DISCLAIMER...(head of Office of Audit Services) (head of Office of Audit Services) ----April 20, 2015 April 20, 2015 HCCAHCCAAnnual Compliance Institute Annual Compliance Institute

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©2015 Foley & Lardner LLP • Attorney Advertising • Prior results do not guarantee a similar outcome • Models used are not clients but may be representative of clients • 321 N. Clark Street, Suite 2800, Chicago, IL 60654 • 312.832.4500

HEALTH CARE COMPLIANCE ASSOCIATION

REGIONAL CONFERENCEJune 19, 2015

Santa Ana, CA

OIG HOSPITAL COMPLIANCE AUDITS: OIG HOSPITAL COMPLIANCE AUDITS: OIG HOSPITAL COMPLIANCE AUDITS: OIG HOSPITAL COMPLIANCE AUDITS:

KEEPING YOUR BOAT AFLOAT IN CHOPPY WATERSKEEPING YOUR BOAT AFLOAT IN CHOPPY WATERSKEEPING YOUR BOAT AFLOAT IN CHOPPY WATERSKEEPING YOUR BOAT AFLOAT IN CHOPPY WATERSJUDITH WALTZ, PARTNER, FOLEY & LARDNER LLPJUDITH WALTZ, PARTNER, FOLEY & LARDNER LLPJUDITH WALTZ, PARTNER, FOLEY & LARDNER LLPJUDITH WALTZ, PARTNER, FOLEY & LARDNER LLP

MARC TATARIAN, REGIONAL COMPLIANCE OFFICER, SUTTER HEALTHMARC TATARIAN, REGIONAL COMPLIANCE OFFICER, SUTTER HEALTHMARC TATARIAN, REGIONAL COMPLIANCE OFFICER, SUTTER HEALTHMARC TATARIAN, REGIONAL COMPLIANCE OFFICER, SUTTER HEALTH

©2015 Foley & Lardner LLP

■ The opinions expressed are those of the presenter and The opinions expressed are those of the presenter and The opinions expressed are those of the presenter and The opinions expressed are those of the presenter and are not intended to be statements or reflections of the are not intended to be statements or reflections of the are not intended to be statements or reflections of the are not intended to be statements or reflections of the opinion or position of Sutter Health or Foley & Lardner opinion or position of Sutter Health or Foley & Lardner opinion or position of Sutter Health or Foley & Lardner opinion or position of Sutter Health or Foley & Lardner LLP.LLP.LLP.LLP.

■ This presentation is general in scope, seeks to provide This presentation is general in scope, seeks to provide This presentation is general in scope, seeks to provide This presentation is general in scope, seeks to provide relevant background and hopes to assist in the relevant background and hopes to assist in the relevant background and hopes to assist in the relevant background and hopes to assist in the identification of pertinent issues and concerns. The identification of pertinent issues and concerns. The identification of pertinent issues and concerns. The identification of pertinent issues and concerns. The information is not intended to be, nor should it be information is not intended to be, nor should it be information is not intended to be, nor should it be information is not intended to be, nor should it be construed or relied upon, as legal advice.construed or relied upon, as legal advice.construed or relied upon, as legal advice.construed or relied upon, as legal advice.

■ The presenters did not receive compensation from any The presenters did not receive compensation from any The presenters did not receive compensation from any The presenters did not receive compensation from any vendor or consulting firm referenced during the vendor or consulting firm referenced during the vendor or consulting firm referenced during the vendor or consulting firm referenced during the presentation.presentation.presentation.presentation.

DISCLAIMER

Waltz/Tatarian HCCA June 2015 2

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■Who in this Room has experienced a hospital Who in this Room has experienced a hospital Who in this Room has experienced a hospital Who in this Room has experienced a hospital

compliance audit? compliance audit? compliance audit? compliance audit?

Waltz/Tatarian HCCA June 2015

Is it You?

3


““““OIGOIGOIGOIG is using information technologies and analytics, is using information technologies and analytics, is using information technologies and analytics, is using information technologies and analytics, including data mining, trend evaluation, and modeling, to including data mining, trend evaluation, and modeling, to including data mining, trend evaluation, and modeling, to including data mining, trend evaluation, and modeling, to better identify fraud vulnerabilities and target our oversight better identify fraud vulnerabilities and target our oversight better identify fraud vulnerabilities and target our oversight better identify fraud vulnerabilities and target our oversight efforts. efforts. efforts. efforts. OIGOIGOIGOIG is leveraging an analytical foundation that is leveraging an analytical foundation that is leveraging an analytical foundation that is leveraging an analytical foundation that provides an enterprise view of questionable activities, provides an enterprise view of questionable activities, provides an enterprise view of questionable activities, provides an enterprise view of questionable activities, suspected fraud trends, and prevention opportunities. When suspected fraud trends, and prevention opportunities. When suspected fraud trends, and prevention opportunities. When suspected fraud trends, and prevention opportunities. When united with the expertise of our agents, auditors, and program united with the expertise of our agents, auditors, and program united with the expertise of our agents, auditors, and program united with the expertise of our agents, auditors, and program evaluators, evaluators, evaluators, evaluators, OIGOIGOIGOIG brings a formidable combination of cutting brings a formidable combination of cutting brings a formidable combination of cutting brings a formidable combination of cutting edge techniques and traditional investigative skills to the fight edge techniques and traditional investigative skills to the fight edge techniques and traditional investigative skills to the fight edge techniques and traditional investigative skills to the fight against fraud, waste, and abuse.” against fraud, waste, and abuse.” against fraud, waste, and abuse.” against fraud, waste, and abuse.”

Source: “OIG Chief Counsel Lewis Morris Testifies on the Role of New Technology in Fighting Health Care Fraud”: (July 12, 2011)

BACKGROUND


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■ Inpatient and Outpatient Payments to Acute Care Hospitals: Using prior audits, investigations, and : Using prior audits, investigations, and : Using prior audits, investigations, and : Using prior audits, investigations, and evaluations, along with computer and dataevaluations, along with computer and dataevaluations, along with computer and dataevaluations, along with computer and data----matching techniques, matching techniques, matching techniques, matching techniques, OIGOIGOIGOIG identified multiple identified multiple identified multiple identified multiple areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at each facility. The goals of these audits are to each facility. The goals of these audits are to each facility. The goals of these audits are to each facility. The goals of these audits are to identify overpayments for recovery, assist the identify overpayments for recovery, assist the identify overpayments for recovery, assist the identify overpayments for recovery, assist the hospitals in improving their internal controls and hospitals in improving their internal controls and hospitals in improving their internal controls and hospitals in improving their internal controls and compliance with Medicare rules, and increase compliance with Medicare rules, and increase compliance with Medicare rules, and increase compliance with Medicare rules, and increase provider awareness of common billing errors and provider awareness of common billing errors and provider awareness of common billing errors and provider awareness of common billing errors and the importance of compliancethe importance of compliancethe importance of compliancethe importance of compliance

Health Compliance Reviews

Will Continue

Source: DHHS/OIG FY 2016: Justification of Estimates for Appropriations Committees

5Waltz/Tatarian HCCA June 2015


■Gloria Jarmon, CPA, CGRM, Deputy I.G., HHSGloria Jarmon, CPA, CGRM, Deputy I.G., HHSGloria Jarmon, CPA, CGRM, Deputy I.G., HHSGloria Jarmon, CPA, CGRM, Deputy I.G., HHS----OGC OGC OGC OGC (head of Office of Audit Services) (head of Office of Audit Services) (head of Office of Audit Services) (head of Office of Audit Services) ---- April 20, 2015 April 20, 2015 April 20, 2015 April 20, 2015 HCCAHCCAHCCAHCCA Annual Compliance Institute Annual Compliance Institute Annual Compliance Institute Annual Compliance Institute

» Over 600 auditors on team

» 132 hospital compliance audits to date (reports issued)

» Responsible for $1T health care dollars

» Reference to CIAs as model for risk assessments –expectations for controls (CIAs are NOT a cost of doing business!)

» Responding to audits: “Cooperation is the key”!


Tips from the “Inside” (OIG-OAS)

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■Per OIG (K. Per OIG (K. Per OIG (K. Per OIG (K. RapozaRapozaRapozaRapoza) in 2013 Podcast) in 2013 Podcast) in 2013 Podcast) in 2013 Podcast

» Payments to acute care hospitals make up 45% of Medicare FFS payments

» Hospital billing is very complex, making it prone to errors – OIG’s initial focus was on 27 areas flagged over prior 20 years

■Per OIG (G. Jarmon) Per OIG (G. Jarmon) Per OIG (G. Jarmon) Per OIG (G. Jarmon) –––– January 2015January 2015January 2015January 2015» Per Improper Payments calculations, big issue is the medical necessity of hospital inpatient claims (e.g., short stays) [note RAC reviews of this issue currently on hold]


Why focus on hospitals?

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■Civil Monetary Penalties (failure to grant timely Civil Monetary Penalties (failure to grant timely Civil Monetary Penalties (failure to grant timely Civil Monetary Penalties (failure to grant timely access)access)access)access)

■Permissive Exclusion (obstruction of an Permissive Exclusion (obstruction of an Permissive Exclusion (obstruction of an Permissive Exclusion (obstruction of an investigation or auditinvestigation or auditinvestigation or auditinvestigation or audit))))

■Payment SuspensionPayment SuspensionPayment SuspensionPayment Suspension

■Disallowed claims/Overpayment (Section Disallowed claims/Overpayment (Section Disallowed claims/Overpayment (Section Disallowed claims/Overpayment (Section 1833(e) of the Social Security Act (precludes 1833(e) of the Social Security Act (precludes 1833(e) of the Social Security Act (precludes 1833(e) of the Social Security Act (precludes payment to any provider of services without payment to any provider of services without payment to any provider of services without payment to any provider of services without information necessary to determine the information necessary to determine the information necessary to determine the information necessary to determine the amount due); see also 42 amount due); see also 42 amount due); see also 42 amount due); see also 42 C.F.RC.F.RC.F.RC.F.R. 424.5(a)(6)). 424.5(a)(6)). 424.5(a)(6)). 424.5(a)(6))


“Sticks” for Cooperation

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■Recent audit reports (Hospital Compliance Recent audit reports (Hospital Compliance Recent audit reports (Hospital Compliance Recent audit reports (Hospital Compliance

Audits and other types of audits) Audits and other types of audits) Audits and other types of audits) Audits and other types of audits)

■OIG Work Plan (and now MidOIG Work Plan (and now MidOIG Work Plan (and now MidOIG Work Plan (and now Mid----Year updates and Year updates and Year updates and Year updates and

additions) additions) additions) additions)

■Think about your data footprint: Medicare Think about your data footprint: Medicare Think about your data footprint: Medicare Think about your data footprint: Medicare –––– 9 9 9 9

years of claims data (Integrated Data years of claims data (Integrated Data years of claims data (Integrated Data years of claims data (Integrated Data

Repository Repository Repository Repository –––– A,B & D claim data back to A,B & D claim data back to A,B & D claim data back to A,B & D claim data back to

January 2006) January 2006) January 2006) January 2006)

■CMS audits (RACs) CMS audits (RACs) CMS audits (RACs) CMS audits (RACs) –––– identified issuesidentified issuesidentified issuesidentified issues


Anticipating an audit: Identify

common risk areas

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©2015 Foley & Lardner LLPWaltz/Tatarian HCCA June 2015

DACG Organization

(CMS Data-Mining Efforts)

“Medicaid and Predictive Analytics,” CMS Presentation by Thomas J. Kessler, Esq. (9/11/2013)

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■“OIG chooses hospitals based on data “OIG chooses hospitals based on data “OIG chooses hospitals based on data “OIG chooses hospitals based on data

analysis, discussions with Medicare analysis, discussions with Medicare analysis, discussions with Medicare analysis, discussions with Medicare

contractors, or based on other OIG work.”contractors, or based on other OIG work.”contractors, or based on other OIG work.”contractors, or based on other OIG work.”

■Nearly 3,600 acuteNearly 3,600 acuteNearly 3,600 acuteNearly 3,600 acute----care hospitals so OIG does care hospitals so OIG does care hospitals so OIG does care hospitals so OIG does

not have the resources to audit each one.not have the resources to audit each one.not have the resources to audit each one.not have the resources to audit each one.

Source: K. Rapoza (OIG Podcast 2013)


How are hospitals chosen for audit?

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■Notice of Audit Notice of Audit Notice of Audit Notice of Audit –––– scheduling entrance interviewscheduling entrance interviewscheduling entrance interviewscheduling entrance interview

■Hospital should designate “person in charge” and Hospital should designate “person in charge” and Hospital should designate “person in charge” and Hospital should designate “person in charge” and committee (CEO, CFO, Nursing, Medical Records)committee (CEO, CFO, Nursing, Medical Records)committee (CEO, CFO, Nursing, Medical Records)committee (CEO, CFO, Nursing, Medical Records)

■ Identify space to accommodate the auditorsIdentify space to accommodate the auditorsIdentify space to accommodate the auditorsIdentify space to accommodate the auditors

■Document requests (charts) Document requests (charts) Document requests (charts) Document requests (charts) –––– with deadlines for with deadlines for with deadlines for with deadlines for response response response response

■ Identify key individuals to participate in audit Identify key individuals to participate in audit Identify key individuals to participate in audit Identify key individuals to participate in audit response (typically case management, coding, response (typically case management, coding, response (typically case management, coding, response (typically case management, coding, medical records liaison, compliance officer)medical records liaison, compliance officer)medical records liaison, compliance officer)medical records liaison, compliance officer)

■ SelfSelfSelfSelf----audits audits audits audits –––– of identified issuesof identified issuesof identified issuesof identified issues» Consider Attorney-Client privilege

Preparing for an audit


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■ Focus on process and structureFocus on process and structureFocus on process and structureFocus on process and structure

■ Billing ProcessBilling ProcessBilling ProcessBilling Process» “Describe the billing process, internal controls, and quality controls for inpatient claims.”

■General ControlsGeneral ControlsGeneral ControlsGeneral Controls

» Roles and responsibilities of those involved in claims billing processing

» Case management and utilization review processes.

» Use of outside consultants for claims processing

» Current or previous audits by hospital or external agencies.

INTERNAL CONTROLS

QUESTIONNAIRE



■Specific ControlsSpecific ControlsSpecific ControlsSpecific Controls

» Description of key internal control and common

edits for identified risk areas employed during

period of review

■PurposePurposePurposePurpose

» “To get an understanding of the overall billing

process within your organization.”

INTERNAL CONTROLS

QUESTIONNAIRE


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■“[Hospitals] should keep in mind that these “[Hospitals] should keep in mind that these “[Hospitals] should keep in mind that these “[Hospitals] should keep in mind that these

reviews are based on data from their Medicare reviews are based on data from their Medicare reviews are based on data from their Medicare reviews are based on data from their Medicare

claims and that each hospital review is claims and that each hospital review is claims and that each hospital review is claims and that each hospital review is

unique. … [W]e review different risk areas at unique. … [W]e review different risk areas at unique. … [W]e review different risk areas at unique. … [W]e review different risk areas at

different hospitals and use both statistical and different hospitals and use both statistical and different hospitals and use both statistical and different hospitals and use both statistical and

nonnonnonnon----statistical methods for selecting our statistical methods for selecting our statistical methods for selecting our statistical methods for selecting our

samples.”samples.”samples.”samples.”

Kim Rapoza, Audit Manager, Office of Audit Services, Transcript for Audio Podcast: Hospital

Compliance Initiative (2013)


Issues to be audited

15


INPATIENTINPATIENTINPATIENTINPATIENT

■ short short short short stays,stays,stays,stays,

■ highhighhighhigh----severityseverityseverityseverity----level level level level DRGDRGDRGDRG codes,codes,codes,codes,

■mechanical mechanical mechanical mechanical ventilation,ventilation,ventilation,ventilation,

■ kyphoplastykyphoplastykyphoplastykyphoplasty services,services,services,services,

■ hospitalhospitalhospitalhospital----acquired acquired acquired acquired conditions and conditions and conditions and conditions and presentpresentpresentpresent----onononon----admission indicator admission indicator admission indicator admission indicator reporting,reporting,reporting,reporting,

■ claims claims claims claims paid in excess of charges,paid in excess of charges,paid in excess of charges,paid in excess of charges,

■ canceled canceled canceled canceled elective surgical procedures,elective surgical procedures,elective surgical procedures,elective surgical procedures,


Issues: Loma Linda Univ. Med. Center

(A-09-13-02056 May 2015)

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OUTPATIENTOUTPATIENTOUTPATIENTOUTPATIENT

■ surgeriessurgeriessurgeriessurgeries billed with units greater than one,billed with units greater than one,billed with units greater than one,billed with units greater than one,

■ outpatient claims billed for Herceptin,outpatient claims billed for Herceptin,outpatient claims billed for Herceptin,outpatient claims billed for Herceptin,

■ manufacturer credits for manufacturer credits for manufacturer credits for manufacturer credits for replaced medical devicesreplaced medical devicesreplaced medical devicesreplaced medical devices,,,,

■ dental services,dental services,dental services,dental services,

■ intensityintensityintensityintensity----modulated radiation therapy (modulated radiation therapy (modulated radiation therapy (modulated radiation therapy (IMRTIMRTIMRTIMRT) planning ) planning ) planning ) planning services,services,services,services,

■ Lupron injections,Lupron injections,Lupron injections,Lupron injections,

■ doxorubicin hydrochloride,doxorubicin hydrochloride,doxorubicin hydrochloride,doxorubicin hydrochloride,

■ evaluation and management services, andevaluation and management services, andevaluation and management services, andevaluation and management services, and

■ modifier modifier modifier modifier ----59 (indicating that a procedure or service was 59 (indicating that a procedure or service was 59 (indicating that a procedure or service was 59 (indicating that a procedure or service was distinct from other services performed on the same day).distinct from other services performed on the same day).distinct from other services performed on the same day).distinct from other services performed on the same day).


Loma Linda, issues, cont.

17


Issues: Northwestern Memorial

A-05-13-00051 (March 2015)

■ InpatientInpatientInpatientInpatient

» Short stays

» Manufacturer credits

for replaced medical

devices

» Transfers

» High severity level

DRG codes

■OutpatientOutpatientOutpatientOutpatient

» Modifier -59

» Observation services

resulting in outlier

payments


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■High Risk Areas as Identified by Request for High Risk Areas as Identified by Request for High Risk Areas as Identified by Request for High Risk Areas as Identified by Request for Records (Notice letter will tell you what issues Records (Notice letter will tell you what issues Records (Notice letter will tell you what issues Records (Notice letter will tell you what issues have been identified for your hospital)have been identified for your hospital)have been identified for your hospital)have been identified for your hospital)

» Sample will not be organized as to which issue is related to which risk area

» Review the requested charts IN ADVANCE – with medical records and claims detail

• What if you identify problems? » Consider if clearly refundable (60-day refund rule) or rebillable(timely filing limits)

» May need to engage additional resources to review (e.g., physician review of in-patient short stay)

Audit Issues and Strategies



■ The Exit InterviewThe Exit InterviewThe Exit InterviewThe Exit Interview

■Corrective Action Plan (later also to CMS)Corrective Action Plan (later also to CMS)Corrective Action Plan (later also to CMS)Corrective Action Plan (later also to CMS)

■ Controls QuestionnaireControls QuestionnaireControls QuestionnaireControls Questionnaire

■ Report Report Report Report –––– and time to respond (best practice: by and time to respond (best practice: by and time to respond (best practice: by and time to respond (best practice: by

management or to whom the letter is addressed)management or to whom the letter is addressed)management or to whom the letter is addressed)management or to whom the letter is addressed)

■ Final Report Final Report Final Report Final Report –––– response to Provider’s responseresponse to Provider’s responseresponse to Provider’s responseresponse to Provider’s response

■ Posting on the internet (prepare for press Posting on the internet (prepare for press Posting on the internet (prepare for press Posting on the internet (prepare for press

inquiries)inquiries)inquiries)inquiries)


The Audit Result

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■Assessment of overpayments and Assessment of overpayments and Assessment of overpayments and Assessment of overpayments and

“recommendations” for “recommendations” for “recommendations” for “recommendations” for repayment repayment repayment repayment

■Appeal Appeal Appeal Appeal rights?rights?rights?rights? No appeal rights are given in No appeal rights are given in No appeal rights are given in No appeal rights are given in

the audit notice; can appeal through CMSthe audit notice; can appeal through CMSthe audit notice; can appeal through CMSthe audit notice; can appeal through CMS

» Rebilling if within timely filing limits

• (Documents to OIG – RAs)

■Demand letter from CMS (starts the Demand letter from CMS (starts the Demand letter from CMS (starts the Demand letter from CMS (starts the

overpayment appeal processoverpayment appeal processoverpayment appeal processoverpayment appeal process) ) ) ) –––– but consider but consider but consider but consider

the 60the 60the 60the 60----day refund ruleday refund ruleday refund ruleday refund rule


The Audit Result

21


■ OIG uses different methodology from CMS for extrapolation OIG uses different methodology from CMS for extrapolation OIG uses different methodology from CMS for extrapolation OIG uses different methodology from CMS for extrapolation sample identificationsample identificationsample identificationsample identification

» Judgmental vs. random (i.e., sample of identified risk areas)

» No probe sample

» Lower limit of confidence interval (high was $13,949,278

» Strata by risk area (not claim value)

■ Northwestern (3/2015) Northwestern (3/2015) Northwestern (3/2015) Northwestern (3/2015) –––– Stratified random sample of 171 Stratified random sample of 171 Stratified random sample of 171 Stratified random sample of 171 claims totaling $1,449,820 (out of 7,506 potentially at risk claims totaling $1,449,820 (out of 7,506 potentially at risk claims totaling $1,449,820 (out of 7,506 potentially at risk claims totaling $1,449,820 (out of 7,506 potentially at risk totaling $48,550,382 in the identified risk areas for CY totaling $48,550,382 in the identified risk areas for CY totaling $48,550,382 in the identified risk areas for CY totaling $48,550,382 in the identified risk areas for CY 2011 and 2012), 98 inpatient and 73 outpatient. Net 2011 and 2012), 98 inpatient and 73 outpatient. Net 2011 and 2012), 98 inpatient and 73 outpatient. Net 2011 and 2012), 98 inpatient and 73 outpatient. Net overpayment of $272,181; extrapolated total overpayment: overpayment of $272,181; extrapolated total overpayment: overpayment of $272,181; extrapolated total overpayment: overpayment of $272,181; extrapolated total overpayment: $6,389,095. $6,389,095. $6,389,095. $6,389,095.

■ Total payments to hospital of $438,065,380 for 24,063 Total payments to hospital of $438,065,380 for 24,063 Total payments to hospital of $438,065,380 for 24,063 Total payments to hospital of $438,065,380 for 24,063 inpatients and 235,427 outpatient claims. inpatients and 235,427 outpatient claims. inpatients and 235,427 outpatient claims. inpatients and 235,427 outpatient claims.


Extrapolation – e.g., Northwestern

(3/2015)

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■Used since at least 2013 Used since at least 2013 Used since at least 2013 Used since at least 2013 –––– In 2015, OIG says to In 2015, OIG says to In 2015, OIG says to In 2015, OIG says to AHA that use of sampling and extrapolation are AHA that use of sampling and extrapolation are AHA that use of sampling and extrapolation are AHA that use of sampling and extrapolation are “well established and has repeatedly been upheld “well established and has repeatedly been upheld “well established and has repeatedly been upheld “well established and has repeatedly been upheld on administrative appeal within the Department on administrative appeal within the Department on administrative appeal within the Department on administrative appeal within the Department and by Federal Courts”.and by Federal Courts”.and by Federal Courts”.and by Federal Courts”.

» “both economical and in the best interest of the provider and the Government”

■Note limitations on contractor use of Note limitations on contractor use of Note limitations on contractor use of Note limitations on contractor use of extrapolation under the statute (limited to high extrapolation under the statute (limited to high extrapolation under the statute (limited to high extrapolation under the statute (limited to high level of payment error or failed documented level of payment error or failed documented level of payment error or failed documented level of payment error or failed documented educational intervention) educational intervention) educational intervention) educational intervention)


Extrapolation

23


■ Inpatient and Outpatient Payments to Acute Care Hospitals: Using prior audits, investigations, and : Using prior audits, investigations, and : Using prior audits, investigations, and : Using prior audits, investigations, and evaluations, along with computer and dataevaluations, along with computer and dataevaluations, along with computer and dataevaluations, along with computer and data----matching techniques, matching techniques, matching techniques, matching techniques, OIGOIGOIGOIG identified multiple identified multiple identified multiple identified multiple areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at areas of risk to be reviewed in a single audit at each facility. The goals of these audits are to each facility. The goals of these audits are to each facility. The goals of these audits are to each facility. The goals of these audits are to identify overpayments for recovery, assist the identify overpayments for recovery, assist the identify overpayments for recovery, assist the identify overpayments for recovery, assist the hospitals in improving their internal controls and hospitals in improving their internal controls and hospitals in improving their internal controls and hospitals in improving their internal controls and compliance with Medicare rules, and increase compliance with Medicare rules, and increase compliance with Medicare rules, and increase compliance with Medicare rules, and increase provider awareness of common billing errors and provider awareness of common billing errors and provider awareness of common billing errors and provider awareness of common billing errors and the importance of compliancethe importance of compliancethe importance of compliancethe importance of compliance

Health Compliance Reviews Will

Continue!

Source: DHHS/OIG FY 2016: Justification of Estimates for Appropriations Committees


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■ Need for physician order for inpatient admissions Need for physician order for inpatient admissions Need for physician order for inpatient admissions Need for physician order for inpatient admissions ––––consistent with CMS policiesconsistent with CMS policiesconsistent with CMS policiesconsistent with CMS policies

■ Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery –––– OIG notes OIG notes OIG notes OIG notes room overbooking; preoperative exam showed patient no room overbooking; preoperative exam showed patient no room overbooking; preoperative exam showed patient no room overbooking; preoperative exam showed patient no longer qualified for the procedure longer qualified for the procedure longer qualified for the procedure longer qualified for the procedure –––– no medical necessityno medical necessityno medical necessityno medical necessity

■ Rebilling Part A under Part B Rebilling Part A under Part B Rebilling Part A under Part B Rebilling Part A under Part B –––– up to CMS and OIG will work up to CMS and OIG will work up to CMS and OIG will work up to CMS and OIG will work with themwith themwith themwith them

■ Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period –––– up to up to up to up to CMS to decide how to resolve these claimsCMS to decide how to resolve these claimsCMS to decide how to resolve these claimsCMS to decide how to resolve these claims

■ “We have voluntarily suspended reviews of inpatient short “We have voluntarily suspended reviews of inpatient short “We have voluntarily suspended reviews of inpatient short “We have voluntarily suspended reviews of inpatient short stay claims after October 1, 2013, consistent with the stay claims after October 1, 2013, consistent with the stay claims after October 1, 2013, consistent with the stay claims after October 1, 2013, consistent with the moratorium placed on the recovery audit contractors.” moratorium placed on the recovery audit contractors.” moratorium placed on the recovery audit contractors.” moratorium placed on the recovery audit contractors.”


OIG – January 2015 Response to AHA

(Addressed to Melinda Reid Hatton)

25


■Need for physician order for inpatient admissions Need for physician order for inpatient admissions Need for physician order for inpatient admissions Need for physician order for inpatient admissions –––– consistent with CMS policiesconsistent with CMS policiesconsistent with CMS policiesconsistent with CMS policies

■Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery Medicare reimbursement for canceled surgery ––––OIG notes room overbooking; preoperative exam OIG notes room overbooking; preoperative exam OIG notes room overbooking; preoperative exam OIG notes room overbooking; preoperative exam showed patient no longer qualified for the showed patient no longer qualified for the showed patient no longer qualified for the showed patient no longer qualified for the procedure procedure procedure procedure –––– no medical necessityno medical necessityno medical necessityno medical necessity

■ Rebilling Part A under Part B Rebilling Part A under Part B Rebilling Part A under Part B Rebilling Part A under Part B –––– up to CMS and up to CMS and up to CMS and up to CMS and OIG will work with themOIG will work with themOIG will work with themOIG will work with them

■Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period Review of claims outside 4 year reopening period –––– up to CMS to decide how to resolve these up to CMS to decide how to resolve these up to CMS to decide how to resolve these up to CMS to decide how to resolve these claimsclaimsclaimsclaims


OIG – January 2015 Response To AHA

26

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ERROR SUMMARY REPORTS

Error Type:

Applicable Medicare Criteria:

Samples in Error:

Please describe why these errors occurred:

Please describe the hospital’s corrective action plan:



RECORD TOOLSTOOLSTOOLSTOOLS

Billing RecordBilling RecordBilling RecordBilling Record

OIG Claim #:OIG Claim #:OIG Claim #:OIG Claim #:

MR#:MR#:MR#:MR#:

Acct #:Acct #:Acct #:Acct #:

First Name:First Name:First Name:First Name:

Last Name:Last Name:Last Name:Last Name:

Admit Date:Admit Date:Admit Date:Admit Date:

Discharge Date:Discharge Date:Discharge Date:Discharge Date:

Service Area:Service Area:Service Area:Service Area:

Total Pages:Total Pages:Total Pages:Total Pages:

Medical RecordMedical RecordMedical RecordMedical Record

OIG Claim #:OIG Claim #:OIG Claim #:OIG Claim #:

MR#:MR#:MR#:MR#:

Acct:#Acct:#Acct:#Acct:#

First Name:First Name:First Name:First Name:

Last Name:Last Name:Last Name:Last Name:

Admit Date:Admit Date:Admit Date:Admit Date:

Discharge Date:Discharge Date:Discharge Date:Discharge Date:

Service Area:Service Area:Service Area:Service Area:

Total Pages:Total Pages:Total Pages:Total Pages:


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TRACKING TOOLS

Inpatient

Outpatient



Risk Mitigation

High Risk Areas


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Questions?

Judith A. WaltzJudith A. WaltzJudith A. WaltzJudith A. Waltz

PartnerPartnerPartnerPartner

Foley & Lardner LLPFoley & Lardner LLPFoley & Lardner LLPFoley & Lardner LLP

415.438.6412415.438.6412415.438.6412415.438.6412

[email protected]@[email protected]@foley.com

Marc Marc Marc Marc TatarianTatarianTatarianTatarian

Regional Compliance Regional Compliance Regional Compliance Regional Compliance

OfficerOfficerOfficerOfficer

Sutter HealthSutter HealthSutter HealthSutter Health

415.600.7022415.600.7022415.600.7022415.600.7022

[email protected]@[email protected]@sutterhealth.org
