Current Regulatory Environment 6/5/2013. Compliance Audit Update Recent Developments and What to Expect in the Year Ahead. Agenda

Size: px
Start display at page:

Download "Current Regulatory Environment 6/5/2013. Compliance Audit Update Recent Developments and What to Expect in the Year Ahead. Agenda"

Transcription

1 Compliance Audit Update Recent Developments and What to Expect in the Year Ahead Seattle HCCA June 14, 2013 John Valenta, Director Deloitte & Touche LLP Agenda Current regulatory environment Recent government audit activity OIG Hospital Compliance Reviews and other areas of audit and enforcement activity 2 Copyright 2013 Deloitte Development LLC. All rights reserved. Current Regulatory Environment 1

2 Many "Eyes" are watching Medicare Administrative Contractors (MAC) Medicare Recovery Auditors (formerly RAC ) Office of the Inspector General (OIG) Department of Justice (DOJ) Health Resources and Services Administration (HRSA) State Attorneys General Third Party Payors 4 Copyright 2013 Deloitte Development LLC. All rights reserved. Federal enforcement initiatives Fiscal Year (FY) 2012 in review For every dollar spent on health care-related fraud and abuse investigations in the last three years, the government recovered $7.90 Highest three-year average return on investment in the 16-year history of the Health Care Fraud and Abuse Control (HCFAC) Program In FY 2012, the government s enforcement efforts recovered a record $4.2 billion in taxpayer dollars, up from $4.1 billion in FY 2011 Recovery efforts have more than doubled in the past four years; $14.9 billion has been recovered up from $6.7 billion over the prior fouryear period Since 1997, the HCFAC Program has recovered more than $23 billion Source: The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year Copyright 2013 Deloitte Development LLC. All rights reserved. Federal enforcement initiatives Fiscal Year (FY) 2012 in review (cont.) HEAT (Healthcare Fraud Prevention and Enforcement Action Team): February: indictment and arrest of a Texas physician, office manager, and five owners of home health agencies (HHA); single, largest fraud case orchestrated by one doctor May: coordinated Strike Force teams across 7 cities, resulted in charges against 107 individuals for alleged participation in Medicare fraud involving over $450 million; highest amount of false billings in a single takedown in the Strike Force s history; HHS took other administrative action against 52 providers Source: The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal 6 Year 2012, released February 2013 Copyright 2013 Deloitte Development LLC. All rights reserved. 2

3 Federal enforcement initiatives are becoming preventive through use of technology Beginning in June 2011, CMS began screening all fee-for-service Medicare claims through the new Fraud Prevention System, which is similar to the technology used by credit card companies The Fraud Prevention System applies predictive analytic technology to claims prior to payment to identify aberrant and suspicious billing patterns. In its first year of implementation, the Fraud Prevention System: Generated leads for 538 new fraud investigations Provided new information for 511 existing investigations Triggered 617 provider interviews and 1,642 beneficiary interviews Source: Information on the fraud prevention accomplishments under the Affordable Care Act at 7 Copyright 2013 Deloitte Development LLC. All rights reserved. OIG Semiannual Report to Congress OIG Semiannual Report to Congress describes: Significant problems Abuses Deficiencies Investigative outcomes All relating to the administration of HHS programs and operations that were disclosed during the reporting period Recent edition addresses work completed during the second half of Federal FY 2012 (April 1, 2012 September 30, 2012) Source: 8 Copyright 2013 Deloitte Development LLC. All rights reserved. Expected recoveries are on the rise.. Per the OIG s Fall Semiannual Reports to Congress for the past three federal fiscal years, expected recoveries continue to rise. Year Expected Recoveries (in billions) $8.0 $7.0 $6.0 FY 2010 $4.9B Billions $5.0 $4.0 FFY 2011 $5.2B $3.0 $2.0 FFY 2012 $6.9B $1.0 $0.0 FY 2010 FY 2011 FY2012 Sources: OIG Semiannual Report To Congress (April 1, 2012 September 30, 2012); OIG Semiannual Report To Congress (April 1, 2011 September 30, 2011); OIG Semiannual Report To Congress (April 1, 2010 September 30, 2010) 9 Copyright 2013 Deloitte Development LLC. All rights reserved. 3

4 Rise in Whistleblower Activity Year Reports Made Total 697 Qui tam reports made have steadily increased since 2009 Settlements awarded from qui tam reports have skyrocketed to $670 million in 2012 Relator share awards have also increased dramatically with awards totaling $133 million in 2012 Millions $800.0 $700.0 $600.0 $500.0 $400.0 $300.0 $200.0 $100.0 Qui Tam Settlements and Judgments Sources: 10 Copyright 2013 Deloitte Development LLC. All rights reserved. $ Settlements & Judgments Relator Share Awards RAC Activity is on the Rise As recently reported by the American Hospital Association (AHA) in their 4 th Quarter 2012 RACTRAC Survey, over 1,200 hospital survey participants across the country continued to report increases in RAC activity. According to this latest AHA quarterly report, relative to 1 st Quarter 2012 : Medical record requests are up 61% The number of denials is up 88% The dollar value of denials is up 69% 11 Source: AHA RACTrac Survey 4 th Quarter 2012 Copyright 2013 Deloitte Development LLC. All rights reserved. RAC activity and denials Different types and sizes of hospitals reported that they were subject to RAC review RAC activity was especially high among teaching hospitals and hospitals with 200+ beds Since Q1 2012, RAC Automated and Complex Denials have steadily increased $1.1 billion in denials were reported through the third quarter of 2012, up 26% from the second quarter Source: 12 Copyright 2013 Deloitte Development LLC. All rights reserved. 4

5 Update on Recent Government Audit Activity Examples of recent Medicare program reviews Home Health Care Agencies - Claims With Questionable Billing* Characteristics One in every four home health agencies (HHA) exceeded a threshold that indicated unusually high billing (for at least one of six measures) Physicians - Increase in Use of Service Codes That Result in Higher Reimbursements From 2001 to 2010 physicians increased their billing of higher level, more complex and expensive Evaluation and Management (E/M) codes and reduced billing of lower level, less complex and expensive E/M codes in all 15 visits reviewed Between 2001 and 2010, payments for E/M services increased by 48 percent (from $22.7 billion to $33.5 billion) compared to 43 percent for Part B goods and services generally. Several factors contributed to the overall increases, including increases in the number of services provided, increases in the average payment rate for E/M services, and changes in physicians billing of E/M codes. Source OIG Semiannual Report To Congress (April 1, 2012 September 30, 2012) *Refers to claims that exhibit certain characteristics that may indicate fraud 14 Copyright 2013 Deloitte Development LLC. All rights reserved. Examples of recent Medicare program reviews Hospitals - Outpatient Payments Exceeding Charges* Line items exceeded billed charges revealed frequent errors; including incorrect units of services, incorrect codes, a combination of those, billing for unallowable services, and inadequate supporting documentation causing Medicare s payments for the services to be improper Millions of dollars in overpayments occurred in part because key Medicare systems did not have sufficient edits in place during these audit periods Part B Drugs Billing of Incorrect Units of Service (Herceptin)* Three reports (issued in July and August 2012) revealed most payments that contractors made to health care providers for full vials of Herceptin were incorrect Payments were improper because billing providers reported units of service for the entire content of one or more vials, each containing 440 milligrams of Herceptin, rather than reporting the units of service for the amount actually administered Providers supporting documentation was inadequate or providers could not store unused doses for later use. When this occurred, providers improperly billed Medicare for the entire vial, including waste. Source OIG Semiannual Report To Congress (April 1, 2012 September 30, 2012) *Medicare s supporting systems did not have sufficient edits in place during the audit period to prevent / detect the improper billings 15 Copyright 2013 Deloitte Development LLC. All rights reserved. 5

6 Billing Medicare for drug waste Coverage of discarded drugs applies only to single use vials Multi-use vials are not subject to payment for discarded amounts of drug When billing for waste associated with a single use vial, an itemized bill should be submitted with the claim to verify how the drug was supplied Hospitals are encouraged to schedule patients in such a way that the hospital can use the drug most efficiently However, if the hospital must discard the remainder of a single use vial after administering part of it to a Medicare patient, the provider may bill for the amount of drug discarded along with the amount administered Sources: Copyright 2013 Deloitte Development LLC. All rights reserved. Recent Skilled Nursing Facility Audits According to the March 4, 2013 issue of Report on Medicare Compliance A jury on Feb. 11 found a Skilled Nursing Facility (SNF) liable for substandard care to its patients and falsifying documents to appear to be in compliance with Medicare and state standards The case was filed by two whistleblowers who were former nurses Case closed at $28.1 million owed to the U.S. Government and the state A SNF and its parent company will pay the government $350,000 to resolve allegations of worthless care provided to the residents of its nursing facilities Sued by the Department of Justice Companies will retain an independent consultant with quarterly progress reports on quality of care improvement and both companies will be responsible the associated costs Source: Report on Medicare Compliance Volume 22, Number 9 March 4, Copyright 2013 Deloitte Development LLC. All rights reserved. Recent Inpatient Rehab Facility Audit Summary: Norwalk Hospital billed inpatient rehabilitation facility (IRF) claims that did not comply with Medicare documentation requirements. Findings: Improper payments calculated to equal: $2.7 million for 100 sampled claims $5.2 million for 225 IRF claims not in sample Conclusion: Medical records did not include sufficient documentation to support any required IRF elements. Outcome: OIG recommended the Hospital: Refund $2.7 million related to sampled claims Work with OIG to resolve $5.2 million in claims not sampled Identify other IRF claims that did not meet Medicare documentation requirements and refund overpayments Develop and implement new improved procedures Source: Copyright 2013 Deloitte Development LLC. All rights reserved. 6

7 Selected OIG recoveries through January 2013 Source: Section 8L of the Inspector General Act, 5 U.S.C. App., requires that OIG post its publicly available reports on the OIG Web site. 19 Copyright 2013 Deloitte Development LLC. All rights reserved. Additional Areas of Audit and Enforcement Activity OIG Hospital Compliance Reviews 7

8 OIG Hospital Compliance Reviews Inpatient Risk Areas Short hospital stays (0 and 1 day) High-severity level MS-DRGs Same day discharge and readmission Transfers to post-acute care providers Transfers to inpatient hospice care Manufacturer medical device credits Claims paid amount in excess of claims charged amount Claims with payments greater than $150,000 Blood-clotting factor drugs Hospital acquired conditions and present on admission reporting Outlier payments 22 Copyright 2013 Deloitte Development LLC. All rights reserved. OIG Hospital Compliance Reviews Outpatient Risk Areas Observation outlier payments Facility E&M coding and new vs. established patient Manufacturer medical device credits Services billed with modifier 59 E&M services billed with surgical services (modifier 25) Claims paid amount in excess of claims charged amount Outpatient services billed during inpatient stays Thee-day payment window rule Surgeries billed with units greater than one Services billed during skilled nursing facility stays Outpatient dental services 23 Copyright 2013 Deloitte Development LLC. All rights reserved. Other OIG Risk Areas Other Risk-Areas identified in the OIG Work Plan and recent audits Inpatient psychiatric facility interrupted stays Inpatient psychiatric facility emergency department adjustments Skilled Nursing Facility payments for ultra high therapy Inpatient Rehabilitation Facility documentation requirements Outpatient brachytherapy reimbursement Outpatient claims billed using J codes Observation services during outpatient visits Hemophilia services and septicemia services Intensity modulated radiation therapy planning services Outpatient claim payments greater than $25, Copyright 2013 Deloitte Development LLC. All rights reserved. 8

9 Provider experiences with OIG Hospital Compliance Reviews Audit notice and initial request received via telephone call and facsimile OIG is typically onsite within 2-4 weeks after this notification The initial OIG request typically includes 200 or more records, with larger facilities typically being asked for 300 or more 66% Inpatient 33% Outpatient The OIG audit team is typically on-site for several weeks, but this can vary OIG typically expects the provider to review all of the records first and have the provider complete an OIG worksheet/audit tool The sample can be expanded while the OIG is on-site 25 Copyright 2013 Deloitte Development LLC. All rights reserved. Provider experiences with OIG Hospital Compliance Reviews (cont.) Disagreement on findings may go to the QIC for additional review (e.g. short-stay cases reviewed by a physician) In addition to agreeing or disagreeing with the findings, providers are asked to provide brief written corrective action plans to the OIG for each audit area Results of the OIG Hospital Compliance Reviews cannot be extrapolated as the samples are targeted, not random Depending on the error rates noted, the OIG may request that the provider conduct a follow-up self-audit of one or more areas using OIGapproved sampling methodology and extrapolation over the designated review period (e.g., modifier 25 reviews) 26 Copyright 2013 Deloitte Development LLC. All rights reserved. Short Stays / Medical Necessity 9

10 Short Stay Denials are Costly The issue of medical necessity and short-hospital stays is a primary area of focus by the Medicare Recovery Audit Program, the OIG, DOJ and even private payers Given the difference in payment between an inpatient case and an outpatient case, hospitals face significant compliance risk and the potential for lost revenue if they fail to correctly assess and bill patient status A complex denial costs hospitals $5,556 per Medicare claim Recently, a hospital reached a settlement worth over $8M with the U.S. government to settle allegations of unnecessary short-stay claims with Medicare and Medicaid. 28 Source: AHA RACTrac Survey November 2012 Copyright 2013 Deloitte Development LLC. All rights reserved. The Consequences of Short Stay Denials Retro denials can result in total recoupment of inpatient payment If within one-year timely filing period, hospitals may receive Part B ancillaries (limited ancillaries, such as diagnostic x-rays and laboratory tests, prosthetic devices, outpatient physical, speech, occupational therapy, etc.) May result in higher outpatient co-insurance (vs. inpatient deductible) for patients No coverage of self-administered drugs 29 Copyright 2013 Deloitte Development LLC. All rights reserved. The Impact on Patients Patients who are placed in observation status (yet remain in a hospital bed for one or more days) may face significantly higher out-of-pocket costs than if admitted Observation status also negates a patient s ability to qualify for Medicare SNF or rehab coverage If a patient s inpatient stay is denied by a hospital after discharge and the patient went to a SNF, this can invalidate the patients SNF Medicare coverage for post-acute care under Medicare Part A. 30 Copyright 2013 Deloitte Development LLC. All rights reserved. 10

11 The Impact on Patients A CNN Money article told the story of a retired teacher who spent five days in a hospital bed after a fall only to learn that her subsequent rehabilitation was not covered by Medicare. The rehab care was not covered because she was kept in observation status. This patient s story underscores how this issue is causing confusion, frustration and dissatisfaction within the industry for hospitals and their patients See 31 Copyright 2013 Deloitte Development LLC. All rights reserved. Leading Practices to Consider for Compliance Review short stays prior to submitting claim to Medicare Correct short stay claims that do not meet for medical necessity Verify the patient s status in the billing system matches the patient status ordered Maintain an active Utilization Review Committee (URC) Continually monitor short-stay denials from both pre-payment and post-payment reviews Ensure adequate Case Management support to pre-screen for medical necessity at key points of admission (e.g. the ED, for transfers in and for elective surgeries) Enlist the help of one or more physician champions to serve as the physician advisors 32 Copyright 2013 Deloitte Development LLC. All rights reserved. 340B Drug Pricing Program Compliance and Enforcement 11

12 340B Compliance and Enforcement Impact of healthcare reform on 340B a rapidly changing environment Recertification requirements includes additional requirements and new application process HRSA to increase audit activities Expanded access, including increased use of contract pharmacies, has led to increased risks 34 Copyright 2013 Deloitte Development LLC. All rights reserved. Enhanced Oversight The Affordable Care Act amended the 340B statute to require HRSA to develop procedures to enable and require Covered Entities to regularly update information (at least annually) Goal is to ensure program integrity, compliance, transparency, and accountability by requiring Covered Entities to ensure accuracy of the information in the 340B database HRSA has emphasized the importance of maintaining current and accurate information in its database of Covered Entities Used by manufacturers to screen Covered Entities Publicly available at HRSA recommends listing all sites that will utilize 340B drugs HRSA requires registration of all contract pharmacy arrangements 35 Copyright 2013 Deloitte Development LLC. All rights reserved. HRSA Audits of Covered Entities All Covered Entity types may be audited In FY 2012, HRSA began conducting both random and targeted audits of Covered Entities, 51 audits were completed Random audits focus on program types with higher risk, due to volume of purchases, complexity of program administration, or use of contract pharmacies Targeted audits may be triggered by whistleblowers, manufacturers, or self-reporting 36 Copyright 2013 Deloitte Development LLC. All rights reserved. 12

13 HRSA Audits of Covered Entities (cont.) Focus areas of HRSA audits: Verification of eligibility Review of policies and procedures and how they are operationalized Review of internal controls to prevent diversion and duplicate discounts Review of contract pharmacy compliance Test of 340B drug transaction records on sample basis Results of HRSA audits are posted 37 Copyright 2013 Deloitte Development LLC. All rights reserved. Manufacturer Audits of Covered Entities Manufacturers are also authorized to audit 340B Covered Entities regarding compliance with drug diversion and duplicate discount requirements Manufacturers must submit an audit work plan to OPA prior to conducting audits Genentech audit 38 Copyright 2013 Deloitte Development LLC. All rights reserved. Health Care Reform: New Sanction Authority for 340B Violations Potential Sanctions: Forfeiture of 340B discounts to the manufacturer Monetary penalties: applicable interest for being aware of violations and not reporting to the OPA, and intentional violations Disqualification from the program for systematic and egregious violations Possible referral to OIG or other federal agencies for further review Disqualification and prohibited re-entry in the 340B program 39 Copyright 2013 Deloitte Development LLC. All rights reserved. 13

14 Ways to help achieve Compliance/Prepare for Audits 340B Covered Entities should have a 340B compliance plan in place Ensure all employees involved in the program are trained and understand the compliance plan Covered entities (and any contract pharmacy) must maintain accurate records documenting compliance with 340B program requirements Records are subject to audit by a OPA or by a manufacturer Procedures and systems controls designed to ensure compliance with rules regarding diversion and duplicate discounts should be developed and regularly reviewed/updated Covered entities should have a complete audit trail from purchase to pick-up by the patient 40 Copyright 2013 Deloitte Development LLC. All rights reserved. Ways to help achieve Compliance/Prepare for Audits (cont.) Pay special attention to mixed-use settings where inpatients and outpatients receive drugs (e.g., ER or oncology clinic) and to the relationships and drug distribution within a health care system in which some entities are 340B Covered Entities and some are not Covered entities should establish procedures to periodically audit their own records and the records of contract pharmacies Make sure to keep information on the OPA Covered Entity database current Consider privileged compliance review/audit 41 Copyright 2013 Deloitte Development LLC. All rights reserved. Medical Record Copying and Cloning Risks 14

15 Risks of Copying and Cloning Medical Records A New York Times article Medicare Bills Rise as Records turn Electronic sites the rise in Medicare payments related to the use of electronic medical records Conducted a study that found hospitals received $1B more in Medicare payments in 2010 than they did 5 years ago Electronic Health Records (EHR) have the ability to: Automate generation of patient histories Cut and paste or cloning examination findings for multiple patients Lead to up-coding of clinic visits Sources: Risks of Copying and Cloning Medical Records - NGS said to deny payment for treatments using cloned documentation 10/9/12 Source: 43 Copyright 2013 Deloitte Development LLC. All rights reserved. Risks of Copying and Cloning Medical Records (cont.) For Fiscal Year 2013, the OIG will place focus on identical information found in Electronic Health Records due to the potential for inaccurate documentation that may lead to incorrect billing Providers may be considered as engaging in fraudulent activity and subject to the False Claims Act if the medical record contains an inaccurate reflection of care given Sources: Risks of Copying and Cloning Medical Records - NGS said to deny payment for treatments using cloned documentation 10/9/12 Source: 44 Copyright 2013 Deloitte Development LLC. All rights reserved. New Cloning Study and Concerns New study has been published in the journal Critical Care Medicine focusing on progress note plagiarism at a Cleveland medical center 82% of residents and 74% of attendings progress notes contained 20% or more information that was copied 66% of residents and 94% of attendings copied from their previous day notes Concerns Impacted patient care as a result of reusing old and/or out of date information indecipherable medical records as a result of reusing old and/or out of date information Shift in progress notes as a mean for billing purposes rather than the ordinal use of communication Improper billing by providers Source: 45 Copyright 2013 Deloitte Development LLC. All rights reserved. 15

16 Recommendations for Compliance Officers Seek to gain an understanding of EHR tools available at your facility Shadow physicians in multiple work settings to assess how services are provided and notes are created Encourage clinicians to summarize diagnostic test findings into notes rather than copying and pasting the whole report Actively contribute to the EHR training plans and educate trainers on key compliance concepts Source: AAMC Compliance Officers Forum Appropriate Documentation in an EHR: Use of Information That Is Not Generated During the Encounter for Which the Claim is Submitted: Copying/Importing/Scripts/Templates 46 Copyright 2013 Deloitte Development LLC. All rights reserved. Recommendations for Compliance Officers (cont.) Participate in provider training courses to ensure that the information is accurate and to be available as a compliance resource Attend vendor courses and meetings to gain an understanding of the software Continually test and audit with live data to reveal risk that are not otherwise apparent Source: AAMC Compliance Officers Forum Appropriate Documentation in an EHR: Use of Information That Is Not Generated During the Encounter for Which the Claim is Submitted: Copying/Importing/Scripts/Templates oninanehr.pdf 47 Copyright 2013 Deloitte Development LLC. All rights reserved. Contact Information and Speaker Biographies 16

17 Contact Information and Bios John Valenta, Director Deloitte & Touche LLP John has over 24 years of experience in the healthcare and life sciences industries and advises clients on regulatory and compliance issues as well as financial, risk management, and other operational issues. He has extensive consulting experience on issues related to compliance, government regulations, government program reimbursement, enterprise risk management, internal controls and other financial and operational issues. John has assisted organizations with performing risk assessments, compliance program effectiveness assessments, developing policies and procedures, providing education and evaluating the organizational structure of the compliance and internal audit functions. He has led numerous compliance reviews of areas including physician contracting/compensation, RAC Audit preparedness, coding for short stays and various HIPAA Privacy issues. 49 Copyright 2013 Deloitte Development LLC. All rights reserved. About Deloitte Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee, and its network of member firms, each of which is a legally separate and independent entity. Please see for a detailed description of the legal structure of Deloitte Touche Tohmatsu Limited and its member firms. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting. This presentation contains general information only and Deloitte is not, by means of this presentation, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This presentation is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this presentation. Copyright 2013 Deloitte Development LLC. All rights reserved. Member of Deloitte Touche Tohmatsu Limited 17

Government Focus in Home Health

Government Focus in Home Health Government Focus in Home Health November 8, 2011 Cheryl Golden Director Deloitte & Touche LLP Contents Current Regulatory Focus in Home Health Government Programs HHS OIG Work Plan 2012 Auditing and Monitoring

More information

HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans

HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN Kelly Priegnitz # Chris Puri # Kim Looney Post Acute Provider Specific Sections from 2012-2015 OIG Work Plans I. NURSING HOMES

More information

Examining Compliance from an Internal Audit Perspective

Examining Compliance from an Internal Audit Perspective Examining Compliance from an Internal Audit Perspective Beth A. Schindler, CPA, CIA, CISA, CHC April 19, 2016 0 Houston Methodist Who We Are About Houston Methodist A leading Academic Medical Center 7

More information

Responding to Today s Health Care Regulatory Environment

Responding to Today s Health Care Regulatory Environment Responding to Today s Health Care Regulatory Environment St. Joseph s Health Michael R. Holper SVP, Compliance and Audit Services October 26, 2016 2014 Trinity Health. All Rights Reserved. 1 We operate

More information

2013 OIG Work Plan. Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas

2013 OIG Work Plan. Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas 2013 OIG Work Plan Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas 77002 713.646.1390 smcbride@bakerlaw.com Webinar Essentials * Session is currently being recorded, and will

More information

Complex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor. NJHFMA Finance for Clinicians Session March 24, 2016

Complex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor. NJHFMA Finance for Clinicians Session March 24, 2016 1 Complex Challenges/Financial Impact Medical Necessity Compliance Role of the Physician Advisor NJHFMA Finance for Clinicians Session March 24, 2016 Complex Challenges 2 Declining Inpatient Admissions

More information

Office of Inspector General Hospital Compliance Audit

Office of Inspector General Hospital Compliance Audit Office of Inspector General Hospital Compliance Audit HCCA Desert Southwest Regional Annual Conference November 16, 2012 Marc Tatarian, MBA, RN, CHC Regional Compliance Officer, Sutter Health DISCLAIMER

More information

Medicare Recovery Audit Contractors. Chicago, IL August 1, 2008

Medicare Recovery Audit Contractors. Chicago, IL August 1, 2008 Medicare Recovery Audit Contractors Chicago, IL August 1, 2008 1 Recovery Audit Contractors Demo Summary National Rollout AHA Strategy AHA RACTrac Overview 2 Recovery Audit Contractors Medicare Modernization

More information

CURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS

CURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS 10 th Annual HCCA Compliance Institute Session Las Vegas, NV April 25, 2006 CURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS MARK HARDIMAN HOOPER, LUNDY & BOOKMAN, INC. 1875

More information

Diane Meyer, CHC (650) Agenda

Diane Meyer, CHC (650) Agenda The Road Ahead and How to Navigate It Kevin D. Lyles, Esq. kdlyles@jonesday.com (614) 281-3821 Diane Meyer, CHC DMeyer@stanfordmed.org (650) 724-2572 Frank E. Sheeder, Esq. fesheeder@jonesday.com (214)

More information

Regulatory Compliance Risks. September 2009

Regulatory Compliance Risks. September 2009 Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation

More information

6/25/2013. Knowledge and Education. Objectives ZPIC, RAC and MAC Audits. After attending this presentation, the attendees will be able to :

6/25/2013. Knowledge and Education. Objectives ZPIC, RAC and MAC Audits. After attending this presentation, the attendees will be able to : Objectives ZPIC, RAC and MAC Audits Approach After attending this presentation, the attendees will be able to : 1. Understand the different types of audits related to reimbursement: ZPIC, RAC, and MAC

More information

A Unique Approach to Auditing the Primary Care Exception

A Unique Approach to Auditing the Primary Care Exception A Unique Approach to Auditing the Primary Care Exception HCCA 2014 Compliance Institute San Diego March 31, 2014 Christine Anusbigian, MBA, CHC Specialist Leader, Health Sciences, Governance, Risk and

More information

A Unique Approach to Auditing the Primary Care Exception

A Unique Approach to Auditing the Primary Care Exception A Unique Approach to Auditing the Primary Care Exception HCCA 2014 Compliance Institute San Diego March 31, 2014 Christine Anusbigian, MBA, CHC Specialist Leader, Health Sciences, Governance, Risk and

More information

State Medicaid Recovery Audit Contractor (RAC) Program

State Medicaid Recovery Audit Contractor (RAC) Program State Medicaid Recovery Audit Contractor (RAC) Program Section 6411 of the Patient Protection and Affordable Care Act 2010 (ACA) requires by December 31, 2010 each state Medicaid program to contract with

More information

General Documentation Compliance. Review for Provider Reappointment

General Documentation Compliance. Review for Provider Reappointment U N C U H N E C A L H T E H A L C T A H R E C A S R Y E S T E M General Documentation Compliance Review for Provider Reappointment May 2018 Objectives 1 2 Review the principles of compliant billing and

More information

OIG Medicare Compliance Audits: Tactical Tips for Surviving One from the Battlefield

OIG Medicare Compliance Audits: Tactical Tips for Surviving One from the Battlefield OIG Medicare Compliance Audits: Tactical Tips for Surviving One from the Battlefield Catherine R. McCarthy, CPC-H Billing Compliance Director Brigham & Women's Faulkner Hospital, Brigham & Women s Hospital

More information

Hospice House Network Inpatient Conference

Hospice House Network Inpatient Conference Hospice House Network Inpatient t Conference Trends & Recent Developments in Hospice General Inpatient Care Policy and Enforcement June 7, 2013 1 www.morganlewis.com Presented by Howard J. Young, Esq.

More information

Recovery Audit Contractors: AHA Perspective. Elizabeth Baskett, Policy, AHA February 23, 2012

Recovery Audit Contractors: AHA Perspective. Elizabeth Baskett, Policy, AHA February 23, 2012 Recovery Audit Contractors: AHA Perspective Elizabeth Baskett, Policy, AHA February 23, 2012 Agenda Lay of the Land = Audit Overload RACs (Medicare & Medicaid) MACs ZPICs and OIG and DOJ, oh my! AHA and

More information

Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare

Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare In health care, we are blessed with an abundance of rules, policies, standards and laws. In Health

More information

General Inpatient Level of Care: Managing Risks

General Inpatient Level of Care: Managing Risks General Inpatient Level of Care: Managing Risks THE CAROLINAS CENTER, 2015 1 Presenter Annette Kiser, MSN, RN, NE-BC Director of Quality & Compliance The Carolinas Center akiser@cchospice.org THE CAROLINAS

More information

Combating Medicaid Fraud & Abuse NCSL New England Fiscal Leaders Meeting February 22, 2013

Combating Medicaid Fraud & Abuse NCSL New England Fiscal Leaders Meeting February 22, 2013 Combating Medicaid Fraud & Abuse NCSL New England Fiscal Leaders Meeting February 22, 2013 Kavita Choudhry State Health Care Spending Project Pew Charitable Trusts Pressure on state and local budgets Source:

More information

Pharmacy Compliance: Beyond Med Errors. Overview

Pharmacy Compliance: Beyond Med Errors. Overview Pharmacy Compliance: Beyond Med Errors Daniel P. Fitzgerald, Senior Attorney Litigation & Regulatory Law Department Walgreen Co. James S. Mathis, Esq., Nashville, TN Overview Med Errors & Controlled Substances

More information

CORPORATE COMPLIANCE POLICY AUDIT & CROSSWALK WHERE ADDRESSED

CORPORATE COMPLIANCE POLICY AUDIT & CROSSWALK WHERE ADDRESSED QUALITY OF CARE Sufficient Staffing Inadequate staffing levels or insufficiently trained (inadequate clinical expertise) or insufficiently supervised staff providing medical, nursing, and related services

More information

RECENT INVESTIGATION AND ENFORCEMENT TRENDS

RECENT INVESTIGATION AND ENFORCEMENT TRENDS RECENT INVESTIGATION AND ENFORCEMENT TRENDS Texas and New Mexico Hospice Organization Mark S. Armstrong Member of the Firm EPSTEIN, BECKER & GREEN, P.C. Houston, Texas 2014 Epstein Becker & Green, P.C.

More information

ENFORCEMENT, COMPLIANCE, & LONG TERM CARE: HOME HEALTH, HOSPICE, & NURSING HOMES

ENFORCEMENT, COMPLIANCE, & LONG TERM CARE: HOME HEALTH, HOSPICE, & NURSING HOMES ENFORCEMENT, COMPLIANCE, & LONG TERM CARE: HOME HEALTH, HOSPICE, & NURSING HOMES HEALTHCARE ENFORCEMENT COMPLIANCE INSTITUTE: OCTOBER 29, 2017 NICOLE MARTIN, DIRECTOR OF QUALITY & COMPLIANCE AT SAMARITAN

More information

Topics. Overview of the Medicare Recovery Audit Contractor (RAC) Understanding Medicaid Integrity Contractor

Topics. Overview of the Medicare Recovery Audit Contractor (RAC) Understanding Medicaid Integrity Contractor RACS, ZPICS & MICS John Falcetano, CHC-F, CCEP-F, CHPC, CHRC, CIA Chief Audit and Compliance Officer University Health Systems of Eastern Carolina jfalceta@uhseast.com Topics Overview of the Medicare Recovery

More information

Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care

Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc.,

More information

Assessment. SMP Foundations Training Kit. Table of Contents

Assessment. SMP Foundations Training Kit. Table of Contents SMP Foundations Training Kit Assessment Table of Contents Participant Assessment Questions and Answer Form Assessment Questions... 10 Pages Answer Form... 2 Pages Trainer s Resources Answer Key... 2 Pages

More information

Hospice Program Integrity Recommendations

Hospice Program Integrity Recommendations Hospice Program Integrity Recommendations Projected increases in the elderly population and the number of Medicare beneficiaries will likely result in continued growth in utilization of hospice services.

More information

Compliance Program Updated August 2017

Compliance Program Updated August 2017 Compliance Program Updated August 2017 Table of Contents Section I. Purpose of the Compliance Program... 3 Section II. Elements of an Effective Compliance Program... 4 A. Written Policies and Procedures...

More information

Automating documentation helps hospice agencies withstand greater scrutiny

Automating documentation helps hospice agencies withstand greater scrutiny White Paper Automating documentation helps hospice agencies withstand greater scrutiny Documenting care plan, procedures key to staying in regulatory compliance Abstract The importance of strong documentation

More information

FEDERAL AND NYS TARGETED RISK AREAS FOR HOME HEALTH AGENCIES AND COMPLIANCE STRATEGIES

FEDERAL AND NYS TARGETED RISK AREAS FOR HOME HEALTH AGENCIES AND COMPLIANCE STRATEGIES FEDERAL AND NYS TARGETED RISK AREAS FOR HOME HEALTH AGENCIES AND COMPLIANCE STRATEGIES HCA Corporate Compliance Symposium Albany, New York October 1, 2014 Connie A. Raffa, J.D., LL.M. Partner raffa.connie@arentfox.com

More information

Office of Inspector General (OIG) Medicare Compliance Reviews

Office of Inspector General (OIG) Medicare Compliance Reviews Office of Inspector General (OIG) Medicare Compliance Reviews HCCA 2014 Compliance Institute, 4:30-5:30 Facilitators Steve Gillis, Director, Compliance Coding Billing & Audit Partners HealthCare Boston,

More information

Office of Inspector General (OIG) Medicare Compliance Reviews

Office of Inspector General (OIG) Medicare Compliance Reviews Office of Inspector General (OIG) Medicare Compliance Reviews HCCA 2014 Compliance Institute, 4:30-5:30 Facilitators Steve Gillis, Director, Compliance Coding Billing & Audit Partners HealthCare Boston,

More information

QUALITY AND COMPLIANCE

QUALITY AND COMPLIANCE 2015 HCCA SOUTHEAST CONFERENCE JANUARY 23, 2015 QUALITY AND COMPLIANCE Katie Fink Donna Lewis Susan Walberg Presenters Katie Fink Senior Counsel Office of Counsel to the Inspector General U.S. Department

More information

Managed Care Fraud: Enforcement and Compliance HCCA Compliance Institute March 28, 2017

Managed Care Fraud: Enforcement and Compliance HCCA Compliance Institute March 28, 2017 Managed Care Fraud: Enforcement and Compliance HCCA Compliance Institute March 28, 2017 Pamela Coyle Brecht, Partner Pietragallo Gordon Alfano Bosick & Raspanti, LLP Risk Area: False Data and/or Certifications

More information

Medicare Regulations and Rules Update What Should You Know?

Medicare Regulations and Rules Update What Should You Know? Medicare Regulations and Rules Update What Should You Know? Presenters: Gary Massey, CPA & Emily Wetsel, CPA Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC, an

More information

CCT Exam Study Manual Update for 2018

CCT Exam Study Manual Update for 2018 CCT Exam Study Manual Update for 2018 This document reflects updates made to the instructional content from the CCT Exam Study Manual 2017 to the 2018 version of the manual. This does not include updates

More information

The Intersection of Health Care Fraud and Patient Safety

The Intersection of Health Care Fraud and Patient Safety The Intersection of Health Care Fraud and Patient Safety Anthony Baize, Inspector General January 16, 2018 Wisconsin Department of Health Services Office of the Inspector General Overview The Wisconsin

More information

Using SNF Data to Manage Federal & State Audit Initiatives

Using SNF Data to Manage Federal & State Audit Initiatives Using SNF Data to Manage Federal & State Audit Initiatives 2012 OIG & GAO Reports In 2009 OIG estimated that 47% of claims had misreported information on the MDS that caused significant errors in Billing

More information

Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011

Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011 Patient Protection and Affordable Care Act: Highlights of Program Integrity Provisions Managed Care Delivery System Subcommittee June 9, 2011 1 Provider Screening and Other Enrollment Requirements Provider

More information

Riding Herd on Fraud, Waste and Abuse

Riding Herd on Fraud, Waste and Abuse Riding Herd on Fraud, Waste and Abuse Dan McCullough Judi McCabe Juanita Henry Kim Hrehor 1 Taking Stock: Surveying the Landscape of Fraud, Waste and Abuse 2 How Big is the Problem? The simple truth is

More information

Florida Health Care Association 2013 Annual Conference

Florida Health Care Association 2013 Annual Conference Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #51 Navigating Health Care Reform: Creating a Road Map for Success Thursday, August 8 8:15 to 9:45 a.m. Regency

More information

Using PEPPER and CERT Reports to Reduce Improper Payment Vulnerability

Using PEPPER and CERT Reports to Reduce Improper Payment Vulnerability Using PEPPER and CERT Reports to Reduce Improper Payment Vulnerability Cheryl Ericson, MS, RN, CCDS, CDIP CDI Education Director, HCPro Objectives Increase awareness and understanding of CERT and PEPPER

More information

Agenda. OIG Medicare Compliance Reviews: A Compliance Officer s Guide to Survival. Introduction History and Purpose Facility Selection Evolution

Agenda. OIG Medicare Compliance Reviews: A Compliance Officer s Guide to Survival. Introduction History and Purpose Facility Selection Evolution OIG A Compliance Officer s Guide to Survival Shannon DeBra Bricker & Eckler LLP sdebra@bricker.com Linn Swanson UPMC swansonlm@upmc.edu Agenda Introduction History and Purpose Facility Selection Evolution

More information

340B Compliance. Overview

340B Compliance. Overview 340B Compliance LIFE AFTER A HRSA AUDIT AND IMPLEMENTING A CORRECTIVE ACTION PLAN HCCA Compliance Institute March 27, 2017 Presented by: Melissa Singleton Sarah Bowman, CHC Overview 340B Program Background

More information

Proposed Fraud & Abuse Rule Implementing ACA Provisions. Ivy Baer October 26, 2010

Proposed Fraud & Abuse Rule Implementing ACA Provisions. Ivy Baer October 26, 2010 Proposed Fraud & Abuse Rule Implementing ACA Provisions Ivy Baer ibaer@aamc.org 202-828-0499 October 26, 2010 Comments Due November 16, 2010 To submit: Refer to: CMS-6028-P http://www.regulations.gov 2

More information

Summary of U.S. Senate Finance Committee Health Reform Bill

Summary of U.S. Senate Finance Committee Health Reform Bill Summary of U.S. Senate Finance Committee Health Reform Bill September 2009 The following is a summary of the major hospital and health system provisions included in the Finance Committee bill, the America

More information

HOT TOPICS IN HEALTHCARE FRAUD. Presented by: Jeffrey W. Dickstein and Amy L. Easton Phillips and Cohen LLP

HOT TOPICS IN HEALTHCARE FRAUD. Presented by: Jeffrey W. Dickstein and Amy L. Easton Phillips and Cohen LLP HOT TOPICS IN HEALTHCARE FRAUD Presented by: Jeffrey W. Dickstein and Amy L. Easton Phillips and Cohen LLP Hot Topics in Healthcare Fraud- Agenda FCA 101- the Basics DOJ Recoveries and Statistics Cases

More information

Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1

Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1 Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor Agenda Session 1: History and basics of PEPPER IPF PEPPER target

More information

Compliance Update NMAC ~ May Angelique M. Culver, Esq., LLM, CHC Chief Compliance & HIPAA Officer Vibra Healthcare, LLC

Compliance Update NMAC ~ May Angelique M. Culver, Esq., LLM, CHC Chief Compliance & HIPAA Officer Vibra Healthcare, LLC Compliance Update NMAC ~ May 2017 Angelique M. Culver, Esq., LLM, CHC Chief Compliance & HIPAA Officer Vibra Healthcare, LLC Objectives Ø To be able to identify Vibra s Obligations under its Corporate

More information

HealthStream Regulatory Script. Corporate Compliance: A Proactive Stance. Version: [February 2007]

HealthStream Regulatory Script. Corporate Compliance: A Proactive Stance. Version: [February 2007] HealthStream Regulatory Script Corporate Compliance: A Proactive Stance Version: [February 2007] Lesson 1: Introduction Lesson 2: Importance of Compliance & Compliance Programs Lesson 3: Laws and Regulations

More information

The Intersection of Compliance and Quality Health Care Compliance Association North Central Regional Annual Conference

The Intersection of Compliance and Quality Health Care Compliance Association North Central Regional Annual Conference The Intersection of Compliance and Quality Health Care Compliance Association North Central Regional Annual Conference October 1, 2010 Mark J. Swearingen, Esq. Hall, Render, Killian, Heath & Lyman One

More information

Medicare Part A Update

Medicare Part A Update Medicare Part A Update Jennifer Bogenrief, JD Manager, Regulatory Affairs AOTA AOTA Specialty Conference: Effective Documentation Friday, September 12, 2014 1 Topics Medicare Therapy Documentation Requirements

More information

The Department of Justice s Focus on Failure of Care Fraud Cases

The Department of Justice s Focus on Failure of Care Fraud Cases The Department of Justice s Focus on Failure of Care Fraud Cases HCCA 17 TH ANNUAL COMPLIANCE INSTITUTE WASHINGTON, DC APRIL 21, 2013 SUSAN C. LYNCH, ESQ. U.S. DEPARTMENT OF JUSTICE SUSAN.LYNCH@USDOJ.GOV

More information

AAPC Webinar 3/28/2016

AAPC Webinar 3/28/2016 Short Stays for the Coder Where Are We Now? Heather Greene, MBA, RHIA, CPC, CPMA AHIMA Approved ICD-10 CM/PCS Trainer Copyright 2016 AAPC Agenda The Two-Midnight Rule Supportive documentation Observation

More information

10/2/2015. Agenda. Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician buy-in Summary

10/2/2015. Agenda. Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician buy-in Summary Medicare Compliance Updates and Best Practices for Providers Joe Crea, DO, MHA Vice President, Clinical and Regulatory Agenda Medicare Compliance DOJ OIG Contractors 2016 OPPS Best Practices Physician

More information

Day 2, Morning Plenary 1 CMS and OIG Joint Briefing: Importance and Progress of Improved Background Screenings for Long Term Care

Day 2, Morning Plenary 1 CMS and OIG Joint Briefing: Importance and Progress of Improved Background Screenings for Long Term Care Day 2, Morning Plenary 1 CMS and OIG Joint Briefing: Importance and Progress of Improved Background Screenings for Long Term Care Don Howard, CMS Ernie Baumann, CNA Tricia Fields, OIG Michala Walker, OIG

More information

Payment Policy: 30 Day Readmission Reference Number: CC.PP.501 Product Types: ALL

Payment Policy: 30 Day Readmission Reference Number: CC.PP.501 Product Types: ALL Payment Policy: 30 Day Readmission Reference Number: CC.PP.501 Product Types: ALL Effective Date: 01/01/2015 Last Review Date: 04/28/2018 Coding Implications Revision Log See Important Reminder at the

More information

2017 OIG Work Plan and Current Compliance Topics - Home Health and Hospice

2017 OIG Work Plan and Current Compliance Topics - Home Health and Hospice HCCA Web Conference November 20, 2015 2017 OIG Work Plan and Current Compliance Topics - Home Health and Hospice Bill Musick, BS, MBA, CHC, CHCP Senior Associate & Consulting Projects Manager Your trusted

More information

A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans. Optimizing revenue from a compliance perspective

A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans. Optimizing revenue from a compliance perspective A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans Keith Ponitz, M.D. October 16,2012 Agenda Background Optimizing revenue from a compliance perspective Mitigate

More information

Agenda. National Landscape. Background. Optimizing revenue from a compliance perspective. Mitigate the risk: Data mining and coding audits

Agenda. National Landscape. Background. Optimizing revenue from a compliance perspective. Mitigate the risk: Data mining and coding audits A Physician Led Comprehensive Coding Compliance Program: Datamining to Disciplinary Action Plans Keith Ponitz, M.D. October 16,2012 Agenda Background Optimizing revenue from a compliance perspective Mitigate

More information

Legal Update. Michael B. Glomb, Partner Marisa Guevara, Associate Elizabeth Issie Karan, Associate September 22, 2015

Legal Update. Michael B. Glomb, Partner Marisa Guevara, Associate Elizabeth Issie Karan, Associate September 22, 2015 Legal Update Michael B. Glomb, Partner Marisa Guevara, Associate Elizabeth Issie Karan, Associate September 22, 2015 LEGAL DISCLAIMER This presentation is educational in nature and does not constitute

More information

AN ANALYSIS OF TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY

AN ANALYSIS OF TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY AN ANALYSIS OF TITLE VI TRANSPARENCY AND PROGRAM INTEGRITY Summaries of Key Provisions in the Patient Protection and Affordable Care Act (HR 3590) as amended by the Health Care and Education Reconciliation

More information

9/25/2012 AGENDA. Set the Stage Monitoring versus Audit Identifying Risk Strategies related to an audit plan Corrective Action Plans Examples

9/25/2012 AGENDA. Set the Stage Monitoring versus Audit Identifying Risk Strategies related to an audit plan Corrective Action Plans Examples The Art and Science of Designing a Physician Practice Audit : Unique Techniques Lori Laubach, Partner MOSS ADAMS LLP 1 AGENDA Set the Stage Monitoring versus Audit Identifying Risk Strategies related to

More information

Using the New Home Health Agency (HHA) PEPPER to Support Auditing and Monitoring Efforts

Using the New Home Health Agency (HHA) PEPPER to Support Auditing and Monitoring Efforts Using the New Home Health Agency (HHA) PEPPER to Support Auditing and Monitoring Efforts July 30, 2015 Kimberly Hrehor 2 Agenda History and basics of PEPPER HHA PEPPER target areas Percents, rates and

More information

Medicare Fraud & Abuse: Prevention, Detection, and Reporting ICN

Medicare Fraud & Abuse: Prevention, Detection, and Reporting ICN Medicare Fraud & Abuse: Prevention, Detection, and Reporting ICN 908103 1 Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently

More information

Subtitle E New Options for States to Provide Long-Term Services and Supports

Subtitle E New Options for States to Provide Long-Term Services and Supports LONG TERM CARE (SECTION-BY-SECTION ANALYSIS) (Information compiled from the Democratic Policy Committee (DPC) Report on The Patient Protection and Affordable Care Act and the Health Care and Education

More information

COMPLIANCE GOTCHAS AND EMERGING RISKS

COMPLIANCE GOTCHAS AND EMERGING RISKS COMPLIANCE GOTCHAS AND EMERGING RISKS BROOKE BENNETT AZIERE & JUSTAN SHINKLE DIRECT SUPERVISION OF HOSPITAL OUTPATIENT THERAPEUTIC SERVICES Hospital outpatient therapeutic services generally require direct

More information

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 069 LONG TERM CARE ASSESSMENT

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 069 LONG TERM CARE ASSESSMENT 411-069-0000 Definitions DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 069 LONG TERM CARE ASSESSMENT Unless the context indicates otherwise,

More information

NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals

NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals NE Home Care Conference: Effective & Efficient Preparation for Medicare Audits & Appeals Cheryl Leslie, RN, MPH Director of Home Care & Hospice Services Pamela Meliso, JD, MPH Director of Consulting &

More information

3/12/2012. DRG Validation, cont. New Challenges and Target Areas RACs. Update on RACs [Recovery Audit Contractors] & Other External Auditors

3/12/2012. DRG Validation, cont. New Challenges and Target Areas RACs. Update on RACs [Recovery Audit Contractors] & Other External Auditors Update on RACs [Recovery Audit Contractors] & Other External Auditors Presented by: Mary Legerski, RN, Esq., CHC, CPC, MBA, MPA New Challenges and Target Areas RACs CGI Targets as of 3/7/12 Inpatient claims

More information

Recovery Audit Contractors (RACs) and Medicare. The Who, What, When, Where, How and Why?

Recovery Audit Contractors (RACs) and Medicare. The Who, What, When, Where, How and Why? Recovery Audit Contractors (RACs) and Medicare The Who, What, When, Where, How and Why? 1 Agenda What is a RAC? Will the RACs affect me? Why RACs? What does a RAC do? What are the providers options? What

More information

Medicare Fraud Strike Force Teams Turn Up The HEAT. By Craig A. Conway, J.D., LL.M.

Medicare Fraud Strike Force Teams Turn Up The HEAT. By Craig A. Conway, J.D., LL.M. Medicare Fraud Strike Force Teams Turn Up The HEAT By Craig A. Conway, J.D., LL.M. caconway@central.uh.edu Federal agents have been serving warrants, conducting raids, and making arrests across Houston,

More information

Alignment. Alignment Healthcare

Alignment. Alignment Healthcare Alignment CODE OF CONDUCT Alignment Healthcare Our commitment to ethical conduct and compliance depends on all Alignment Healthcare personnel. If you find yourself in an ethical dilemma or suspect inappropriate

More information

AVOIDING HEALTHCARE FRAUD AND ABUSE; Responsibility, Protection, Prevention

AVOIDING HEALTHCARE FRAUD AND ABUSE; Responsibility, Protection, Prevention AVOIDING HEALTHCARE FRAUD AND ABUSE; Responsibility, Protection, Prevention Presented by: www.thehealthlawfirm.com Copyright 2017. George F. Indest III. All rights reserved. George F. Indest III, J.D.,

More information

Auditing and Monitoring in Smallville, U.S.A.

Auditing and Monitoring in Smallville, U.S.A. Auditing and Monitoring in Smallville, U.S.A. Able to Leap Short Buildings in a Single Bound... Or Maybe Two! Kirk Ruddell, CHC HCCA Compliance Institute April 23-26, 2006 Las Vegas, Nevada Background

More information

COMPLIANCE ROUND-UP. December 13, Aegis Compliance & Ethics Center, LLP 1

COMPLIANCE ROUND-UP. December 13, Aegis Compliance & Ethics Center, LLP 1 COMPLIANCE ROUND-UP December 13, 2011 2011 Aegis Compliance & Ethics Center, LLP 1 Today s Faculty Brian Annulis, JD, CHC Partner, Meade & Roach, LLP 773.907.8343 bannulis@meaderoach.com Ryan Meade, JD,

More information

Compliance. TODAY June High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey.

Compliance. TODAY June High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey. Compliance TODAY June 2013 a publication of the health care compliance association www.hcca-info.org High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey

More information

Cloning and Other Compliance Risks in Electronic Medical Records

Cloning and Other Compliance Risks in Electronic Medical Records Cloning and Other Compliance Risks in Electronic Medical Records Lori Laubach, Partner, Moss Adams LLP Catherine Wakefield, Vice President, Corporate Compliance and Internal Audit, MultiCare 1 AGENDA Basic

More information

Recover Health Training. Corporate Compliance Plan Code of Conduct Fraud & Abuse

Recover Health Training. Corporate Compliance Plan Code of Conduct Fraud & Abuse Recover Health Training Corporate Compliance Plan Code of Conduct Fraud & Abuse 1 The Course Objectives When you complete this course you will be able to: Understand Recover Health s reasons for implementing

More information

A 12-Step Program to Better Compliance: A Practical Approach

A 12-Step Program to Better Compliance: A Practical Approach A 12-Step Program to Better Compliance: A Practical Approach Kim Harvey Looney Anna M. Grizzle 615.850.8722 615.742.7732 kim.looney@wallerlaw.com agrizzle@bassberry.com 11389849 Strict Government Compliance

More information

Coding, Corroboration, and Compliance How to assure the 3 C s are met

Coding, Corroboration, and Compliance How to assure the 3 C s are met Coding, Corroboration, and Compliance How to assure the 3 C s are met Sue Roehl, RHIT, CCS sroehl@eidebailly.com 701-476-8770 OIG 1996 - $23.2 Billion errors Figure 1 Insufficient/No documentation 46.76%

More information

SNF Compliance: What s at Stake?

SNF Compliance: What s at Stake? SNF Compliance: What s at Stake? HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Elisa Bovee, MS OTR/L Vice President of Operations About Elisa Elisa

More information

Federal Update Healthcare Fraud, Waste, and Abuse

Federal Update Healthcare Fraud, Waste, and Abuse Federal Update Healthcare Fraud, Waste, and Abuse Steven Ryan Special Agent In Charge Lori Ahlstrand Regional Inspector General June 2017 1 Overview Understanding the role of the HHS OIG Recent cases and

More information

2017 National Training Program

2017 National Training Program 2017 National Training Program Module 10 Medicare and Medicaid Fraud, Waste, and Abuse Prevention Contents Lesson 1 Fraud, Waste, and Abuse Overview... Lesson 2 CMS Fraud and Abuse Strategies... Lesson

More information

CMS -1599F. The 2 Midnight Rule Effective October 1, 2013

CMS -1599F. The 2 Midnight Rule Effective October 1, 2013 Joseph Nitti, M.D. Medical Director/Physician Advisor Continuum of Care Dept. Morristown Medical Center 973-971-4004 CMS -1599F The 2 Midnight Rule Effective October 1, 2013 Determination of Inpatient

More information

340B Drug Program Summary

340B Drug Program Summary Summary Congress created section 340B of the Public Health Service Act in 1992 to allow eligible health care providers known as Covered Entities to stretch scarce Federal resources, reaching more patients

More information

CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule

CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule John Zelem, MD, FACS Executive Medical Director Audit, Compliance and Education (ACE) AHA Solutions, Inc., a subsidiary

More information

Certified Ophthalmic Executive (COE) Review Day

Certified Ophthalmic Executive (COE) Review Day Certified Ophthalmic Executive (COE) Review Day Compliance Plan & Chart Audits Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Presented

More information

Fraud, Abuse, & Waste, Oh My! Developing an Effective Compliance Program

Fraud, Abuse, & Waste, Oh My! Developing an Effective Compliance Program Fraud, Abuse, & Waste, Oh My! Developing an Effective Compliance Program Program speaker The speaker for this program is Arlene Luu, RN, BSN, JD, CPHRM, Senior Patient Safety & Risk Consultant, MedPro

More information

Office of Inspector General. Semiannual. Report Congress. April 1, 2012 September 30, 2012

Office of Inspector General. Semiannual. Report Congress. April 1, 2012 September 30, 2012 Office of Inspector General Semiannual Report Congress To April 1, 2012 September 30, 2012 OIG Organization The Department of Health and Human Services (HHS) Office of Inspector General (OIG) employs about

More information

Medicare Supplement Plans

Medicare Supplement Plans KPShealth plans P R O V I D E R N E T W O R K If you have questions about any of our Medicare Supplement plans or about the application process, please feel free to contact us at 360-478-6786, or toll

More information

Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1

Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1 Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor Agenda Session 1: History and basics of PEPPER PEPPER target areas Percents and percentiles Comparison

More information

DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF INSPECTOR GENERAL

DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF INSPECTOR GENERAL DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF INSPECTOR GENERAL Washington, D.C. 20201 The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services has created the educational

More information

MDCH Office of Health Services Inspector General

MDCH Office of Health Services Inspector General MDCH Office of Health Services Inspector General Recovery Audit Contract (RAC) Provider Outreach & Education Spring 2014 Background Recovery Audit Contractor Medicare Modernization Act of 2003 created

More information

Testimony Before the United States Senate Committee on Homeland Security and Governmental Affairs

Testimony Before the United States Senate Committee on Homeland Security and Governmental Affairs Testimony Before the United States Senate Committee on Homeland Security and Governmental Affairs Medicaid Fraud and Overpayments: Problems and Solutions Testimony of: Brian P. Ritchie Assistant Inspector

More information

The OIG. What is the OIG

The OIG. What is the OIG The OIG By Charles Hackney Assistant Special Agent in Charge What is the OIG Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs

More information

University of California Health Science Compliance Program Executive Summary*

University of California Health Science Compliance Program Executive Summary* 1. Introduction The UC Academic Medical Centers (AMC) continued to encounter a complex regulatory environment. The Office of Inspector General (OIG) of the Department of Health and Human Services (DHHS)

More information