602 HCCA Presentation 602 Investigations Dwyer & …10.14.2014 HCCA Clinical Compliance Conference...

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Subpoenas and Searches and Suspensions, Oh My!

The Critical Roles of Compliance, Coding, Billing and Medical Records

SpeakersVicki L. Dwyer, MN,

ARNP, CPC, CHCCompliance & Privacy

OfficerIRB Administrator

Vail Valley Medical Center

Vail, Colorado

Nancy C. Kennedy, RHIT, CPC, CHC

Chief Operating Officer Compliance & Privacy

Officer

Galichia Medical Group, P.A.

Wichita, KS

10.14.2014

HCCA Clinical Compliance Conference

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First Investigation October 1996 – Medicare Request for 7

Charts

January 1997 – Qui Tam Compliant Filed

February 1997 – Rumors

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Initial Investigation June 1997 – Civil Investigative Demands

December 1997 – Request to Copy 200 Patient Charts

January – May 1998 – 205 Charts Taken

April 1999 – 11 Charts Audited

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Initial Investigation May to July 1999 – Response to Audit

Findings Early December 1999 – Negotiations with

Office of Inspector General, Department of Justice and the Relators

Late December 1999 – Agreement to a Settlement and Corporate Integrity Agreement

May 2000 – Final Signatures

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Initial Investigation Allegations Unsealed by Court Tip to the US Attorney’s Medicare Hotline Time Period

January 1, 1993 to December 31, 1998 Upcoding Services Double Billed Services Medically Unnecessary Tests & Procedures

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Relators Revealed

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Your Role for Ensuring a Favorable Outcome Establish and Maintain an Effective Compliance

Program: Compliance Officer & Compliance Committee -

TEAM Understandable Policies, Procedures & Code of

Conduct Educate & Train Staff, Providers, Students Promote Open and Effective Lines of Communication Enforce Compliance Standards Through Disciplinary

Actions Audit and Monitor for Compliance Respond to Potential Offenses

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Minimizing Whistleblowers Establish and Maintain a Reliable

Confidential Disclosure Program: Compliance Hotline Open Door Policy Solid Trusting Relationships – LISTEN Follow-up With Team Members Enforce a Strict Non-Retaliation Policy

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The First 4 Years Under the CIA CIA Annual Reviews

June 2001 – Net Underpayment & “Excellent Review”

June 2002 – Net Underpayment August 2002 – OIG Site Visit – No Issues

Identified June 2003 – Net Underpayment June 2004 – Net Underpayment

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Glowing Reviews – False Sense of SecurityUnderstand You are Never “Safe”

Who did it, Who attended, Who taught? What did you do, What happened, What

were the outcomes/results? When did you do it, When did it happen,

When was it fixed? Where did it take place, Where did you

take it? Why did you do it, Why did it happen, Why

did you do what you did? How was it fixed, How did you do it, How will

it not happen again?

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Key Transitions During the First 4 Years Opened Physician Owned Acute Care

Hospital – March 2002 Billing Manager Changes

Hired Mid 2003 From 15+ Years of Experience to Less than 5 Years Experience

Coding Manager Changes Hired 07.29.2004

From 15+ Years experience Physician Practice to 20+ Years experience Physician Practice,

Hospital, Medical Records

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The Rude AwakeningAugust 11, 200410:00 a.m. Call from Legal Counsel to

Compliance Officer3:00 p.m. 3 Agents arrive with Search &

Seize Warrants4:00 p.m. 28 Federal Agents Arrive on Site

(OIG, CMS, DOJ, DOD, NO FBI)5:00 p.m. Media Leak

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The Search Warrant Signed by U.S. District Judge Direction and Building Description Time Period: January 1999 to Present Pictures (taken in April 2004) Diagrams of the Buildings 10 Pages of Specific Patient Records

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Items Included In Warrant Procedures and policies for coding and billing Calendar or appointment books and patient

sign-in sheets or logs Records for current or former employees, their

job function, compensation, disciplinary files, personnel files, bonus or incentive payments

Minutes, meeting notes Electronic data processing and storage

devices, computers, computer systems, CDs, CD-ROMS, DVDs

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Your Role in a Search & SeizureUnderstand You DO have a Major Role Have a Policy in Place on What to Do, AND

EDUCATE EVERYONE Immediately Contact the Attorney if They

Have Not Contacted You. Understand that Agents Can:

Search entire facility, including locked rooms & cabinets

Can remove anything, including Medical Records & Essential Business Records.

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The Search Numbering & Identification of Rooms

Video Taping of Rooms

Search of Rooms & Seizure of Documents

Downloading of Computer files

Patient Charts

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The Search Concessions

“Mini Charts” “Sticky Notes”

Most Agents Left by 12:00 Noon on August 12, 2004. Some (Government Computer Techs)

stayed 3 days

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The Lighter Side 10:00 News, Pizza & the Agents

Aching Feet

3:00 AM Break

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The Lighter Side5:00 a.m.

Telling Federal Agents you need to go change your

cat’s diaper!

Inventory of Items Seized 55 pages of Items Each Item Listed

Box Number Item Number Room Found In Description Where Found

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Examples on Inventory Items Business Office Manager’s Office (G) Memo from [Compliance Officer] to

[Business Office Manager] in regards to OIG Overpayments – on top of desk file cabinet

Compliance Office (LL) Physician & PA Training Records – Back

office, third drawer, left filing cabinet, back wall

Yellow folder titled “Issues with documents pertaining to write-offs” – Back office third shelf of wooden cabinet

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Your Role in the Search Designate a “Point” Person to Respond to

the Execution of a Search Warrant Escort Agents to a Private Conference

Room or Location. Ask for proper identification from the Agents,

including a business card. Request that the Agents delay initiation of

the search until Legal Counsel Arrives If possible, close the facility and send

home all non-essential persons.

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The Search is Over – The Suspension BeginsPayment Suspension August 16, 2004 Notification of suspension Claims Continued to be Process

Local Hospitals React by Trying to Suspend Physician Privileges

Medicaid’s Attempt to Tag On

New Provider Numbers

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And Now the Subpoenas & Demands! September 2004 – 2 Demands

October 2004 – 3 Demands

November 2004 – 3 Demands

January 2005 – 3 Demands

February 2005 – 4 Demands

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And Now the Subpoenas & Demands! March 2005 – 1 Demand April 2005 – 1 Demand May 2005 – 1 Demand February 2006 – 2 Demands March 2006 – 2 Demands April 2006 – 1 Demand

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Your Role in Responding to Subpoenas & Demands Compliance

Point Person, Track Deadlines, DOCUMENT Help Explain the Rules & Regulations

Coding, Billing Support Compliance, Assist Where Needed

Medical Records The Hardest Job – Pulling Records Together

Administration, Management SUPPORT, Have FAITH, Know What’s Going On

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They’re Not Done Yet!Employee Interviews

Requested a List of Employees by Classification

Allowed Our Attorney’s to be Present4 Agents

1 Grand Jury Subpoena

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Your Role in the Interview Process Compliance

Use Your Knowledge, Explain the Rules & Regulations

Educate & Train Staff so They Know the Processes Coding, Billing

Know the Rules & Regulations, and Don’t be Afraid to Correct Misconceptions

Administration, Management Know Your Organization, Department, Be Able to

Talk about the Compliance Program and What it Does.

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Finding Closure 2007-2008 Independent Review of Specific Dates

of Service and Use of Modifier 25Government Identified Dates of ServiceUS Assistant Attorney Gave Auditor

“Direction”Key Issues Incident-to Billing Documentation of Chief Complaint and

History of Present IllnessAuditor Interpretation of Evaluation &

Management Guidelines

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Meeting Face to Face with the OIG & DOJParticipants

US Attorney, Civil Division, Department of Justice

2 Representatives from the Office of Inspector General

2 Practice AttorneysPractice Compliance Officer

Smoking Gun and Agreement to Settle

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Final Closure! February 27, 2009 3 Year Integrity Agreement with the OIG

Required a lot of negotiation. Less stringent than the first CIA

$1.3 Million Settlement with the DOJSame Settlement Agreement Provision Based on Incident-to, Who Could

Document Chief Complaint & History of Present Illness.

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Your Role in the Final NegotiationsRemember - YOU Will Have to Live With It Get Involved, Be a Part of the Negotiations,

You are Credible! Sell Yourself! Share Your Program, What it Does, How it

Identifies Potential Risks and How They are Corrected.

Keep Other Department’s Apprised of the Negotiations – What’s In It For Them.

Let Your Attorney Know What’s Doable and What’s Not Doable.

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Questions?

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Thank You!Nancy C. Kennedy, RHIT, CPC, CHC

Chief Operating OfficerCompliance & Privacy Officer

Galichia Medical Group, P.A.Wichita, Kansas

[email protected]

Vicki L. Dwyer, MN, ARNP, CPC, CHCCompliance & Privacy Officer

IRB AdministratorVail Valley Medical Center

Vail, Colorado970.477..5197

[email protected]

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602 HCCA Presentation 602 Investigations Dwyer & …10.14.2014 HCCA Clinical Compliance Conference...

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