back do you look? What is your “universe?” Add’l hour of infusion time billed but not documented: nurse
who misunderstood was only there for 3 months
Doctor billed a 99215 with every 99387 for 3 years
Check credit balances regularly – run reports, keep track
of accounts
Overpayment = refund or recoup
Credit balance may not = overpayment
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Physician Compliance: Refunds
If your providers balk at paying back overpayments, show them the law!
18 U.S.C. § 669
Health care embezzlement applies to all payers (not just Medicare, Medicaid, other gov’t programs)
Keeping overpayments is a Federal crime
Biggest Compliance Program Failures
Identification of compliance risk areas and non-
compliance
No follow-up of identified issues
CMS is developing its own version of a FICO score
to be able to identify providers who may be/are at
risk for being out of compliance.
4/10/11, James Sheehan
2013 OIG Work Plan (next slide)
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OIG Work Plan 2013: Review of Part A and Part B Claims
Submitted by Top Error-Prone Providers We will review Medicare Part A and Part B claims submitted by error-prone
providers to determine their validity, project our results to each provider’s
population of claims, and recommend that CMS request refunds on projected
overpayments. Previous OIG work illustrated a methodology for identifying
error-prone providers using CMS’s Comprehensive Error Rate Testing
(CERT) Program data. Using this methodology, we identified providers that
consistently submitted claims found to be in error over a 4-year period. In this
review, we will select the top error-prone providers on the basis of expected
dollar error amounts and match the selected providers against the National
Claims History file to determine the total dollar amount of claims paid. We
will then conduct a medical review on a sample of claims. Providers must
submit accurate claims for services provided to Medicare beneficiaries.
(CMS’s Medicare Claims Processing Manual, Pub. 100-04.) (OAS; W-00-13-35565;
various reviews; expected issue date: FY 2013; new start)
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U.S. Attorney Spencer Turnbull*
“Compliance is more than just rules. It’s ethical
conduct and a culture of ethical conduct. The
question in a kickback case is not ‘can I do this,’
but ‘why am I doing this?’”
*Speaker, HCCA Compliance Institute,
Chicago, IL, April 2007
The Choices
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Do nothing
Cross your fingers!
ADRs and Prepayment
audits
CIAs
Up to 5 years
Fines, penalties and jail time
Soon you will have no choice
May not have one now
Identify the right resource
Practice specific
More than just a book on the
shelf
A process that requires
commitment
Cost effective protection
Check your managed care
contracts –
They may require a
compliance program!
Back to where we started – 7 Elements
1. Conducting internal monitoring and auditing through the performance of periodic audits
2. Implementing compliance and practice standards through the
development of written standards and procedures.
3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards.
4. Conducting appropriate training and education on practice
standards and procedures.
5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to
appropriate Government entities.
6. Developing open lines of communication to keep practice
employees updated regarding compliance activities. Non-retaliation policy.
7. Enforcing disciplinary standards through well-publicized guidelines
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Useful Websites and Resources
www.stopmedicarefraud.gov/
OIG Work Plan, Exclusions List, Compliance
Guidance:
www.oig.hhs.gov
CERT Reports
www.cms.gov/cert
CMS Manuals (can’t live without them!)
www.cms.gov/manuals
Your Medicare Contractor
Compliance Toolkit for Physician Practices
www.aapc.com/toolkit
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Jean Acevedo, LHRM, CPC, CHC, CENTC Acevedo Consulting Incorporated
561.278.9328
www.AcevedoConsultingInc.com