1

Compliance Guidance for Physicians: Keeping Your Practice Safe

American Academy of Professional Coders

2012 Annual Meeting

Presented byJean Acevedo, LHRM, CPC, CHC, CENTC

All rights reserved

HHS NEWSFOR IMMEDIATE RELEASETuesday, February 14, 2012

HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT EFFORTS RESULT IN RECORD-BREAKING RECOVERIES

TOTALING NEARLY $4.1 BILLION Largest Sum Ever Recovered in Single Year

WASHINGTON –Attorney General Eric Holder and Department of Health

2

y pand Human Services (HHS) Secretary Kathleen Sebelius today released a new report showing that the government’s health care fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in Fiscal Year (FY) 2011. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.

Health care fraud is a serious problem

2

Fraud includes obtaining a benefit through intentional misrepresentation or concealment of material facts

Waste includes incurring unnecessary costs as a result of deficient management, practices,

t lor controls

Abuse includes excessively or improperly using government resources

Who is Looking at You?Who is Looking at You?

Physician

The Fight Against Fraud & Abuse CMS Carrier/MAC

ADRs Prepayment Review

Statistical Valid Random Sampling (SVRS) ZPICs

Formerly Program Safeguard Contractors (PSCs) Recovery Audit Contractors (RACs) Comprehensive Error Rate Testing (CERT) contractor Medicaid Integrity Program (MIP)

Don’t forget the Private Payers! Special Investigative Units (SIU) Contracted audit companies

3

Lessons from New York

7

Lessons from New York…

Medicaid Audit & Data Mining Some results from the NY OMIG: Men who gave birth (OMIG confirmed that managed care

plans were paid for 90 such claims during a 2-year period)

Women who gave birth to themselves

Colonoscopies performed on women the same day they Colonoscopies performed on women the same day they delivered children

Babies born twice

Medicaid Audit & Data Mining Some results from the NY OMIG: Women who had babies and then gave birth to another

baby 5 months later

Children under 10 giving birth

50-year-old women who gave birth with no corresponding fertility treatments “we recovered $500 000 on thisfertility treatments – we recovered $500,000 on this alone.”

4

OIG Recovery Efforts –2011 Semi-Annual Report

FBI’s HCFU

11

FBI Health Care Fraud Unit – FY 2009* Areas investigated include: Billing for services not rendered

Upcoding

Performing unnecessary services

Kickbacks

Unbundling to obtain higher reimbursement

DME fraud

Drug diversion

OP surgery fraud

Internet pharmacy sales

*last reporting year available

5

“Daniel Maynard, D.O., has been…”

Permanently excluded from federal health care programs;

And will pay $253,000 to resolve allegations that he submitted false claims to the Tx Medicaid program & Medicare between 1999 and 2003Medicare between 1999 and 2003.

On 32 separate days, Maynard billed for patient encounters that added up to more than 24 hrs each day seeing & treating patients. Yes, that’s just 32 days in a 5 year period in which the

doctor probably worked 1250 days - (just 6 or 7 days a year)

www.usdoj.gov/usao/txn, June 2008

And in Florida…. FCSO data mining showed, in FY 2010 One doctor billed up to 51 hours in a day - 24 dates of

service

Another billed over 24 hours in a day - 63 dates of service

And another billed over 16 hours in a day - 120 dates of serviceservice

As of May 10, 2011 30 providers in Florida identified with similar aberrancies

Are you monitoring your own data?

14

Your best protection: An Effective

15

ect eCompliance Program

6

“We expect that every health care provider will have an effective compliance program.”Daniel Levinson, Inspector General, Office of the Inspector General 2009 Compliance Institute Las

16

Inspector General, 2009 Compliance Institute, Las Vegas, NV

The OIG’s Seven Components

1. Conducting internal monitoring and auditing through the performance of periodic audits

2. Implementing compliance and practice standards through the development of written standards and procedures.

3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards.

4 Conducting appropriate training and education on practice standards

17

4. Conducting appropriate training and education on practice standards and procedures.

5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities.

6. Developing open lines of communication to keep practice employees updated regarding compliance activities. Non-retaliation policy.

7. Enforcing disciplinary standards through well-publicized guidelines.

Identified Risk Areas for Physicians Proper coding and billing Ensuring that services are reasonable and

necessary Proper documentation Medical record CMS 1500

18

CMS-1500

Avoiding improper inducements, kickbacks and self-referrals

7

Coding and BillingCoding and Billing Upcoding, unbundling and improper use of modifiers

Misuse of provider’s identification numbers

Q6 (locum tenens) is not to be used to bill for services while you are waiting for Medicare to process the new doctor’s enrollment application.

Billing for:

19

Billing for:

Items/services not provided

Equipment, supplies and services not medically necessary

Non-covered services as covered

CBC, CMP, EKG as part of an “annual physical”

G0438/39 billed for an “annual physical”

Reasonable and Necessary ServicesReasonable and Necessary Services

Local Coverage Determinations

Advanced beneficiary notice

Certificate of medical necessity

20

Reasonable & Necessary….

The Physicians Clinic of Spokane Resolves Claim for Overcharging Medicare (U.S. Attorney for the Eastern District of Washington)Spokane – On June 8, 2010, James A. McDevitt, United States Attorney for the Eastern District of Washington, announced that the Physicians Clinic of Spokane has paid the United States $656,000 to resolve allegations that it overcharged Medicare. …from March 2002 to March

21

2007, Physicians Clinic of Spokane (PCS) performed …lipid panel tests and a cholesterol test without any intervening review to determine whether the second test was medically necessary.The second test (a Low Density Lipoprotein test) can only be billed to Medicare if it is performed after reading the first test results and then if it is determined to be medically necessary. Since the two tests occurred simultaneously, this was an improper testing and billing practice, according to Medicare’s rules and regulations.

8

Medical Record DocumentationMedical Record Documentation

If it is not written - it did not occur

Document medical necessity

Complete, legible and signed!

Do you use scribes? How is that fact

22

Do you use scribes? How is that fact documented?

If on an EMR

Copy & paste

Cloning

CMS CMS 1500 Documentation1500 Documentation

Match diagnosis to documentation in medical recordmedical record

Match diagnosis with procedure code

Identify secondary insurance coverage

23

Inducements, Kickbacks and Inducements, Kickbacks and SelfSelf--ReferralsReferrals

Knowledge of or willfully providing or receiving anything ofreceiving anything of value that can alter medical decision making resulting in increased referrals or utilization of services is not permitted

24

9

Under the OIG’s MicroscopeUnder the OIG’s Microscope

Financial arrangements that can influence referralsreferrals

Joint ventures with entities supplying goods or services

Consulting contracts and medical directorships

25

Why should I comply? It’s the right thing to do.

Enhances correct billing

Reduces denials

Increases billing efficiency

Minimizes the risk of a Government audit

26

Minimizes the risk of a Government audit

Minimizes the risk of a substantial overpayment.

With all the talk about an “ ff ti ” li

27

“effective” compliance program……

10

CMS Compliance Effectiveness Pilot

3 year pilot

Ended early 2007

16 hospitals in the NE participated

84 hospitals applied 84 hospitals applied

#1 Element: Communication Communication across the organization re: auditing results and training “Communication makes a difference.” Kimberly Brandt,

Director, Medicare Program Integrity, HCCA Compliance Institute, April 2007

The more these 3 elements interfaced the more The more these 3 elements interfaced, the more there was an increase in the accuracy of claims Communication Auditing Education

Outcomes of Raw Claims Data

When the contractor initiated action it was already too late

Much less resources/$$ when the provider found an issue & acted Based on audit results

Based on the OIG work plan

Etc.

11

Outcomes of Raw Data CMS would like contractors to provide semi-annual

data to providers very similar to what the pilot participants received

Little changes in the compliance program made big differences.

Bottom line: denied & rejected claims decreased

Outcome: Education

Problem with documentation? Web based training does not work

1-on-1 training does work

Can decrease claims denial rate

Coding/Medical Necessity g y Small groups work

1-on-1 intensive sessions work By people who speak the same language .

Physicians training physicians works best

Outcome: Auditing & Monitoring

All auditing results need to be communicated throughout the organization

Then, training & staff education

Makes a difference if the organization makes a commitment and emphasis on compliancecommitment and emphasis on compliance A culture of compliance

Commitment from the top people must be seen in meetings/training.

Important that the compliance officer “gets out there.”

12

Physician Compliance: Refunds

All $$ inappropriately paid or received, whether due to provider error or not, must not be kept (or held for any period of time)

Never ignore a request for a refund

Appeal request if provider disagrees

Work with payors on refund v. recoup

Physician Compliance: Refunds

Medicare refunds should be made w/in 60 days of discovery Revised FCA – any $ not refunded become false claims!

Medicare refund shuffle – some carriers ask for refund, then recoup before refund is processed

Check credit balances regularly – run reports, keep track of accounts

Physician Compliance: Refunds

Credit balances should be worked to spot overpayments and necessary refunds

Overpayment = refund or recoup

Credit balance may not = overpayment

Unclaimed refunds

13

Physician Compliance: Refunds If your providers balk at paying back overpayments,

show them the law! 18 U.S.C. § 669 Health care embezzlement applies to all payors (not

just Medicare, Medicaid, other gov’t programs) Keeping overpayments is a Federal crime Keeping overpayments is a Federal crime

Biggest Compliance Program Failures

Identification of compliance risk areas and non-compliance

No follow up of identified issues

CMS is developing its own version of a FICO score to be able to identify providers who may be/are at risk for being out of compliance. 4/10/11, James Sheehan

38

Whistleblowers Government intervenes 23% of the cases 70% of FCA cases are health care 95% of cases are settled w/o going to trial

“We expect health care providers, in light of p p , geverything we know today, to have a real compliance program.”Dan Anderson, Asst. Director, Commercial Litigation, US DOJ.

14

CIA vs. CCA OIG is much more comfortable in agreeing to a

Corporate Compliance Agreement rather than a Corporate Integrity Agreement when there is Self disclosure

An effective compliance program in place w/a strong audit componentcomponent

Settlements In general, OIG expects 2.5 times damages if it is

not going to pursue a trial

Exit Interviews A good thing

Shows the organization has tried one more time to flush out if there are any compliance concerns they need to address

15

U.S. Attorney Spencer Turnbull*

“Compliance is more than just rules. It’s ethical conduct and a culture of ethical conduct. The question in a kickback case is not ‘can I do this,’ but ‘why am I doing this?’”

*Speaker, HCCA Compliance Institute, Chicago, IL, April 2007

2012 OIG Work Plan (excerpts)(excerpts)

45

16

46

47

48

17

49

50

51

18

12 ways to become a False Claims Act target

1. Fail to respond to a patient or family member billing inquiry. You’ll find yourself the victim of a “1-800-put your doctor in jail” call.

2. Adopt a compliance program, but fail to implement it. “We have it, I just can’t find it. I think the Office M k h it i ”

52

Manager knows where it is.”

12 ways….cont’d3. Advertise your compliance violations. “Don’t worry

about those co-payments..we’ve got you covered.” 2002 Fraud Advisory: Beneficiary Inducements

4. Stand out against your peers in the carrier’s computer analysis. “I don’t understand this E/M d i ff I’ll j bill l l 3 f

53

documentation stuff. I’ll just bill a level 3 for everyone.”

12 ways…cont’d5. Fail to change your practices after an adverse

audit.

6. Decide to “correct” your medical records after you receive an audit notice or subpoena, but don’t list the date of the edits.

54

19

12 ways…cont’d7. Tell your officer manager or biller to upcode or

cluster. Or, just let her figure out that’s what you’re doing. Then fire her – for any reason!

8. Terminate your physician employee and then enforce a non-compete against him.

55

12 ways…cont’d9. Find out no one in your practice knows what CCI

stands for. Randomly ask employees “So, what’s your CCI?” and they don’t have a clue what you’re talking about.

10. Allow your biller to rebill denied services by h i d ICD 9 d ith t li i l

56

changing procedure or ICD-9 codes without clinical basis.

“I don’t know, just find a code to get it paid!”

12 ways…cont’d11. Fail to read those “silly” carrier bulletins.

11. Distribute those payer newsletters and make it mandatory that everyone read them.

12. Rely on something “Sally” at the carrier told you w/o documenting the guidance received.

11. Document every call to Medicare; perhaps have one

57

y ; p pcentral person.

20

The Choices Do nothing

Cross your fingers!

ADRs and PrePayment audits

CIAs Up to 5 years

Identify the right resource Practice specific

More than just a book on the shelf

A process that requires commitment

58

Fines, penalties and jail time Cost effective protection

Check your managed care contracts – They may require a compliance

program!

Useful Websites and Resources http://www.stopmedicarefraud.gov/

OIG Work Plan, Exclusions List, Compliance Guidance: www.oig.hhs.gov

CERT Reports www.cms.gov/cert

CMS Manuals (can’t live without them!) www.cms.gov/manuals

Your Medicare Contractor

Compliance Toolkit for Physician Practices www.aapc.com/toolkit

59

Jean Acevedo, LHRM, CPC, CHC, CENTCAcevedo Consulting Incorporated

561.278.9328

www AcevedoConsultingInc comwww.AcevedoConsultingInc.com