AN ENTERPRISE FREE ZONE

Transcription

1 Mandatory Compliance Requirements and Alaska Audit Update AN ENTERPRISE FREE ZONE 1

2 Acronym Soup ACA AS MIP/MIG/MIC EHR OIG MFCU SURS RAC PERM CHIP Objectives Understand the Affordable Care Act requirements related to mandatory compliance plans Understand the current status and focus of: Audits conducted under AS Audits conducted by the Medicaid Integrity Contractor Electronic Health Record Medicaid Fraud Control Unit Audits conducted by the Recover Audit Contractor Payment Error Rate Measurement program Discuss how to avoid overpayments Creating a quality assurance team Discuss medical reviewers and most common errors 2

3 Mandatory compliance requirements Section Accountability Requirements for Skilled Nursing Facilities and Nursing Facilities Section Provider Screening and other enrollment Requirements under Medicare Medicaid and CHIP. ACA Section 6102 Requirements Requires a facility to have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations and promotes quality of care. Effective March 23, 2013 Requires regulations effective March 23, OOPS 3

4 ACA Section 6102 Compliance and ethics program requirements Establish compliance standards and procedures used by employees and agents capable of reducing criminal, civil and administrative violations Specify high level personnel to oversee compliance and establish standards and procedures The organization must use due care to ensure employees with substantial discretionary authority do not have a propensity to engage in criminal, civil, and administrative violations. (background checks) The organization must have effective communication of compliance standards and procedures through training and ACA Section 6102 continued Establish audit and review mechanism to ensure compliance standards are being followed and also ensure employees and agents are free to report violations with no fear of retaliation Ensure consistent enforcement of and discipline for individuals who fail to identify an offense After an offense is detected, the organization must take all reasonable steps to prevent similar offenses from repeating The organization must periodically reassess its compliance program and make necessary improvements 4

5 ACA Section 6401 Requirements Applies to all healthcare providers and suppliers participating in federal healthcare programs including Medicare, Medicaid, and Children's Health Insurance Program (CHIP) Requires levels of screening based on risk of fraud, waste and abuse Requires imposition of application fees Requires periodic revalidation of enrollment Provides for authority to adjust payments to providers with same tax ID Provides for temporary moratorium on new provider enrollment by category of provider Requires providers to establish a compliance program that contains the core elements established by secretary in consultation with the OIG ACA Section 6401 continued OIG guidance has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements 5

6 AS (Myers and Stauffer) Medicaid Integrity Program (MIP) 6

7 Electronic Health Record (EHR) Medicaid Fraud Control Unit (MFCU) 7

8 Examples of Fraud Schemes in Health Care Billing for services not rendered Billing for higher level of services than actually performed Billing for more services than actually performed Charging higher rates for services to Medicaid than others Upcoding procedures for higher reimbursement Providing and billing for unnecessary services Misrepresenting an unallowable service in a Medicaid billing Falsely diagnosing so Medicaid will pay for more services Surveillance and Utilization Review Subsystem (SURS) 8

9 Recovery Audit Contractor (RAC) Payment Error Rate Measurement (PERM) 9

10 How to Avoid Overpayments Create a Quality Assurance Program Quality assurance programs have one major focus, assuring that an organization is adhering to standards Create policies and procedures in conjunction with your standards Create standards for your business and criteria for the standards Create a quality program description Establish a quality committee that include employees from departments other than your own department Implement corrective action plans when results are unsatisfactory and performance needs improvement Medical Record Reviewers Do not fill in gaps in a note Each visit must stand alone Documentation is critical to supporting services provided Will not look back at prior notes to support a level of service 10

11 Most Common Findings of an Overpayment Lack of documentation to support the services provided Insufficient documentation to support the number of units billed Lack of documentation to support medical necessity for service billed (i.e., required physician orders, prescriptions, treatment plans, or plans of care that were not updated timely or did not order services billed, etc..) Not properly billing available third-party or Medicare resources prior to billing Medicaid Submission of duplicate billings (i.e., two or more line items with the same recipient, date of service, procedure code, units and paid amount) Be prepared and you won t have any problems 11

12 Links MFCU XEROX CMS / PERM Compliance-Programs/PERM/Cycle_3.html OIG RAC DHSS We look forward to working with your teams QUESTIONS? Doug Jones Stangl Douglas.jones@alaska.gov Renee.stangl@alaska.gov Renee Feb