Compliance Guidance for Physicians: Keeping Your Practice Safe AAPC 2013 Regional Conference Presented by Jean Acevedo, LHRM, CPC, CHC, CENTC All rights reserved Agenda The 7 Elements The new climate Effectiveness CMS demonstration Grading your compliance program Internal auditing and monitoring Reporting Education 2 The OIG s Seven Elements 1. Conducting internal monitoring and auditing through the performance of periodic audits 2. Implementing compliance and practice standards through the development of written standards and procedures. 3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards. 4. Conducting appropriate training and education on practice standards and procedures. 5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities. 6. Developing open lines of communication to keep practice employees updated regarding compliance activities. Non-retaliation policy. 7. Enforcing disciplinary standards through well-publicized guidelines. 3 1
Identified Risk Areas for Physicians Proper coding and billing Ensuring that services are reasonable and necessary Proper documentation Medical record CMS-1500 Avoiding improper inducements, kickbacks and selfreferrals 4 Coding and Billing Upcoding, unbundling and improper use of modifiers Misuse of provider s identification numbers 5 Q6 (locum tenens) is not to be used to bill for services while you are waiting for Medicare to process the new doctor s enrollment application. Billing for: Items/services not provided Equipment, supplies and services not medically necessary Non-covered services as covered CBC, CMP, EKG as part of an annual physical MAC s LCD does not cover 76942; billed 76881 instead Reasonable and Necessary Services Local coverage determinations Advanced beneficiary notice Certificate of medical necessity 6 2
Medical Record Documentation If it is not written - it did not occur Document medical necessity Complete, legible and signed! Do you use scribes? How is that fact documented? If on an EMR Copy & paste Cloning 7 CMS 1500 Documentation Match diagnosis to documentation in medical record Match diagnosis with procedure code Identify secondary insurance coverage 8 Inducements, Kickbacks and Self-Referrals Knowledge of or willfully providing or receiving anything of value that can alter medical decision making resulting in increased referrals or utilization of services is not permitted 9 3
Inducements, Kickbacks and Self-Referrals Claim induced by a kickback is a false claim How does your State define an inducement, kickback or self-referral? Stark and self-referrals Florida s Patient Self Referral Act of 1992 FS 456.053 What does your state say? 10 The New Climate All rights reserved The New Climate: Whistleblowers Support and encouragement of whistleblower cases by leading prosecutors Whistleblower web sites Whistleblower support organizations How-to books, checklists, advice 12 4
The New Climate: Whistleblowers As of the end of 2012, there were more than 1200 federal qui tam cases under investigation, with no decision as to whether the DOJ will intervene Of these cases, over 800 involve healthcare fraud, many against multiple defendants. 13 The New Climate: Whistleblowers 1/4/2013: $4.4M settlement EMH Regional Medical Center, Ohio Unnecessary angioplasty and stent procedures Former catheterization lab manager accused hospital of doing procedures on patients with insufficient blockage. Received $661,000 award 14 The New Climate: ACA Mandatory reporting, repayment, and explanation of overpayments by persons Knowing retention of overpayment beyond 60 days is a false claim With all its fines, penalties and whistleblower provisions Mandatory Compliance Plans First, nursing homes, later other providers Mandatory reporting of overpayments Mandatory review and follow-up State requirements NY Medicaid 15 5
The New Climate: Enforcement All rights reserved Recent Cases 2013 Salesman Admits Role In Bribes-For-Test-Referrals Scheme Involving New Jersey Clinical Laboratory Planned Parenthood Pays $4.3 Million To Settle Allegations Of Unnecessary Medical Care, TX Long Island Physician to Pay U.S. $388,000 to Settle False Claims Act Allegations Related to Overbilling Medicare, NY Seven Oncologists Charged With Importing Unapproved Drugs, Ohio Johnson City Physician Sentenced To Serve Two Years In Prison For Unapproved Foreign Drugs, TN Doctor Convicted in Kickback Scheme Involving a Philadelphia Hospice, PA Medical Clinic Director, CEO Plead Guilty To Health Care Fraud, False Tax Return, Kansas All rights reserved Medical Clinic Director, CEO Plead Guilty To Health Care Fraud By pleading guilty, the Rysers admitted that they engaged in fraudulent billing by upcoding and falsifying claims submitted to insurers (including Blue Cross Blue Shield, Cigna, United Healthcare and others, as well as government programs such as Medicare and Tricare) in an effort to be paid more than the amount to which HCA was entitled. The Ryser s scheme included: (a) billing for physician office visits when Carol Ryser was out of town; (b) billing for physician office visits when Carole Ryser had little or no involvement with the patient; (c) billing for physician office visits when the patient contact was by telephone call; (d) billing for physician supervised services when no physician was on duty at the clinic; and (e) improperly billing for consultation services. The federal indictment describes six variations of billing fraud and includes tables of claims demonstrating each type of billing fraud. For those claims specifically included in the indictment, the total amount 18 billed on those claims was $359,168. The total amount that was actually paid on those claims by health care benefit programs was 6
Medical Clinic Director, CEO Plead Guilty To Health Care Fraud Carol Ann Ryser, 76, and Michael Earl Ryser, 68, both of Mission Hills, Kan., pleaded guilty before U.S. District Judge Greg Kays to the charges contained in a June 26, 2012 federal indictment. Carol Ryser owned Health Centers of America-Kansas City, LLC (HCA), a medical clinic in Kansas City, Mo.. HCA purported to specialize in the diagnosis and treatment of chronic diseases such as Lyme disease, chronic fatigue syndrome, fibromyalgia, and other auto immune diseases. Carol Ryser, who was a medical doctor and the clinic s medical director, surrendered her medical license today as a condition of her plea agreement. Carol Ryser may never again seek licensing to practice medicine in the United States and she may never be involved as an owner or employee (or in any other capacity) with any medical clinic, hospital or other health care provider. Michael Ryser was the CEO, chief administrator and vice-president. 19 Medical Clinic Director, CEO Plead Guilty To Health Care Fraud Under the terms of the 3/22/2013 plea agreements, Michael Ryser will be sentenced within a range of 24 to 30 months in federal prison without parole. Carol Ryser will receive a sentence of three years of probation, including six months of home detention. The Rysers must pay $51,789 in restitution to the health care benefit programs that were defrauded. 20 Measuring Effectiveness 21 7
CMS Compliance Effectiveness Pilot 3 year pilot Ended early 2007 16 hospitals in the NE participated 84 hospitals applied #1 Element: Communication Communication across the organization re: auditing results and training Communication makes a difference. Kimberly Brandt, Director, Medicare Program Integrity, HCCA Compliance Institute, April 2007 The more these 3 elements interfaced, the more there was an increase in the accuracy of claims 1. Communication 2. Auditing 3. Education Outcomes of Raw Claims Data When the contractor initiated action it was already too late Much less resources/$$ when the provider found an issue & acted Based on audit results Based on the OIG work plan Etc. 8
Outcomes of Raw Data CMS would like contractors to provide semi-annual data to providers very similar to what the pilot participants received CBRs in 2013 Little changes in the compliance program made big differences. Bottom line for the hospitals: Denied and rejected claims decreased Outcome: Education Problem with documentation? Web-based training does not work 1-on-1 training does work Can decrease claims denial rate Coding/Medical Necessity Small groups work 1-on-1 intensive sessions work By people who speak the same language Physicians training physicians works best Outcome: Auditing & Monitoring All auditing results need to be communicated throughout the organization Then, training & staff education Makes a difference if the organization makes a commitment and emphasis on compliance A culture of compliance Commitment from the top people must be seen in meetings/training. Are your doctors/executive management present at annual training? Compliance. OSHA. HIPAA Important that the compliance officer gets out there. 9
Measuring Effectiveness OIG s Supplemental Compliance Program Guidance: Every effective compliance program necessarily begins with a formal commitment to compliance by the hospital s governing body and senior management. Evidence of that commitment should include: Active involvement of the organizational leadership Allocation of adequate resources A reasonable timetable for implementation of the compliance measures; and The identification of a compliance officer and compliance committee vested with sufficient autonomy, authority and accountability to implement and enforce appropriate compliance measures. 28 Measuring Effectiveness Policies & Procedures Documentation all employees have received Code of Conduct, P&P? Attestations P&P are clearly written and relevant to day-to-day responsibilities Documentation of training at orientation 29 Measuring Effectiveness Training The OIG Guidance clarifies that education and training and continual retraining of all personnel at all levels are significant elements of an effective compliance program. Updated compliance training materials used and maintained Training is documented Sign-in sheets with agenda Specialized training Coding and billing training Coding rules 30 LCDs Manager/Supervisor training Treating each question/report confidentially Non-retaliation against any employee asking a question/making a report Documenting and tracking questions and reports When to report to Compliance Officer 10
Measuring Effectiveness Monitoring and Auditing The OIG Guidance clarifies that the organization should develop detailed annual audit plans designed to minimize the risks associated with improper claims and billing practices. Conduct a risk assessment Develop a tool Keep it simple and practical Determining your risk universe OIG Work Plan ADRs, Denials Payer audits Alerts, Bulletins received AAPC Coding Edge! 31 Measuring Effectiveness Monitoring and Auditing The OIG Guidance clarifies that the organization should develop detailed annual audit plans designed to minimize the risks associated with improper claims and billing practices. Audits Determine parameters Baseline, focused, ongoing What to do with results Education Follow up audit Repayment? Let s talk about this a bit. 32 Physician Compliance: Refunds Medicare refunds should be made w/in 60 days of discovery Revised FCA any $ not refunded become false claims! But how to determine the full extent of the overpayment? When does that 60-day clock start ticking? How far back do you look? What is your universe? Add l hour of infusion time billed but not documented: nurse who misunderstood was only there for 3 months Doctor billed a 99215 with every 99387 for 3 years Check credit balances regularly run reports, keep track of accounts Overpayment = refund or recoup Credit balance may not = overpayment 11
Physician Compliance: Refunds If your providers balk at paying back overpayments, show them the law! 18 U.S.C. 669 Health care embezzlement applies to all payers (not just Medicare, Medicaid, other gov t programs) Keeping overpayments is a Federal crime Biggest Compliance Program Failures Identification of compliance risk areas and noncompliance No follow-up of identified issues CMS is developing its own version of a FICO score to be able to identify providers who may be/are at risk for being out of compliance. 4/10/11, James Sheehan 2013 OIG Work Plan (next slide) 35 OIG Work Plan 2013: Review of Part A and Part B Claims Submitted by Top Error-Prone Providers We will review Medicare Part A and Part B claims submitted by error-prone providers to determine their validity, project our results to each provider s population of claims, and recommend that CMS request refunds on projected overpayments. Previous OIG work illustrated a methodology for identifying error-prone providers using CMS s Comprehensive Error Rate Testing (CERT) Program data. Using this methodology, we identified providers that consistently submitted claims found to be in error over a 4-year period. In this review, we will select the top error-prone providers on the basis of expected dollar error amounts and match the selected providers against the National Claims History file to determine the total dollar amount of claims paid. We will then conduct a medical review on a sample of claims. Providers must submit accurate claims for services provided to Medicare beneficiaries. (CMS s Medicare Claims Processing Manual, Pub. 100-04.) (OAS; W-00-13-35565; various reviews; expected issue date: FY 2013; new start) 36 12
U.S. Attorney Spencer Turnbull* Compliance is more than just rules. It s ethical conduct and a culture of ethical conduct. The question in a kickback case is not can I do this, but why am I doing this? *Speaker, HCCA Compliance Institute, Chicago, IL, April 2007 The Choices Do nothing Cross your fingers! ADRs and Prepayment audits CIAs Up to 5 years Fines, penalties and jail time Soon you will have no choice May not have one now Identify the right resource Practice specific More than just a book on the shelf A process that requires commitment Cost effective protection Check your managed care contracts They may require a compliance program! 38 Back to where we started 7 Elements 1. Conducting internal monitoring and auditing through the performance of periodic audits 2. Implementing compliance and practice standards through the development of written standards and procedures. 3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards. 4. Conducting appropriate training and education on practice standards and procedures. 5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities. 6. Developing open lines of communication to keep practice employees updated regarding compliance activities. Nonretaliation policy. 7. Enforcing disciplinary standards through well-publicized guidelines 39 13
Useful Websites and Resources www.stopmedicarefraud.gov/ OIG Work Plan, Exclusions List, Compliance Guidance: www.oig.hhs.gov CERT Reports www.cms.gov/cert CMS Manuals (can t live without them!) www.cms.gov/manuals Your Medicare Contractor Compliance Toolkit for Physician Practices www.aapc.com/toolkit 40 Jean Acevedo, LHRM, CPC, CHC, CENTC Acevedo Consulting Incorporated 561.278.9328 www.acevedoconsultinginc.com 14