Coders’ Role in Anti-Fraud Investigations

Margaret Chambers, RN, CPC, CPC-P, AHFI

Senior Investigator Premera Blue Cross

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

Disclaimer

This presentation is based on my experience in my particular SIU.

These are my insights and observation.

HealthCare Fraud and Abuse

And the

Special Investigations Unit

SIU

What is Health Care Fraud?

“Fraud is an intentional act of deception, misrepresentation or concealment of a material fact or information.”

=

Did you pay your 2012 Taxes?

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 )

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.).

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

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

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

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.

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

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

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

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

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

Investigation

And

Information Gathering

Data Assessment

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)

Using Coding Skills

Patient intake form.

This provider did not signed the intakes which include a review of systems

Sometimes they make it easy

First page

The only

examination was

vital signs and ----

Billing new patient

code 99204

(Detailed new

patient) with code

99402 (preventive

medicine

counseling)

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

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”

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.

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

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.

DOH Findings Fraud does harm patients:

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

White Out

White out

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

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

A

CASE OF

CLONING &

DOWN RIGHT BAD BEHAVIOR

Documentation Neuromuscular reeducation, Code 97112

Examinations; being created especially for us

EMR “déjà vu”

How far will the SIU go to investigate possible fraud and/or abuse?

23 miles north of the

Arctic Circle!

Kotzebue Alaska at -31º

Laura Erickson,

Senior Analyst