oders’ Role in Anti -Fraud...
Transcript of oders’ Role in Anti -Fraud...
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Coders’ Role in Anti-Fraud Investigations
Margaret Chambers, RN, CPC, CPC-P, AHFI
Senior Investigator Premera Blue Cross
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Objectives
• Understand a coder’s role in fraud investigations
• Obtain an understanding of the scope of Health Care Fraud
• Recognize how a coder supports the investigation team
• Understand the components of an investigation
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Disclaimer
This presentation is based on my experience in my particular SIU.
These are my insights and observation.
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HealthCare Fraud and Abuse
And the
Special Investigations Unit
SIU
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What is Health Care Fraud?
“Fraud is an intentional act of deception, misrepresentation or concealment of a material fact or information.”
=
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Did you pay your 2012 Taxes?
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How Big is the Problem • United States spends more than $2.8 trillion
on health care every year.
• NHCAA estimates that:
3%; over $75 billion to $250 billion is lost to health care fraud per year
• Patient harm is an unfortunate side effect of health care fraud
(National Health Care Anti-Fraud Association )
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February 11, 2013 LA Times
• Federal government recovered a record $4.2 billion in the last fiscal year from medical providers and others who fraudulently billed government healthcare programs
• The Justice Department also reported that 826 people were convicted of crimes related to healthcare fraud last year
• That report drew stern criticism from members of Congress from both parties. "This lack of progress is deeply disappointing," said Sen. Thomas R. Carper (D-Del.).
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Our SIU 2012 Statistics Cases > 100
4 -Convictions
Recovered $1,084,241 (hard $)
75 providers removed from our panel
Members: 1.7 million
Staffing:
3 investigators
3 Analysts
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What Does an SIU Do? • Detect health care fraud and abuse
Referrals/complaints
• Assess Substantiate allegations
• Investigate Interviews
Coding and billing practice
• Report Case summary for internal and external parties
• Final resolution Restitution
Law enforcement/conviction
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Reactive (Pay and Chase) • Investigative Sources
• Fraud Hot-line calls – Hotline number is on our website and on the
explanation of benefits (EOB)
• Internal referrals – Customer service
– Claims
• External referrals – Ex-employees
– Practice partners
• Health Care Fraud Info Sharing Network – Washington Medical Fraud quarterly meetings
– Other Plan peers
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Proactive Encourage our associates within the company to
be on the watch for questionable claims but this is no longer adequate for successful pre-payment detection.
Pre-payment analytics is essential in a SIU. The money has to be stopped before it goes out.
“Pay and chase” has been the traditional method of recouping dollars but it has many drawbacks.
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Proactive
The majority of SIUs use “anti-fraud” software:
• Identifies “outliers”
• Uses past claims data as a source
Pay and chase is necessary for certain cases but the pre-payment model is now considered essential.
• Centers for Medicare and Medicaid Services (CMS) is moving to this model.
• Predictive modeling techniques
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SIU Strategies • Prosecution Oriented SIU Staffing
– Former law enforcement; federal, state and local
– Goal is prosecution
• Team Oriented
– Teams organized around; geography, skill set, specialty
– Investigators, analysts and coders
• Financial Recovery Oriented
– Pursue lost funds
– Auditors, investigators, coders, nurses
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Team Member Requirements • Education background
– Law enforcement, medicine, coding
• Experience
– Law enforcement, insurance, statistics, coding
• Required technical and investigative skills
– Interviewing, software proficiency, report writing, curiosity.
• Communication skills
– Ability to interact with varying audiences
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Coder’s Role • Use suspect information to start looking for
billing issues or patterns
– Look for patterns/trending
» Do they bill an E/M code with every procedure
» Do they use an excess number of high end E/M
• On-Site Audits/Desk audits
– Investigators are CPC, CPC-P, CPMA
» Accredited Health Care Fraud Investigators
» Compare the chart notes with the documentation
» Determine if the correct codes are being used
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Coder’s Role • Review investigation findings with the
provider
– Investigators meet with the providers to review the results and discuss the rationale
– Offer provider education and resources
• Prepare the referrals to other agencies
– Department of Health
– Medicare Medicaid
– Office of the Insurance Commissioner
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Investigation
And
Information Gathering
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Data Assessment
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Investigation Process • Use information to start looking for billing issues
or patterns
• Collect retrospective claims data
• On-Site Audits/Desk audits
• Interviews
• Review investigation findings with the provider
• Recovery
• Referral & Cooperation with Law Enforcement (HHS, FBI, OIC, DOH)
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Using Coding Skills
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Patient intake form.
This provider did not signed the intakes which include a review of systems
Sometimes they make it easy
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First page
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The only
examination was
vital signs and ----
Billing new patient
code 99204
(Detailed new
patient) with code
99402 (preventive
medicine
counseling)
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Fraudulent and Abusive Billing
• Services/Procedures/Supplies not provided or performed
– Bill for a procedure that “is sort of like” what was performed
– Provider does a referral and bills for a consultation
– Dispenses a scooter and billed Medicare for a wheelchair
– Bills for a septoplasty and performs a rhinoplasty
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Billed as code 93882 “duplex scan of extra-cranial arteries; unilateral or limited.”
The correct code is 0126T “common carotid intima-media thickness study”.
Considered investigational at our Company.
Example of “Cloaking”
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EarCheck Pro™ Tympanometry
This physician was using the EarCheck Pro™ on every patient at every visit.
He was billing code 92567, tympanometry and being paid $27.00 (2006).
In a 24 month period he had been paid $93,560.00.
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Fraudulent and Abusive Billing
• Bills for services of a non-licensed person
– Billed for the services of a fitness trainer using physical medicine codes
• Bill for more costly services than provided (up-coding)
– Higher level E/M than documented
– Bill for an adjacent tissue transfer when an intermediate or complex closure was performed
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Billing More Costly Services Physician owned his ASC and professed to be an “expert” on skin cancer.
He would excise the lesions with a laser, undermine the wound edges and close.
He consistently billed adjacent tissue transfer codes because they paid an ASC fee and he would also bill the excision. In fact he was doing an intermediate closure.
He was investigated by our Company and eventually ended up investigated by the Department of Health.
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DOH Findings Fraud does harm patients:
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Other Issues • Altering medical records
– While the investigation team was waiting for EMR, the staff was altering the medical records
– White-out
• Members misrepresenting dependents
– Girlfriends as wives
– Unrelated children
• Altering member submitted claims
– Changing numbers on the claims
– Fabricating treatment records
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White Out
White out
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Coders Challenges • Know something about everything
– Need to do research
– Need to have resources
• CPT® Assistant
• Anatomy book
• Dental coding
• PDR drug references
• AAPC
– Time consuming but fascinating
– Company wide resource person
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Coders Challenges
• Opportunities to educate on coding guidelines and anti-fraud efforts
– Meet the providers on a common ground
– When it is abuse or ignorance assist the providers in compliance.
– Don’t tell them how to bill but instead we help them find the resources to bring them into compliance
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A
CASE OF
CLONING &
DOWN RIGHT BAD BEHAVIOR
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Documentation Neuromuscular reeducation, Code 97112
Examinations; being created especially for us
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EMR “déjà vu”
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How far will the SIU go to investigate possible fraud and/or abuse?
23 miles north of the
Arctic Circle!
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Kotzebue Alaska at -31º
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Laura Erickson,
Senior Analyst
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