Disclamer Let Ethics Drive Compliace AAPC North Florida Cetral Chapter Gaiesville October 22 d, 2016 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS AHIMA-Approved ICD-10-CM/PCS Traier ekuz@bellsouth.et This material is desiged to offer basic iformatio for codig ad billig ad is preseted based o the experiece, traiig ad iterpretatio of the author. Although the iformatio has bee carefully researched ad checked for accuracy ad completeess, the preseter does ot accept ay resposibility or liability with regards to errors, omissios, misuse, or misiterpretatio. This presetatio ad hadout is iteded as a educatio guide oly. 2 1. Legal Issues Coders Need to Kow ad Comply With 2. Ethical Issues i Codig ad Billig Outlie 1: Legal Issues Coders Need to Kow ad Comply With 3. Examples of Uethical Practices 4. Practical ad Professioal Ways to Hadle Ethical Dilemmas HIPAA & HITECH False Claims Act (FCA) Ati-Kickback Statute (AKS) Stark Law 3 4 OIG Strategic Pla 2014-2018 OIG HEAT Deliberate Igorace U.S. Departmet of Health ad Huma Services Office of Ispector Geeral (OIG): Four Goals 1. Fight Fraud, Waste, ad Abuse 2. Promote Quality, Safety, ad Value 3. Secure the Future 4. Advace Excellece ad Iovatio https://oig.hhs.gov/reports-ad-publicatios/strategic-pla/files/oig-strategic-pla-2014-2018.pdf 5 Kow or should have kow Source: Health Care Fraud Prevetio ad Eforcemet Actio Team (HEAT) http://oig.hhs.gov/heat/ 6 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 1
CMS Medicare: Fraud makig false statemets or represetatios of material facts to obtai some beefit or paymet for which o etitlemet would otherwise exist Kowigly billig for services that were ot furished ad/or supplies ot provided, icludig billig Medicare for appoitmets that the patiet failed to keep; ad Kowigly alterig claims forms ad/or receipts to receive a higher paymet amout. Both fraud ad abuse ca expose providers to crimial ad civil liability Source: CMS Medicare Fraud & Abuse: Prevetio, Detectio, ad Reportig 7 CMS Medicare: Abuse practices that, either directly or idirectly, result i uecessary costs to the Medicare Program Misusig codes o a claim, Chargig excessively for services or supplies, ad Billig for services that were ot medically ecessary. Laws to address Fraud & Abuse False Claims Act, Ati-Kickback Statute, Physicia Self Referral Law (Stark), Social Security Act, ad U.S. Crimial Code Source: CMS Medicare Fraud & Abuse: Prevetio, Detectio, ad Reportig 8 HIPAA & HITECH Health Isurace Portability ad Accoutability Act (HIPAA) govers the trasmissio of medical records cotaiig medical iformatio Regulates the disclosure of patiet protected health iformatio (PHI) The Health Iformatio Techology for Ecoomic ad Cliical Health Act (HITECH) of 2009 icreased regulatios ad requiremets fro prevetig ad reportig PHI breaches False Claims Act (FCA) Eacted durig the America Civil War, also kow as the Licol Act Fies ragig from $5,500 to $11,000 ad treble damages for kowigly presetig a false or fraudulet claim to the govermet Revised over the years to stregthe the pealties Modified i 2009: 60 days to repay a overpaymet (kow or should have kow) 9 10 Stark Law & Ati-Kickback Statute (AKS) AKS prohibits offerig, payig, solicitig, or receivig aythig of value to iduce or reward referrals or geerate federal healthcare busiess Stark Law (Physicia Self Referral Law) prohibits a physicia from referrig Medicare patiets for desigated health services (DHS) to a etity with which the physicia (or immediate family member) has a fiacial relatioship Strict liability law What Ca Happe? Restitutio heavy fies Pealties are predetermied Probatio Corporate Itegrity Agreemets (CIA) 11 12 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 2
DOJ FCA Settlemets DOJ 2/11/13: Dr. Wasserma, Dermatologist, Veice, FL: agreed to pay $26.1M to resolve allegatios that he violated the False Claims Act (FCA) by: Acceptig kickbacks from a pathology laboratory & Billig the Medicare program for medically uecessary services DOJ Nov 12: Dr. J.Natale, Vascular Surgeo, Arligto, IL: servig 10 moth priso setece for usig CPT codes that allegedly represeted more complicated procedures tha the surgeries he performed Setecig Judge: accurate codig is of extraordiary importace. 2: Ethical Issues i Codig ad Billig What to Do About Them Codig Complexity & Frequet Chages Physicia s Cocers Coder s Resposibility (Source: Departmet of Justice Website) 13 14 Codig Complexity Codig Chage & Ambiguity Icreased difficulty Correct Codig has become a idustry Require experiece ad traiig AAPC- CPC AHIMA- CCS-P CMS Web based Billig Program Cosultats advice- be cautious! Rapid Chages & Aual Updates CPT Jauary 1 ICD-10-CM- October 1 Coflictig policies Private Payers, CMS, Medicaid E/M Documetatio Guidelies Codig versus Billig 15 16 Icorrect Codig/Billig Proper Actio Physicias & Coders Ethical resposibility to code services correctly Ethical duty to take actio whe become aware of uethical or iappropriate codig or billig Compliace Program Offers guidelies Report ad retur overpaymet 60 days from idetificatio Sometimes ot aware of their resposibility Physicia s Cocers Frequet chages i codig practice ad policy Complexity & ambiguity Icreased cocer that uitetioal mistakes i codig could lead to prosecutio for Medicare fraud 17 18 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 3
Physicia s Resposibility Physicias are required to comply with all the applicable statutes, regulatios ad guidelies i order to be reimbursed by Medicare Part B. They have a duty to be kowledgeable i the statutes, regulatios ad guidelies regardig coverage for Medicare services. Physicias certify that they are kowledgeable of Medicare s requiremets i the provider erollmet form they submit ad each time they submit CMS 1500 claim form, or have such form submitted o their behalf. Source: Physicia Certificatio o CMS 1500 Claim Form 19 Icreased Idividual Accoutability Govermet is icreasig efforts to hold idividuals accoutable i order to chage behavior OIG has authority to exclude owers ad maagig employees from federal programs Executives ca be implicated by the Resposible Corporate Officer Doctrie (RCOD) Yates Memo (2015) 20 Held to a higher stadard Certificatios Code of Ethics (AAPC & AHIMA) Coder s Resposibility Accurate codig is ot oly a ethical resposibility but also ecessary to comply with federal laws Commitmet to ethical professioal coduct expected Refuse to participate i or coceal uethical practices Frot ed defese & offese Possible ethical dilemma Follow Chai of Commad Iteral Compliace Program 21 Crimial ad Civil Liability Examples DOJ 8/30/13: Former office maager for defuct Health Care Solutios Network Ic. (HCSN) i Miami seteced to 68 moths i priso for her role i fraud scheme that resulted i more tha $63M i fraudulet claims U.S.D.C., NY, 2003, Govermet idicted both the physicia, Dr. Sigh ad his coder, Toi Coos for improperly upcodig claims ad improperly billig icidet to claims FBI TX 2012: Former biller RGV DME- more tha 11 years i Federal priso for role i $11M health care fraud scheme Providers ame o the claim, but everyoe who took part i the claim may be liable 22 3: Examples of Uethical Practices Up-codig & Ubudlig Medical Necessity Iappropriate Use of Modifiers Professioal Courtesy Up-codig Replacig the most appropriate code for service/procedure with a code for a more complex service. Uethical if doe itetioally to provide higher reimbursemet Provider says it s level 4 You disagree should you speak up? Show me how to documet all my visits as level 4 23 24 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 4
U.S.Warig to Hospitals o Medicare Bill Abuses Differet Codig Patter Amog Physicias i Same Practice EHR/CAC geerates higher E/M codig levels NY Times 9/25/12: There are troublig idicatios that some providers are usig this techology to game the system, possibly to obtai paymets to which they are ot etitled. False documetatio of care is ot just bad patiet care; it s illegal. http://www.ytimes.com/2012/09/25/busiess/us-warshospitals-o-medicare-billig.html?_r=0 Letter from Obama Admiistratio o Hospital Billig America Hospital Associatio (AHA) Respose to Obama Admiistratio 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% -20.00% The coflictig distributio of established office visits betwee the two physicias poits to disparate codig methods ad appears to be a aomaly. This type of coflict is ofte see by carriers as a opportuity to coduct a review of the practice* 99211 99212 99213 99214 99215 ` Practice Natioal 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% -20.00% 99211 99212 99213 99214 99215 ` Practice Natioal 25 *Oe physicia ca get the whole practice audited. 26 Presumptive Codig Oly usig oe level of a E/M service i a category, will icreases the risk for audit The physicia is usig CPT 99214 385% more ofte tha his atioal compare group, sigificatly icreasig his risk for third-party audits. 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% -20.00% 99211 99212 99213 99214 99215 Practice Natioal *Oe physicia ca get the whole practice audited. ` 27 Ubudlig Billig for multiple procedure codes for a group of procedures that are covered by a sigle comprehesive code 2012 ew CPT code 22633, prior to this service was reported with two procedure codes, 22630 ad 22612 Uitetioal misuderstadig of codig Itetioal- icrease reimbursemet Ambiguity ca lead to disagreemet Cosider seekig advice 28 Global Days & Paymet Modifier Compliace Risk- Are You a Outlier? CPT 22612 Lumbar Fusio (Arthrodesis, posterior or posterolateral techique, sigle level; lumbar) 090 or 90 days $1,659.50 Total Medicare Paymet 50 40 Modifier -25 Usage October 2012: Georgia Cacer Specialist $4.1M settlemet for misuse of modifier -25 30 20 10 If the surgeo provided oly the surgical portio of the procedure, the reimbursemet would be based o 69% of the approved fee schedule amout, $1,145.06. 0 Dr. Adams Dr. Joes Dr. Smith Dr. Thomas 29 30 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 5
Medical Uecessary Service: Iappropriate Admissio Implatable cardioverter defibrillator: Ipatiet stay (HIPPS) DRG 226 approximate paymet $33,000. Outpatiet stay (HOPPS) APC 0108 approximately $25,000 Oce deied, the hospital would oly be allowed to rebill for certai acillary services uder Part B. Physicia reports same CPT codes (MPFS) 31 Professioal Courtesy Discout exteded to physicias (or their immediate family members or office staff) If discout offered ad physicia is covered uder private isurace the pla must be otified (caot accept isurace paymets ad waive co-pays) May violate the federal ati-kickback statute if oe purpose of the discout is to iduce referrals of healthcare busiess paid by a Federal Healthcare Program May violate state law if it ca be costrued as a bribe, kickback or illegal solicitatio Best practice: Create a policy ad have legal review 32 4: Practical ad Professioal Ways to Hadle Ethical Dilemmas Values & Commo Sese Effective Compliace Program Best Practice Values & Commo Sese Cofusig rules & regulatios How will you kow if you are doig the right thig? Ca you defed your decisio? Values as your guide (yard stick/commo sese)? Legal? Fair? Does it feel right? 33 34 Compliace Program: 7 Compoets Coder s Resposibility If Fraud is Suspected 1. Coduct iteral moitorig ad auditig 2. Implemet compliace ad practice stadards 3. Desigate a compliace officer or cotact 4. Coduct appropriate traiig ad educatio 5. Respod appropriately to detected offeses ad develop corrective actio 6. Develop ope lies of commuicatio with employees 7. Eforce discipliary stadards through wellpublicized guidelies 35 Review documetatio & research guidelies Gather facts ahead of time to support correct codig Make sure you are ot mistake Collect iformatio from more tha oe sources Do t take someoe s word for it Follow Chai of Commad Iteral Compliace Program Possible Ethical Dilemma Refer to AAPC/AHIMA code of ethics Be true to your values You may have to fid aother job Govermet audits reiforce the importace of accurate codig 36 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 6
Best Practice Summary Compliace Program vs Ethical Culture Examples set by leadership Not just laguage i Code of Ethics Give employees examples of what is right ad wrog withi idustry Cosistet reprimad if those lies are crossed 37 Review your billig practices & aalyze data; Use audits to assess the documetatio for every physicia i your practice; Documet ay issues idetified ad the traiig provided; Liste to the cocers of all employees; Have a coflict of iterest protocol & o retaliatio policies; Eforce accoutability for everyoe; ad Retur idetified overpaymets withi 60 days! 38 Resources AAPC : Healthcare Busiess Mothly OIG Compliace Guidace for Small Physicia Practices OIG New Physicia Road Map http://oig.hhs.gov/compliace/physicia-educatio/idex.asp AHIMA Code of Ethics AAPC Code of Ethics February & April 2014: Prepare for Icreased Audit Scrutiy CMS Provider Updates: Lik to sig up: CMS Medicare FFS Provider e-news http://www.leagle.com/decisio/2004558390f3d168_1548 39 40 Questios? Thak you! Eli Baklid-Kuz ekuz@bellsouth.et https://www.likedi.com/i/elibaklidkuz 41 Eli Baklid-Kuz, MBA, CHC, CPC, CPMA, CCS 7