Managing Towards Compliance Presented by Bruce Rappoport, MD, CPC, CPCO AAPC National Conference April 14, 2014 Disclaimer This presentation is designed to provide educational information in regard to the subject matter covered. The information is based on the experience, training and interpretation of materials from various sources. Every reasonable effort has been made to assure the accuracy of the information in this presentation but the presenter and Broward Health make no warranty or representation as to its accuracy. The presenter and Broward Health are not responsible or liable, directly or indirectly, for any form of damages whatsoever resulting from the use (or misuse) of information contained in or implied by this presentation. The information provided should not be considered as a legal opinion or consulting advice and should not be relied upon as such. 1
Overview Employee Relations Medical Record Integrity Office Policies and Procedures Coding, Billing and Compliant Collections Communicating with Payers Risk Management Basics Documentation Communication 2
Employee Relations Human Resource Manual Job Description Disciplinary action steps Benefits 3
Hiring Office Personnel Licensure (if applicable) Education Employment history References Pre-employment testing Check OIG exclusion list Hiring a New Doctor Education (including medical school, internship, residency and fellowship) Licensure and DEA Board eligibility or certification/recertification Work history Present hospital affiliations References Check OIG exclusion list Medicare opt-out list 4
Allied Health Providers Delineation of privileges Written job description Written guidelines What can be done independently Can they write prescriptions Availability of supervising physician Monitor and evaluate performance Performance Evaluations Tied to job duties and responsibilities Incorporate mission, vision and values Incorporate code of conduct Goals and objectives Documentation and signatures 5
Medical Record Integrity Reliance on the Medical Record Historical document Medical necessity Claim adjudication Quality of care review Compliance HIPAA 6
Medical Records Documentation should be done at time of patient encounter Medical information should not be left in accessible areas When information is provided from the medical record it should be documented Medical Record as a Historical Document Accurate reflection of events for each encounter Documentation for diagnostic, therapeutic and consultant reports Medical decision analysis and differential diagnoses considered Complete and legible 7
Risk Management Mantra If it is not documented you can not prove it occurred If it is not clearly documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Medical Record Under Scrutiny Do not alter Do not destroy Keep complete medical record secure Do not release original documents Use electronic templates wisely 8
Documentation Key Points Part 1 Medicare expects documentation to be generated at time of service or shortly thereafter Delayed entries within a reasonable time frame (24-48 hrs) are acceptable for purposes of clarification, error correction, addition of information not initially available, and if certain unusual circumstances prevented generation of the note at time of service The medical record cannot be altered Errors must be legibly corrected so that reviewer can draw an inference as to their origin Corrections or additions must be dated, preferably timed, and legibly signed or initialed First Coast Service Options: Medicare Part B Update; Vol. 4, No. 3 Third Quarter 2006 Documentation Key Points Part 2 Every note must stand alone, i.e., performed services must be documented at outset Delayed written explanations will be considered They serve for clarification only and cannot be used to add and authenticate services billed and not documented at time of service or to retrospectively substantiate medical necessity For that, the medical record must stand on its own with the original entry corroborating that service was rendered and was medically necessary All entries must be legible to another reader to a degree that meaningful review may be conducted All notes should be dated, preferably timed, and signed by the author First Coast Service Options: Medicare Part B Update; Vol. 4, No. 3 Third Quarter 2006 9
Cloning Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. First Coast Service Options: Medicare Part B Update; Vol. 4, No. 3 Third Quarter 2006 Loose Lips Sink Ships Telephone policies Document telephone calls Who can disclose clinical information 10
Storage and Retention of Medical Records Maintenance Storage Transport Retrieval Destruction Computers Screen viewing Password Backup Disaster recovery Virus Protection Program documentation manuals Hacking 11
Disaster Recovery Policies about backups recovery of lost data Policy about restoring systems and data Policies about periodic testing of backups Office Policies and Procedures 12
Patient Scheduling Avoid overbooking Policy for walk-ins Emergent visits Document missed appointments and cancellations Document attempts to reschedule Inform patients when delays occur Providing Patient Instructions Information provided should be documented in the medical record If written material provided a copy should be maintained in a file and referenced in the medical record 13
Follow Up on Test Results Method to assure all test results and consults received Provider review and documentation of all results, consults and correspondence Informing patients Document need for follow up tests and/or appointments Prescriptions Document patient allergies List all current medications Rx sample controls Rx renewal policy Safeguard Rx blanks 14
On Call Coverage Staff should know who, what, when and where Method to access medical records and information Third party payer requirements Signing out to on call Pharmacy refill policy Unhappy Patients Listen Acknowledge what was said Avoid being defensive Explain what you can and can not do DO NOT MAKE PROMISES 15
Coding, Billing & Collections Medical Necessity Still Rules Medical necessity MUST support level of service Documentation MUST support medical necessity 16
Medical Necessity Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code It would not be medically necessary or appropriate to bill a higher level evaluation and management service when a lower level of service is warranted The volume of documentation should not be the primary influence upon which a specific level of service is billed Documentation should support the level of service reported MCPM 100-4 Chap 12-30.6.1 Auditing Practice s own compliance program Payer reviews and audits Comprehensive Error Rate Testing (CERT) Recovery Audit Contractors (RACs) Zone Program Integrity Contractors (ZPICs) Medicaid Integrity Contractors (MICs) 17
Coding Compliance Provide or seek training Avoid over and under coding Code only what was documented Avoid changing codes just to get the claim paid Modifiers can get claims paid But were they used correctly? Just because it s paid, does not make it right Billing and Collection Inform patients of billing policies and processes Do not refuse to treat if account is not current Maintain financial information separate from medical record Financial matters should be private 18
Fair Debt Collections Act Consult the Fair Debt Collections Practices Act Call between 8am and 9pm Do not use or threaten violence or other criminal means to harm the individual, reputation or property of any person Do not threaten to take any action that cannot be taken Collection Compliance Obtain correct patient demographics and verify insurance Create payer binder Develop and maintain proper management reporting Identify and capture lost revenue Maintain and regularly update fee schedules 19
Communicating with Payers Insurance Company Contracts Do you know where your contracts are? Keep a copy of contract Keep all correspondence with contract Monitor contract performance If you don t understand it, don t sign it If you sign it, you will have to comply 20
Communicating with Payers There is no one complete set of guidelines that are applicable for all payers When in doubt, it is best to ask When possible speak with the medical director Get it in writing Thank You For Further Information Bruce Rappoport, MD, CPC, CPCO Brappoport@browardhealth.org 21