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 by: Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group Objectives Executive Summary 1. Review current audit activity 2. Describe a compliance program 3. Discuss the auditing aspect of the program Who does audits CMS error rates Common audit findings Lessons learned Who s watching? Office of Inspector General (OIG) Reference OIG Work Plan Comprehensive Error Rate Testing (CERT) Recovery Audit Contractors (RAC) Program Safeguard Contractors (PSC) & Zone Program Integrity Contractors (ZPIC) Medicare Part C Plans Risk adjustment audits Comprehensive Error Rate Testing (CERT) Randomly selecting a sample of approximately 50,000 submitted claims during each reporting period Requesting medical records from providers who submitted the claims Reviewing the claims and medical records for compliance with Medicare coverage, coding, and billing rules Cannot label a claim fraudulent
Recovery Audit Contractors RAC Program Mission The RAs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Tax payers and future Medicare beneficiaries are protected Source: http://www.cms.gov/rac/downloads/ca%20outreach%20presentation.pdf Recovery Audit Contractors Update CMS announced pause in operations on February 18, 2014 Some automated reviews restarted in August 2014 CMS negotiating new contracts for RACs Expect changes in the program Name change to Recovery Auditors (RA) Source: http://www.cms.gov/research-statistics-data- and-systems/monitoring-programs/medicare-ffs- Compliance-Programs/Recovery-Audit- Program/Recent_Updates.html PSCs / ZPICs The primary goal of the PSC and the ZPIC BI unit is to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped. Medicare Advantage Plans Required to report data back to CMS on specific risk conditions Audits typically based on diagnosis codes Companies contracted to conduct these review (i.e. MedAssurant) Source: http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads//pim83c04.pdf OIG 2010 Report on E/M E/M Code Inflation 42% of E/M services incorrectly coded 26% upcoded (14% overpayment) 15% downcoded (6% underpayment) 2% other coding error (2% error) 19% of E/M services lacking documentation 12% insufficient documentation (8% overpayment) 7% undocumented (6% overpayment) Source: Improper Payments for E/M Services Cost Medicare Billions in 2010, May 2014 Source: Coding Trends of Medicare E/M Services, May 2012
Targets for Scrutiny 2015 OIG Work Plan Place of Service Errors Payments for drugs Ambulatory Surgical Centers Payment System Ophthalmological Services Imaging services Payments for PE Medicare Incentive Payments for Adopting EHR Anesthesia services Personally performed Medicare Part B payment for compounded drugs Security of CEHRT under Meaningful Use Audit Triggers Patient complaint Staffer complaint Extraordinary volume Atypical utilization pattern Frequent errors on claims for reimbursement Source: HHS OIG FY 2015 Work Plan Possible Outliers Possible Mistakes Subspecialist Group practices with collaborating physicians Public health factors Research area Racial factors Geographic practice patterns Litigious community EMR creates note bloat and code creep Oversimplified coding Overly cautious Hyper-aggressive Misunderstanding of reimbursement regulations Inappropriate medical protocol Robotic medical technicians Refund of Overpayments Refund of Credit Balances ACA 60-day rule Failure to return overpayments within 60 days may be a violation of the federal False Claims Act Fines up to $11,000 per false claim plus triple damages Credit balances cannot be kept State laws require refunds, typically within 30-days Federal laws, such as 60-day rule, may apply
Next Steps Compliance Plan Periodic chart review Monitor utilization patterns Remediate errors Staff training Continuous improvement Compliance Defined 1. The act of conforming, acquiescing, or yielding. 2. Conformity; accordance: in compliance with orders. 3. Cooperation or obedience: compliance with the law Source: http://dictionary.reference.com/browse/compliance What s Involved? OIG Guidance Plan Program Office of Inspector General (OIG), HHS Published Compliance Program Guidance for Individual and Small Group Physician Practices October 2000 Source: Federal Register Vol 65, No 194, October 5, 2000 Scope of Voluntary CP Federal health care programs Private payers health plans Benefits of Voluntary CP Speed & optimize proper payment of claims Minimize billing mistakes Reduce chances that an audit will be conducted by CMS or the OIG Avoid conflicts with the self-referral and anti-kickback statutes Source: Federal Register Vol 65, No 194, October 5, 2000 Source: FR Vol 65, No 194, October 5, 2000
Benefits of Voluntary CP Demonstrates good faith effort to comply with laws and regulations Indicates that staff have an affirmative, ethical duty to report billing errors or fraudulent conduct so it may be corrected Compliance Programs Formal compliance plans become mandatory under PPACA Condition of enrollment in federally funded programs Secretary to determine timeline of core elements and implementation date Source: FR Vol 65, No 194, October 5, 2000 Source: Patient Protection & Affordable Care Act (PPACA) Section 6401 Where do you stand? Indications of Non-Compliance Staff turnover Claims paid slowly Frequent problems with claims Problem claims unresolved Staff takes work home Poor morale Irregular accounting You are under scrutiny by Medicare Documentation Tips for Medicare Compliance Provide medically necessary services Document service provided Code from documentation What s Involved? Plan Written document Templates No one size fits all May require legal counsel May require other outside consultants Source: Trailblazer Health 2002
What s Involved? 7 Elements of an Effective CP Activities described in the plan Not a one time activity You may be further along than you think Program 1. Conducting internal monitoring and auditing 2. Implementing compliance and practice standards 3. Designating a compliance officer or contact 4. Conducting appropriate training and education 7 Elements of an Effective CP 7 Elements of an Effective CP 5. Responding appropriately to detected offenses and developing corrective action 6. Developing open lines of communication 7. Enforcing disciplinary standards through well-publicized guidelines 1. Conducting internal monitoring and auditing Auditing and Monitoring Review standards and procedures Claims submission audit Are bills accurately coded? Is documentation complete? Are services reasonable and necessary? Any incentives for unnecessary services? Auditing and Monitoring Baseline audit within 3 months of initial training, and thereafter on an annual basis 5-10 records per physician Source: Federal Register Vol 65, No 194, October 5, 2000 Source: Federal Register Vol 65, No 194, October 5, 2000
Auditor s Attitude Getting Started Extremely important Choose auditor carefully Goal is to educate and correct Don t punish or intimidate A variety of concerns Subjective Findings Assess record for: Indications for care Thorough documentation Accurate dates on chart and claim Accurate coding: CPT, modifiers, ICD-9 Reasonable frequency and utilization Correct payer billed Correct provider identified Adherence to billing rules and payer instructions Handling of incorrect payments over and under Legibility Organization Quality of forms or EHR Registration Signatures Corrections Timeliness Objective Findings Objective Findings Overbilling Upcode LOS Wrong CPT (high) Poor documentation Missing entries Duplicate billing Fragmentation Not medically necessary Underbilling Downcode LOS Wrong CPT code (low) Missed charges Bilateral or multiple procedures Supplies Coding Errors CPT code error with no financial impact Modifier omitted Incorrect modifier Diagnosis code errors Other errors Date errors Too frequent services Indications unclear Wrong provider (credentialing) Patient responsibility
Categories of Services Basic Documentation Requirements Exams and consultations Diagnostic tests Surgical procedures Anesthesia Pharmaceuticals (injected) Post-cataract eyeglasses, CLs New patients Registration and demographics HIPAA notice Assignment of benefits (signature on file) Established patients Update registration and demographics Update insurance information Reviewing Eye Exams Appropriate chief complaint & valid indication for care Written request for consultation (if applicable) Appropriate medical history HPI documented by physician (critical for E/M) Relevant exam elements documented Impression and plan documented Consult letter to requesting physician (if applicable) Accurately coded (either eye code or E/M) Reviewing Diagnostic Tests Indications for service Appropriate order Technicians notes Adequate interpretation On date of test or later? Reasonable frequency for patient s condition Policy Preferred Practice Patterns Coding accuracy Reviewing Surgical Procedures Discussing Your Findings Indications for surgery Adherence surgery billing rules Minor vs. major surgery Exam on day of surgery Global period Assistant surgeon multiple or bilateral surgery NCCI edits Informed consent ABN if needed Praise first Select your audience Limit your battles Have your facts ready Get back up if needed Stay calm Be prepared to offer solutions Coding accuracy Place of service
What Next? Fix identified problems Rebill Refund overpayments Train physicians and staff Create or update practice policies Repeat chart review Focus on problems previously identified Look for new issues Follow Compliance Plan Questions? Additional Assistance (800) 399-6565 Website: www.corcoranccg.com Mobile App: Corcoran 24/7 Email: mpjohnson@corcoranccg.com