Risk Assessment - 101

Documentation & Reporting

Warning Flags & Bow Shots

UCSF Clinical Enterprise Compliance Program

CECP Education SeriesWanda T. Ziemba MFA RHIT CHCO CHCC CHC CPCAssociate Compliance Officer & Clinical Enterprise Compliance Program Educator

MGBS Brown Bag Series

May 19, 2006

Agenda Brief presentation

Role of the HHS – Office of Inspector General Target Issues OIG Workplan OIG Orange Book OIG Red Book Fiscal Intermediary Responsibility What can you do? Information Links Questions

“How can you monitor potential red flags if you do not know what the issues are that are of importance to the Federal Government?”

Your Role Awareness of the Government focus Systematic observation and/or review of

practice reporting patterns Mechanism for providers to access information “Red Flag” savvy

Big Brother is Watching But not really watching the practices directly Monitoring the Fiscal Intermediaries as a function of contract control And who is the OIG anyway?

HHS – Office of the Inspector General

The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General.

The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging.

Issues developed are directed to the fiscal intermediaries, not the provider directly

Effort to reduce waste in the sponsor system Will likely trigger FI focused medical reviews

(FMRs) and/or systematic reductions in reimbursement

Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary.

Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

Target Issues

How Does a Service Become Targeted For

Review? Where billing or reporting expenditures have

increased beyond projections or expectations

Example:Increased reporting of Care Plan Oversight

15 million reported in 200041 million in 2001

Example:Increased utilization of wound care CPT codes

98 million in 1999147 million in 2002

Sudden or increased changes in practice reporting patterns CPT code level or type Provider type

Initiation of new or innovative technology

Unexpected volume changes Increased by carrier Patient type Revenue increases Line item increase

Deviation from the norm or usual for that medical specialty Change in category of

CPT codes reported Radical changes in

clinical procedure

Patient-reported billing issues such as co-pay forgiveness,

incentives, or irregular balance-billing

HHS – OIG Workplan Published annually Addresses all provider types Develop patterns of target issues Predict review patterns Develop policy Focused internal reviews Target education

Specific Issues Professional/Technical components of split

services Cardiography & electrocardiography Office-based pathology services

Matching with other billing provider Determination of duplicate billing for one

component

Duplicate reporting IPPE – G0344 Incentives to Patients Previously performed services

Other Fun Publications Orange Book

Significant, unimplemented changes in operations Increased operational efficiencies Conservation of government resources

Red Book OIG cost-saving recommendations Not fully implemented May require legislative, regulatory or procedural

changes

How Orange is Orange? Orange Book Targets Counseling

Inappropriate payments for mental health Provision of services in physician’s offices as well as

behavioral health professionals >200 million in overpayments noted

Issues Lack of documented Medical Necessity Poor documentation Entire missing records Incorrect submission of CPT and ICD-9-Cm codes Unqualified providers Inappropriate or excessive testing Provision of services to patients who may not benefit

form the care rendered

Recommendations Develop list of mental health testing tools Pre and post payment reviews Education efforts Data analysis of claims Update MedLearn Matters

Are You Seeing Red Yet?

CCI Recommendation that the CCI be implemented on a

state level for Medicaid Currently in use by all Medicare Fiscal Intermediaries Federal Government projects a cost savings of 54

million Become familiar win unbundling rules both CPT

as well as CCI

Nail Debridement & related services Inappropriate Medicare payments Medical necessity

When a nail debridement charge is denied, all related services will also be denied.

Last year 51.2 million inappropriate payments were reported; 45.6 related also denied

Summary Know the rules Be Aware of the billing patterns in your

practice Monitor changes Develop policy Educate Check compliance with policy

Where Is the Information?

Workplan, Redbook, Orangebook http://oig.hhs.gov/publications.html

Changes in Medicare Policy http://www.cms.hhs.gov/center/press.asp

FI Policy Updates http://www.medicarenhic.com/whats_new/whats_new.

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Questions & Next Steps