Payor Audits: Preparation, Response and Opportunities
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Transcript of Payor Audits: Preparation, Response and Opportunities
David E. Jose, Esq.One Indiana Square, Suite 2800
Indianapolis, IN 46204(317) 238-6211
July 29, 2010
Payor Audits:Payor Audits:Preparation, Response and Preparation, Response and
OpportunitiesOpportunities
Audits:Here, There and Everywhere External audits increasingly common Use of audits as mechanism to recoup
“overpayments”, but other purposes and consequences
Financial, regulatory and criminal penalties associated with billing “errors”
Audits:Here, There and Everywhere
Recognize threats and opportunities posed by external audits
Compliance program needs to include a credible internal audit system
Internal audit system addresses external audit, quality of care and performance improvement purposes
Topics for Presentation
Appreciating the Context for Audit Activity RAC Audits as a Representative Sample Preparing for and Responding to an Audit Learning from the Audit
Constituencies Government Payers Commercial Payers Enforcement Authorities Civil Lawsuits Other Treating Providers Staff Patients Competitors
Sources for Concern
Disgruntled Employees Disgruntled Patients
• Senior Medicare Patrol
Increase Awareness of Whistleblowing Opportunities
News Reports
OIG Testimony
ROI of $17 for $1 of Medicare and Medicaid Oversight
FY 2008• 455 Criminal Actions• 337 Civil Actions• 3,129 Excluded Individuals and Entities• 1,750 New Fraud Investigations Opened
OIG FY 2010 Report
$3.1 Billion for first half of FY 2010 $667 Million in Audit Receivables $2.5 Billion in Investigation Receivables 293 Criminal and 164 Civil Actions
Government Enforcement Activities Amounts Recovered
• “Fraud”• Reducing Expenditures
High Profile Practices and Activity Trolling for Excluded Individuals Increased Funding Under Reform
OIG 5-Principle Strategy Scrutinize enrollment Establish payment methodologies responsive to
marketplace Assist providers in adopting practices promoting
compliance, including quality and safety standards
Vigilantly monitor for fraud, waste and abuse Respond swiftly and impose punishment to deter
Examples from OIG Medicaid vulnerabilities relating to school-
based services 2010 Work Plan focus on provider-based
status Implications
• Site-based services• Physician partnering relationships• Procedures vs. outcomes billing debate
RAC Audits Expanding
Health care reform extends RAC program to state Medicaid programs
Recent support in other areas of government contracting announced by President Obama
RAC Audits – What Can Be Learned Automated vs. Complex Review Priority of Targeted Providers (Volume and
Value) Targeted Claims
• Medical Necessity• Coding• Incorrect Payments• Duplicate Claims
Contingency Fee Payments for Independent Audit Contractors
Issues for Claims Review Process
“Certainty Standard” vs. “Good Cause Reason” Request for medical records and timely response Licensed health care professional involvement Notice of full or partial overpayment Recoupment options and time frames
RAC Appeals Process Rebuttal to auditor vs. direct appeal Redetermination Appeal
• Avoiding recoupment pending appeal Reconsideration – Qualified Independent
Contractors Administrative Law Judge
• First judicial-type review• Review can go beyond “the record”
Medicare Appeals Council Review Federal District Court Review
RAC Management Program
Enhancements to Compliance Program Focus on Target Areas (e.g., one-day
stays) Timely Response to Records Requests File Rebuttals and Appeals Tracking System Corrective Actions Opportunities for Improvement
Preparation for Audits
Review Policies• Clinical documentation• Financial billing and collecting• Responding to audit inquiries
Identify Risk Areas Train Employees Protocols for Pre- and Post-Audit
Issues for Billing Audits Retrospective or Prospective Sample Type and Size
• Random• Payer specific• Procedure specific
Issue or Criteria to be Applied Risk Areas
• Coding• Documentation• Modifiers• Medical Necessity
Top Medicare Billing Errors Duplicate Non-Covered Service Medical Necessity Bundled Services Beneficiary Eligibility Incorrect Carrier Medicare Secondary Payer Provider Eligibility Place of Service
OIG Risk Areas
Documentation• Timely• Accurate and legible• Complete (e.g., reason for encounter, history,
examination findings, diagnostic test results, etc.)
• Comparison of denial rates with peer practices
OIG Risk Areas
Reasonable and Necessary Services• Documenting diagnosis and treatment• Seeking denial for secondary payer
OIG Risk Areas Coding and Billing
• Services not rendered• Supplies or services not reasonable and
necessary• Duplicate billing• Non-covered services• Unbundling• Clustering• Upcoding
OIG Risk Areas
Improper Inducements and Relationships• Financial arrangements with potential referral
sources• Joint ventures• Consulting contracts or medical directorships• Office and equipment leases• Gifts and gratuities
“Medical Necessity”
“… unless otherwise required by statute or regulation, means that a Health Service is compensable, as determined by [Insurer] for the treatment of an injury, sickness, or other health condition and is : (1) appropriate and consistent with the diagnosis or symptoms, and consistent with accepted medical standards; (2) not chiefly custodial in nature; (3) not investigational, experimental or unproven; (4) not excessive in scope, duration or intensity…; and (5) not provided only as a convenience to the Covered Individual or professional provider or health care facility.”
Background Preparations
Web Site of Commercial Payers• Provider education• Binding (?) pronouncements
Web Site of Government Payers and Agencies• OIG web site for Corporate Integrity
Agreements Web Sites of Audit Contractors
• Targeted issues
Audit Coordinator Advising personnel of pending audit Ensuring authorization for disclosure of
records Gathering records Overseeing auditor’s on-site activity Organizing exit interview Follow-up communications with auditors
for clarifications or additional documents
American Association of Medical Audit Specialists
Billing Audit Guidelines Use as Standards
• Internal audit • External auditor relationship
Purpose for Health Records
Purpose for Health Record
“Health records exist primarily to ensure continuity of care for a patient; therefore, the use of a patient’s health record for an audit must be secondary to its use in patient care.” - American Assoc. of Medical Audit Specialists
Preparing to Respond Tracking System and Specific Payer/Authority Time Frames, Issues Raised, and
Documentation Needed Medical Necessity or Coding Assistance Internal or External Assistance (including peer
and association support) Statistical Issues Costs, Benefits, Distractions, and
Consequences
Repayment or Recoupment
Regular Repayments Provider Self-Disclosure Protocol Audit Appeal Settlement ** New obligation to repay within 60 days
of “knowledge”
Audits with Potential Criminal Exposure
Confidentiality Compliance with Subpoenas Legal Ethics Joint Defense Arrangements
Preparing to Appeal
Time Frames for Each Stage Venue and Issues Importance of the Record Repayment vs. Delay Designated Staff Assistance Getting the “F-Word” Off the Table
Medicare Audit Defenses: What Can Be Learned?
“I’m right, you’re wrong, and here’s why.” “Treating Physician Rule”
• Best position to opine on medical necessity for patient
Waiver of Liability”• Clarity of contract and provider
communications
Provider Without Fault”
AMA Report on Claims Processing Accuracy
Claims processing inaccuracies cost $15.5 Billion
Potential for errors in commercial audits Most accurate: Coventry @ 88.41% Least accurate: Anthem @ 73.98%
Creative Arguments
Context for the Services Supporting Documentation Technical vs. Fundamental Defect Late Entries and Affidavits Engaging Legal Counsel for Settlement
Operational Benefits from the Audit Policies and Procedures on Outside
Investigations• More than payer audits
Enhanced Corporate Compliance Program• Improvements to internal self-audits• Connecting audits, compliance and quality
Improved Payer Communications Getting Off the “Radar Screen” Limiting Repayments
OIG Corporate Integrity Agreement Employee Training
• Covering a variety of topics
Engagement of Independent Review Organization
Claims Review Process Repayment of Overpayments’ Reporting of “Reportable Events”
Mandatory Compliance Programs
Health care reform legislation authorizes mandated compliance programs
Mandated core elements Potential rigorous self-auditing and self-
reporting features Potential penalties for not having a
credible program
Compliance and Audit Functions
Importance of independence from operations
Clear lines of reporting and authority Management responsible for compliance
and controls Collaborative support for investigations Ensure follow-up on recommendations
Audits, Risks and Quality
Regulatory Compliance Medical Performance Medical Records Patient Safety Supervision
Questions
David E. Jose, Esq.Krieg DeVault LLP
One Indiana Square, Suite 2800Indianapolis, IN 46204
[email protected]: (317) 238-6211Cell: (317) 695-1084Fax: (317) 636-1507