DEFINING LINES OF COMPLIANCE. April 2004 By: Angela Miller Compliance Officer Home Care Supply

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1 DEFINING LINES OF COMPLIANCE April By: Angela Miller Compliance Officer Home Care Supply

2 OUTLINE Broad brush on Audit Responses Finer Policy Points Education: The Vicious Circle A Private Showing: Attorney Client Privilege Voluntary Disclosure: The Palette of Many Colors

3 Broad-Brush on Audit Responses Angela Miller Compliance Officer Home Care Supply

4 RESPONDING TO AUDITS What kind of audits involve compliance? All Medicare & Medicaid Audits Location information, phone numbers, service contracts, contract employees, supplier numbers, etc. All billing audits from any carrier 4

5 RESPONDING TO AUDITS Location Audits (ie, NSC or other carrier onsite visits) Ensure licenses/permits are current Hours posted and location open Is the company listed with directory assistance AND the local phone company with the dba name? Have contracts with employees and servicing companies on hand Have a complete copy of the insurance policy on hand 5

6 RESPONDING TO AUDITS Location Audits (ie, NSC or other carrier on-site visits) You only have 14 days to respond, if dinged by Medicare Keep a copy of the inspectors identification Require your branch to call you when any external person shows up for any type of inspection or audit 6

7 RESPONDING TO AUDITS What information do you provide for billing audits? All insurance carriers, including Medicare and Medicaid, will send a standard letter requesting information for a specific period of time Provide all paperwork for the services being audited even if it is not requested or not within that time period 7

8 RESPONDING TO AUDITS What information do you provide for billing audits? Obtain and provide all applicable medical records from the physician or hospital MD s frequently do not have to respond and do not suffer penalties for failing to respond You are hit with the recoup These errors can lead to extrapolation refunds 8

9 RESPONDING TO AUDITS Why should you provide information not requested? To add validity to your case It is much easier to do this, than face a recoup which could take 6 months or more to retrieve your money. Just recently was a provision passed allowing you to request interest back 9

10 RESPONDING TO AUDITS Provision in the Medicare Prescription Drug Improvement & Modernization Act of 2003, that allows for recovery of interest when the supplier prevails in an appeal on recouped money Section 935 Recovery of Overpayments (b)(2) page 346 for decisions on or after effective date Effective 12/8/03 10

11 RESPONDING TO AUDITS Who reviews the audits prior to mailing? The billing person and the billing manager should review all audits prior to responding to ensure all documents have been provided in an organized manner Note any concerns The compliance officer should receive a complete copy of the response along with the notes of concerns or summary of internal review 11

12 RESPONDING TO AUDITS Review Pointers? Ensure the documents are legible The complete form has been copied including the full signature Review the finer policy points to ensure all criteria has been met If you find a concern, call and request an extension so you can investigate 12

13 RESPONDING TO AUDITS Once you investigate the concern: Provide the response with the concern, if applicable and request a refund letter or a recoup If the concern develops into something much larger, contact legal counsel to discuss your options and corrective action plan 13

14 Finer Policy Points Angela Miller Compliance Officer Home Care Supply Lisa Smith Attorney Brown & Fortunato Heidi Kocher Sr. Director, Reporting & Monitoring, Compliance Tenet, Dallas Office

15 Finer Policy Points It is necessary to really pay much more attention to the finer policy points because Medicare and other organizations are really cracking down in an effort to recoup money for their funding Changes occur so frequently and many times without warning This will increase your collections also 15

16 Oxygen Policy Most carriers follow Medicare criteria, even if not requested initially Testing at rest on room air is the preferred method and is required in conjunction with all other methods (exercise and sleep) or sleep must desaturate 5% for 5 minutes with documentation of hypoxemia and primary cause diagnosis, if no rest test taken Testing at exercise on room air, requires a test at exercise on oxygen to show beneficial improvement 16

17 Oxygen Policy Testing at sleep must show desaturation for 5 total minutes during the study Follow-up tests in the physician record must be clearly documented, especially if tested ON oxygen Unnecessary testing that does not qualify will result in a recoup State Pharmacy Laws require a prescription on file since Oxygen is categorized as a drug Some permit a verbal and other written Some require it yearly and others may be less frequent 17

18 Bipap S & ST Bipap S OSA patients must have been tried on a CPAP and ruled ineffective Bipap ST OSA patients do not qualify for an ST All other diagnosis must obtain the testing as listed in the attached diagram 18

19 Bipap S & ST Both must be re-evaluated by the physician no sooner than the 61 st day after setup Some diagnosis require retesting Both require a beneficiary letter, and a physician letter You may not call these patients for the information in lieu of a letter 19

20 Copies of Test Results Are you obtaining copies of oxygen, CPAP, Bipap, and Bipap ST test results? Since many carriers hold the supplier responsible, I would recommend you obtain 100% of the tests for CPAP and Bipaps patients. Obtain as many as possible for the oxygen patients. 20

21 Power Mobility Many associations are fighting the changes in the clarification of the policy, as this clarification is really a change in policy Inability to ambulate, upper body weakness, inability to propel with feet, and diagnosis must be thoroughly documented Can t just have MD document this in his chart, because Carrier will call patients for verification All Power Wheelchairs and POVs are WOPD as of 10/1/03 21

22 Enteral Nutrition There must be additional documentation in question 15 or in chart notes provided that explains why the patient needs pump feeding rather than another method or it will be denied: gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, or circulatory overload, gastrostomy/jejunostomy tube used for feeding 22

23 Enteral Nutrition Ensure the calories are calculated correctly Can only deliver 1 month supply; span dates cannot overlap May not ingest by mouth/orally 23

24 Manual Wheelchairs Why can t the patient propel with feet OR hands? Not diagnosis driven but common sense is required (applies to all equipment) A diagnosis that does not explain the need (ie, ) just begs for an audit later 24

25 Diabetic Shoes Patient must have Diabetes ( ) Patient must also have one of the following on one or both feet: Amputation Ulceration Deformity Poor circulation Neuropathy 25

26 Diabetic Shoes Ensure that out of the box shoes are not billed as custom molded shoes Not every diabetic patient needs shoes and/or inserts Certifying physician may be MD or DO Ordering physician may be MD, DO, or podiatrist 26

27 Frequent Testers: Diabetic Supplies Evaluated within six months prior to the order or renewal order Why does the patient have to test so frequently? from MD file Documentation of actual testing frequency must be obtained every six months (ie, a copy of the patient testing log) Span dates may not overlap 27

28 CMN s & WOPD Delivery date/date of service must be no greater than three months (90 days) after the "Initial Date " of the CMN or three months (90 days) after the date of the physician's signature Documentation Section of the Manual the heading Completing a CMN Region C Council Questions and Answers dated October 24, 2001, question 23 28

29 Physician Records Physician chart notes can either help or kill a review, hearing, or other appeals process See referral education Also good articles in HCCA news June

30 Education: The Vicious Circle Angela Miller Compliance Officer Home Care Supply

31 Education Who should you educate? All employees Physicians and Referral Sources The Community Inform your vendors of your compliance program and of specific stipulations your organization has that may not be required by Medicare (ie, Power wheelchair documentation) Solicit ombudsman from Medicare and other organizations to do presentations for group meetings 31

32 Education How should you educate these groups? Employees Conference calls and training material, newsletters, regional meetings Materials should be accessible via intranet Referrals Handouts, luncheons, group meetings during lunch at a hospital 32

33 Education How should you educate these groups? Community Handouts, regional meetings in conjunction with Chamber of Commerce or other groups 33

34 Education Why should you take the responsibility to educate these people? Show your dedication to compliance Increase your referrals, by making them comfortable that you do the right thing Reduce improperly completed paperwork Reduce the referrals of non-qualifying patients 34

35 Education Why should you take the responsibility to educate these people? Create a working partnership that is mutually beneficial to you, the referral and most importantly-the patient Shows good faith and diligence in the event of an investigation Hopefully reduce fines and penalties 35

36 Referral Education What should you educate the referral sources and physicians about? Your compliance program The Compliance Hotline number Their risk for referring business to companies that are unethical, for excessive orders, failure to document their charts Keep them updated on the changing guidelines 36

37 Referral Education What should you educate the referral sources and physicians about? The importance of good detailed chart documentation, tests or eval documentation used to make the decision for the order itself, diagnosis, testing on or off oxygen (Chapter 5- PIM) Importance of legible handwriting in the chart notes and on prescriptions Update them on the latest scams, convictions, fines related to physicians 37

38 Education Don t let the organization or your referrals walk around with a target on their fanny. Protect your bottom line and theirs Educate, Educate, Educate It never ends 38

39 Community Education What should you educate the community about? Your compliance program The Compliance Hotline number Different types of insurance coverage Medicare A & B, Medicaid, Private Insurance What the terms deductible, out-ofpocket, and co-insurance mean How to read an EOB so they can report fraud or erroneous billing 39

40 Community Education What should you educate the community about? Call the supplier prior to calling the insurance fraud hotline Refund process (ie, how long it takes) Each paid claim is applied to their lifetime maximum benefit They will not get in trouble for reporting fraud or erroneous billing How fraudulent behavior depletes the funds a payor has to pay claims and increases insurance premiums Current scams 40

41 Educational Defense Education is the best way to combat fraud Report Fraud to appropriate agencies The more knowledge people have the better defensive position they have 41

42 Following the Break A Private Showing: Attorney Client Privilege Voluntary Disclosure: The Palette of Many Colors 42