Audits Are About Money - Upcoming Events · 2019-12-16 · Audits Are About Money • Post payment audits are a tactic utilized by government and private insurance payers to extract

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Could You Survive A Post Payment Audit?

Success Strategies For Practice Compliance

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Audits Are About Money• Post payment audits are a

tactic utilized by government and private insurance payers to extract money previously paid to doctors.

• Insurance profitability experts believe that payment audits are as successful in building insurance companies’ profits as raising premiums or adding members.


How Payer’s Scrutinize Payments

• Payers perform both prepayment claim reviews and post payment audits.

• Prepayment claim reviews use advanced technology similar to credit card fraud detection.

• They are less costly and labor intensive for payers than post payment audits.


Automated Prepayment Claims Review Checks

National Correct Coding Initiative (NCCI)

National Coverage Determination (NCD)

Local Medical Review Policy (LMRP)

Local Coverage Determination (LCD) Rules

Inter-claim Intra-claim Cross-claim Cross-batch

Lifetime Duplicates Date Range Duplicates Un-bundling Modifier Codes E&M Codes Visit Level High Payments Per

Day Unusual Procedures Geographic

Improbabilities And More…


Post-Payment Audits• Post payment audits

cost payers more because they require skilled personnel and cannot be automated.

• The advantage of manually performed vs. automated audits is a higher return to the payer.


What Triggers A Post Payment Audit?

• Provider profiling • Complaint by a

disgruntled patient • Complaint by a

disgruntled employee • Practice advertising • Submission of claims

for care of family members and/or employees

• Random selectionmybreakthrough.com +

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Verification Letters• There are a number of

reasons why there may be an irregularity in a patient's response to a verification letter:

• The service may have been performed, but the patient's recollection of the service was faulty.

• Occasionally a physician has patients with the same name and a claim for payment may have been submitted under an incorrect patient name.


Audit Identification Report

• Once you are selected as the target of an audit, an Audit Identification Report is created.

• This report measures the degree of variance in total annual revenue between you and your peers in the same specialty and geographic area.

• The more successful your practice, the greater your chance of an audit.


Your Audit Ranking• The variance between

your annual revenue and that of your peers is what the payer expects to gain from the audit and results in your audit ranking.

• The claims paid to you that are most likely to fall outside of the standard distribution of your peer group are then targeted for audit.


How Are Audits Conducted?• Request for and

review of office notes and documentation

• Questionnaires to or interviews of patients

• Interviews of employees (current and former)

• Meetings or teleconferences with provider

• Undercover patient (rarely)


Examination of Supporting Documentation

• An auditor reviews your documentation to see if it supports the claims paid to you.

• This is why it’s so important to have carefully managed documentation and office notes readily available for review.


Who Should Care About Post Payment Audits?

• The risks of noncompliance have ramped up from returning money to the exclusion from government programs, loss of practice license and jail time for healthcare fraud.

• Malpractice and general liability insurance do not cover audit defense legal fees and costs.


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Who Can Be Audited?• Any provider who received

insurance payments regardless of in-network or out-of-network status.

• In-network: Right to audit stems from provider agreement.

• Out-of-network: Right to audit stems from case law, statutes and regulations.

• Cash practices are not exempt from compliance with the standard of care and documentation requirements.


What’s My Exposure?• According to a recent

Improper Medicare Payment Report, DCs have the highest provider compliance error rate in Medicare, filing claims incorrectly 30.6% of the time.

• Business Insurance Magazine estimates 5%-10% of all BCBS claims are paid incorrectly which is echoed by Aetna’s estimate of 11% payment errors.


Do I Have To Cooperate With An Audit?

• In-network:

– You have a contractual duty to cooperate.

• Out-of-network:

– No contract to govern the audit, but risk of carrier offsetting or blocking other claims.


What Is Claim Offset/Block?• Claim Offset:

– Offset future reimbursements on a particular patient until past overpayment on that patient is paid in full.

• Claim Block: – Offset future

reimbursements on all patients until past overpayment is paid in full.


What Will It Cost Me?• The insurer reviews a

limited sample (e.g., 20) of patient files and determines % of deficient files within the sample (e.g., 25%).

• Refund Extrapolation: the deficiency % is applied to the reimbursement paid by the insurer over the past 6 years (e.g., 25% deficiency x $1,000,000 receipts over 6 years = $250,000 owed).


What To Do If Audited?• Cooperate with the

audit – stonewalling will get you a more intense audit.

• Don’t volunteer information or talk substance with billing auditors.

• Never change your notes or chart.

• Ensure auditors get all of your supporting documentation.


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What To Do If Audited?• Only send notes for the

time frame being audited and do not send original, only copies.

• Minimize the risk of an audit in the first place by setting up a Compliance Program in your practice to ensure proper coding, documentation and compliance with laws and regulations.


OIG Compliance Program• The Office of Inspector

General (OIG) released the final Compliance Program Guidance for Individual and Small Group Physician Practices in 2000.

• Yet many practices have still not implemented this program of self-auditing.

• The final guidance can be found on the OIG website http://oig.hhs.gov


What Is Health Care Fraud?

• On the Federal level (US Code Title 18,1347)

• “Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to:

• Defraud any health care benefit program;

• Obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services.”


Four Specific Risk Areas


Four Specific Risk Areas • The OIG has focused its investigations and

audits on four specific risk areas:– Proper Coding & Billing– Ensuring That Services Are Reasonable

& Necessary– Proper Documentation– Avoiding Improper Inducements,

Kickbacks, & Self-referralsmybreakthrough.com +

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Coding & Billing Risk Areas

• Billing for items or services not rendered • Double billing• Upcoding the level of service provided• Billing for unbundled services• Failure to properly use coding modifiers• Submitting claims for equipment, supplies and

services that are not reasonable and necessary• Knowing misuse of provider identification

numbers, which results in improper billingmybreakthrough.com +

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CPT® Procedure Codes• There are over 7,500

CPT® codes.

• DCs use only 25-30 codes the majority of the time.

• The CPT® codes you use must describe the services you perform and be within your scope of practice.


Clinical Documentation• Using the correct code alone is

not sufficient• Careful clinical documentation is

required and may be requested by the payer

• Lack of clinical documentation is the number one reason for denial of service by payers

• Most insurers live by this claim handling rule:

• “If it wasn’t written down, it wasn’t done.”


CMT Codes Review

Compliant Coding


CMT Codes• 98940-3 the basic

building blocks and best description of the DCs work.

• Most comprehensive physician code to describe chiropractic services.

• Basic service around which everything else is built.


Correct Coding• Use the CPT® code that best

describes the service you provided.

• Codes should not be interchanged and the type of service performed should match the definition of the CPT® code.

• If an adjustment is performed, the appropriate CMT code should be used.

• If an office visit is performed, the appropriate E/M code should be used.


Coding The CMT• Full Spine Adjustment:

The treating doctor should prioritize the level of adjustment and code for the primary area(s) of concern.

• 98940: 35%• 98941: 55%• 98942: 10%


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Proper Use of Timed Treatment Codes

Compliant Coding


Many Standards• There are three

possible standards to which you can adhere.

• Best to know all of the rules first.

• Use the correct policies required by each carrier.


CMS Rules• The first: CMS rules in

their transmittal AB-00-14, published in 2000.

• The memorandum makes two key points relating to the counting of therapy units.

• The first is with respect to total treatment time and the second deals with how time is counted.


AMA Guidance• The second: AMA delivers guidance

through the CPT® Assistant.• Because the ACA participates in the

AMA coding process, ACA looks to the AMA for guidance.

• In the past, this guidance stated that DCs should use the 15-minute rule.


Individual Carrier Policies• Third: Due to

carrier agreements you have, certain policies may apply.

• Check all your provider agreements so you are up to date.


As Medicare Goes…• The saying is: “As

Medicare goes, so goes the Nation”.

• Because of this, your best policy is to be in line with Medicare policy, as few others are as stringent.


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The 8-Minute Rule• The AMA has recorded in CPT® policy

what is known as the 15 minute rule.• In the past, DCs were instructed to

use this guidance. • This has now changed!• All providers are now guided to use

the same 8-minute counting rules set forth by CMS.


Defining Pre- and Post-Service Time

• The guidelines restrict therapists from counting pre- and post- delivery service time

• Report only the time spent in actual delivery of a therapeutic procedure.

• Exclude rest time, bathroom breaks, etc.


Document Actual Time • CMS says that therapists should document the

beginning and ending time of treatment in the clinical record.

• Therapists should document the start and stop time of each treatment modality – or the beginning and ending time of the treatment.

• Does this mean you must use a stop watch!?? Of course not!

• Be diligent in listing appropriate time in your documentation of timed codes.


Ancillary Services

Compliant Coding


Supervised & Constant Modalities

• Modalities are divided into two types: Supervised and Constant Attendance.

• Different codes are used depending on the level of supervision.

• When the application of the modality does not require direct one-on-one patient contact, it is considered a SUPERVISED modality.

• When direct one-on-one patient contact is provided, it is classified as CONSTANT ATTENDANCE.


Supervised Modalities• 97010-97028 do not require

one-on-one contact by the provider.

• This means that therapists can apply the modality, but they don’t have to be directly working with patients on a one-on-one basis.

• Time is not a factor for supervised modality codes.

• Only one unit of a supervised modality can be billed per day, regardless of the number of areas treated.


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Supervised Modalities• 97010 Hot or Cold

Packs • 97012 Mechanical

Traction • 97014 Electric

Stimulation • 97016 Vasopneumatic

Devices • 97018 Paraffin Bath

Therapy

• 97022 Whirlpool Therapy

• 97024 Diathermy Treatment

• 97026 Infrared Therapy

• 97028 Ultraviolet Therapy

• REMEMBER: Once per encounter!


Constant Attendance Modalities

• Constant attendance modalities (97032 –97039) require direct one-on-one treatment.

• The constant attendance codes indicate application of a modality to one or more areas and includes a 8-minute time component.


Constant Attendance Modalities

• 97032 Electrical Stimulation

• 97033 Electric Current

• 97034 Contrast Bath Therapy

• 97035 Ultrasound Therapy

• 97036 Hydrotherapy mybreakthrough.com +

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Therapeutic Procedures

Compliant Coding


Active Care• Therapeutic Procedures

are time-based codes. • Billed in 15-minute

units beginning at 8 minutes.

• The patient is active in the encounter.

• Require direct one-on-one patient contact by provider of the service.


97110 Therapeutic Exercises

• Develop one functional parameter: strength, endurance, range of motion, or flexibility

• Treadmill for endurance• Isokinetic exercise for

ROM• Lumbar stabilization

exercises for flexibility• Stability ball to stretch

or strengthen


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97112 NeuromuscularRe-education

• Used to describe those activities that affect proprioception

• Balance• Coordination• Kinesthetic sense• Posture• Code is often denied

as Upper Motor Neuron Rehab.


97530 Therapeutic Activities• Used when multiple

parameters are trained including balance, strength, and range of motion.

• Must be related to a functional activity with direct functional improvement expected.

• Use Outcomes Assessment Tools.


97150 Group Therapy• When supervising more

than one individual, for a service that requires direct supervision, use code 97150 for each patient.

• For example, if NMR is performed in a group setting, use code 97150 — do not use 97110 and 97150 at the same time.

• Billed once per session.


97124 Massage• Massage is a passive

procedure used for restorative effect.

• Used for effleurage, petrissage, and/or tapotement, stroking, compression, and/or percussion.

• An independent procedure from CMT and is considered separate and distinct.


97140 Manual Therapy• Includes Soft Tissue

and Joint Mobilization, Manual Traction, Trigger Point Therapies, Passive Range of Motion, and Myofascial Release.

• When billed with a CMT, must be in a separate body region.

• Requires a -59 modifier.


CPT® Modifiers

Compliant Coding


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CPT® Modifiers• 25: Separately

Identifiable Procedure

• 59: Distinct Procedural Service

• 76: Repeat Procedure by Same Physician


25 Separate E&M Procedure

• The 25 modifier means “separately identifiable evaluation and management service by the same physician on the day of a procedure or service.”

• The 25 modifier is used whenever a procedure, such as physical therapy, is performed on the same day as a re-exam.

• Adding a 25 modifier to your 99211-4 re-exams to stop bundling.


CMS 1500 Form

DPROCEDURES, SERVICES OR SUPPLIES

(Explain Unusual Circumstances)CPT/HCPCS MODIFIER

9921398940

25


59 Separate Procedure• 59 is an important modifier; it is used to keep the

insurance company from bundling procedure codes.

• It should be used whenever you bill manual therapy, 97140, together with a chiropractic adjustment, 9894X.

• 59 indicates a distinct procedure was performed. • When 9894X and 97140 are billed on the same

day, they must be performed on separate areas of the body, i.e. neck and lower back.


CMS 1500 Form



9714098940

59


76 Second Procedure Same Date of Service

• The 76 modifier is used to report “a second procedure, which has been previously reported or performed on the same day.”

• This modifier is used when a patient was seen in the morning and needed to come back in the afternoon for more care.


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CMS 1500 Form



9894098940 76


Navigating the

Medicare Maze

Acute Treatment• According to CMS, a

patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam.

• The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient's condition.

Chronic Treatment• CMS defines Chronic as: • A patient's condition is considered chronic when

it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement.

• Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

Maintenance Therapy• CMS defines Maintenance Therapy as: • Chiropractic maintenance therapy is not considered to

be medically reasonable or necessary under the Medicare program, and is therefore not payable.

• Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.

• When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

Should This Whole Case Be Paid By Medicare?

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Functional Functional Daily Notes

Re-Exam

DX/Plan

Re-ExamUpdate DX/Plan

Functional Functional Daily Notes

Discharge Summary





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Reasonable & Necessary• Claims should be submitted

only for services that you find to be reasonable and necessary in a particular case.

• Upon request, you must be able to provide documentation, such as a patient’s records and physician’s orders, to support the appropriateness of a service that you have provided.


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Documentation • The OIG places heavy

emphasis on proper documentation.

• Whether you are appealing a denied claim or defending a lawsuit, your most important asset can be the medical record.

• The medical record must demonstrate all of the services provided to a patient and be completed timely, accurately, and thoroughly.


The Top Post Payment

Audits

Therapeutic Procedures• Not including the number of minutes that a

Therapeutic Procedure was performed for in your Daily Note is a top target for audits.

• The 8-minute rule does not allow you to use a 52 modifier to bill for less than 8 minutes.

• 8 minutes is the minimum you can bill for.• 97530, Therapeutic Activities, requires the

therapeutic rationale of improving an Activity of Daily living and must be documented in your Daily Note.

Monthly Care No Exams• According to the most recent Chiropractic

Economics Fee & Reimbursement Survey, reimbursement declined for all codes except Evaluation & Management (E&M) Codes.

• The lack of E&M procedures to support ongoing care is a major target for Post Payment Audits.

• In particular, patients receiving monthly chiropractic adjustments without supportive E&M documentation.

• This week, pull the files of all monthly patients and schedule them for a re-evaluation.

Other Common Audits

• No linking of ICD diagnosis and CPT procedural codes.

• Lack of change in treatment plan after re-evaluation.

• No documentation in the patient record or diagnosis supporting extremity adjusting 98943.

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Law Enforcement • The second most common reason for law

enforcement actions arises from improper inducements.

• The Anti-kickback Statute prohibits knowing and willfully giving or receiving anything of value to induce referrals of Federal health care patients.

• Examples of inducements include routinely waiving coinsurance or deductible amounts without a good faith determination that the patient is in financial need.


Kickbacks, Inducements & Self-Referrals Risk Areas

• Financial arrangements with outside entities to whom you refer Federal Health Care patients

• Joint ventures with entities supplying goods or services to your practice or patients

• Office and equipment leases with entities to which you refer

• Soliciting, accepting or offering any gift or gratuity of more than nominal value to or from those who may benefit from your referral of Federal Health Care patients


Creating Your Compliance ProgramStep-by-Step Implementation


What You Must Do• Establish written policies

and procedures • Designated Compliance

Officer• Conduct training and

education• Conduct internal

monitoring and audits• Develop accessible lines

of communication• Enforce disciplinary

standards• Respond appropriately to

detected violationsmybreakthrough.com +

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Follow These Steps To Success

• Relax & breathe.• Include the following information in your

Compliance Policies & Procedures (BTC Form 700)– Location of your Compliance Manual– Explanation of your Policies and Procedures

regarding records creation, destruction and retention, including the specific time period that you will retain records.

– Designate a Compliance Officer– Location of an anonymous drop box for clear

safe reporting of potential erroneous or fraudulent actions.


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Time To Train Your Team• Set aside one hour for

uninterrupted team training.• Have a copy of your

Compliance Policies & Procedures for each team member in attendance.

• Instruct everyone that as you go along you will stop for any questions.

• All team members initial all pages, sign & return original document to the C.O..


Create A Compliance Manual

• Remember, this is a public record.

• Use a 3-ring binder to house the contents of your Compliance Manual

• Gather the materials, 3-hole punch them & place them in the manual

• This is a living document. • You must update this manual & reference it

quarterly and as needed to stay current.


Compliance Manual Contents

• Policies & Procedures (BTC Form 700 )

• Office Policy (BTC Form 207)

• Job Descriptions (BTC Form 924)

• Patient Satisfaction Survey (BTC Form 509)


Compliance Related Activities Manual Contents

• Create and maintain a Compliance Related Activities Manual (Private File)

• Use another 3-ring binder to house the self-audit/chart review & investigation information

• This manual must include:

• Minutes of Compliance Meetings

• Dates and Description of Educational Activities

• Claims Submission Audit Checklists

• Compliance Logs • Audit of Top 10 Denials • Audit of Top 10 Services

Provided mybreakthrough.com +

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Self-Audit/Chart Review• The Compliance Officer determines the number of

charts to be reviewed. (2-5 per payer class or 5-10 per physician.)

• Determine the practice demographics, by payer class i.e. Major Medical 50%, Cash 20%, Medicare 10%, PI 10%, W/C 10%.

• Go to the patient chart holding area & select the appropriate number of charts that represent your practice’s demographics.

• For example the above demographics for a 2 Physician Office could mean 20 total charts: 10 MM, 4 Cash, 2 Medicare, 2 PI and 2 W/C.


The Self-Audit Process• The Compliance Officer schedules a date to

perform a Baseline Audit.• Supplies need to complete the audit:

– Selected Charts– Copies of Claims Submission Audit Checklist

(BTC Form 701)– Copies of Quality Assurance Chart Review (BTC

Form 705) – Copies of Compliance Log (BTC Form 702)


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Self-Audit Day• Audit day should be uninterrupted.• Review each Patient Chart for the 7 Principles of

Good Documentation and 4 Specific Risk Areas.• Review all billing for each Patient Chart.• Make sure your audit includes a valid sampling of

your top 10 denials & your top 10 services.• Complete a Log of your Compliance Audit

Activities including any errors encountered• Take appropriate action to remedy the error(s)

encountered. Remember, the 60 day clock has begun upon discovery of an error.


Quarterly Audits• File all completed Audit Forms in your Compliance

Related Activities Manual.• File all Compliance Log Forms in the Compliance

Related Activities Manual.• Schedule any actions needed to resolve any errors

encountered in a timely fashion.• Schedule on your calendar the date for your next

audit & your annual training – No less than once annually – Breakthrough Coaching recommends auditing quarterly.


Legal Counsel• Your Compliance Program

Manuals are legal documents with legal ramifications.

• Consult an attorney during the drafting of your Compliance Program.

• It is important to retain an attorney who is familiar with your state’s laws involved in the process.


Your Intent Counts • To be convicted of fraud there

must be a finding of intent. • The existence of an effective

Compliance Program is evidence that any mistakes were inadvertent.

• This is considered in determining the intent to commit fraud.

• Judges take this into account when handing down sentences.

• The existence of a Compliance Program can reduce fines by 60%.


Are You Confident That• You could perform a

documentation self-audit? • You could perform a billing

and coding self-audit?• Your staff could pass a

compliance training audit?• That you could survive a

payment audit if the call comes on Monday?

• If you answered no to any of the above – take action today!


For Compliance Policy, Updated Notes & Practice Analysis

SurveyText FCC818 to 33444

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Simplify Your Life. • Breakthrough Coaching has built a

solid reputation over 20 years by making practice less complicated, more profitable and more fun.

• Complete and turn in a no cost Practice Analysis Survey today.

Could You Survive A Post Payment Audit?

Success Strategies For Practice Compliance


Documents

Audits Are About Money - Upcoming Events · 2019-12-16 · Audits Are About Money • Post payment audits are a tactic utilized by government and private insurance payers to extract