Compliance Strategies. For Physician Practices Part I

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Stephany Ferguson
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1 Compliance Strategies For Physician Practices Part I

2 Government Enforcement Efforts Healthcare fraud is the #2 priority of the Department of Justice, second only to terrorism and violent crime.

3 Government Enforcement Efforts In FY 2011, there were 614 criminal and 381 civil actions against individuals or entities that engaged in health-care related offenses, resulting in a reported $3.6 billion in Department of Health and Human Services (HHS) investigative receivables

4 Government Enforcement Efforts On May 20, 2009, the HHS Secretary and the Attorney General announced the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), an interagency effort focused specifically on combating health care fraud

5 Government Enforcement Efforts Health & Human Services estimates that $17 will be returned for every $1 invested in fraud & abuse initiatives

6 Recent OIG Semiannual Report To Congress OIG is an excellent investment. Our work results in the recovery of stolen and misspent funds, and our recommendations lead to increased efficiency and effectiveness and fraud prevention. Our results are tangible. For instance, our Medicare Fraud Strike Force activities continue to be successful. During this semiannual reporting period, Strike Force efforts resulted in the filing of charges against 70 individuals or entities, 77 convictions, and $160.8 million in investigative receivables.

7 Healthcare Reform Law and Mandatory Compliance Programs Congress for the first time has mandated that a broad range of providers, suppliers, and physicians adopt a compliance program The Healthcare Reform Law s compliance program mandates are divided into two categories: (1) nursing facilities and (2) all other providers/suppliers.

8 Healthcare Reform Law and Mandatory Compliance Programs Right now specific implementation deadlines for nursing homes but not the others Expect provider/supplier compliance program mandates to be issued on a rolling, industry sector specific basis DME & Home Health first?

9 Enforcement Baltimore physician, specializing in colorectal surgery, arrested for fraud. The complaint alleges that from February 2009 to January 2010, the physician defrauded Medicare and other health care benefit programs by billing for services and surgeries that were never provided.

10 Enforcement New Orleans Doctor and Owner of Medical Equipment Company Each Plead Guilty for Their Roles in Baton Rouge-area Health Care Fraud Scheme. Majority of fraudulent claims were based on prescriptions for medically unnecessary DME that were written and provided by the Doctor. Doctor wrote prescriptions for medically unnecessary DME, such as power wheelchairs, wheelchair accessories and feeding nutrients.

11 ER BILLING COMPANY AND PHYSICIAN FOUNDER TO PAY $15 MILLION FOR HEALTH CARE BILLING FRAUD Billing company typically upcoded claims and billed for services more extensive than those actually provided by the physicians.

12 Enforcement Michigan family practitioner sentenced to three years imprisonment and ordered to pay $649,000 in restitution for his role in a Medicare fraud scheme to submit nearly $1 million in false and fraudulent claims for injection and infusion therapy services that were unnecessary or never provided Arizona internist agreed to pay the federal government $92,000 to settle allegations that he violated the False Claims Act by submitting fraudulent claims to the federal Medicare program for tests he performed on patients who did not meet the Medicare coverage requirements

13 Enforcement North Carolina internist accused of defrauding federal healthcare programs doctor accused of knowingly submitted false or fraudulent claims to Medicare and Medicaid for services that were either never rendered, medical unnecessary or not supported by proper documentation. Doctor also allegedly submitted claims for patients who did not qualify for medical services reimbursement.

14 Enforcement A Detroit-area foot doctor pleaded for his participation in a Medicare fraud scheme. Between January 2003 and December 2006, doctor billed Medicare and Blue Cross Blue Shield of Michigan for a procedure known as an avulsion of the nail plate or nail avulsion procedure. Doctor billed for this procedure thousands of times with respect to hundreds of beneficiaries during that time period. According to court documents, Medicare was billed for nail avulsion procedures that were never rendered.

15 Health Care Fraud (18 U.S.C. 1347) It is a crime to knowingly and willfully execute (or attempt to execute) a scheme to defraud any health care benefit program, or to obtain money or property from a health care benefit program, through a false representation. This law applies not only to federal healthcare programs but to most other types of benefit programs, such as commercial health insurance plans.

16 Conduct to Avoid Billing for services never provided to patients. Upcoding - billing for more extensive services than weren t actually rendered. Falsely certifying that services were medically necessary. Unbundling - billing for each component of the service instead of billing an all-inclusive code.

17 Conduct to Avoid Billing for non-covered services as if covered. Flagrant and persistent over utilization of medical services with little or no regard for results, the patient s aliments, condition, or medical needs. Consistent use of improper or inappropriate billing codes, such as billing for the same level of service or diagnosis code irrespective of the services rendered in the individual case.

18 Top 10 Outpatient Billing Errors 1) Duplicates 2) Bundled Services 3) Facility Information 4) Beneficiary Eligibility 5) Medical Necessity 6) Provider Identification Number Missing 7) Medicare Secondary payer (MSP): 8) Non-Covered Services 9) Unique Provider Identification Number (UPIN) 10)Modifiers

19 Actual Letter From CMS You received this letter because recent analysis of recent data shows you are billing specific E/M services in percentages different from your peers (nationally and state) We ask that your review your billing practices We will continue to monitor your claims submissions to determine if your patterns of billing these services are more in line with Medicare s expectations.

20 What Payors Want Payors (including MEDICARE) require reasonable documentation to ensure that services provided are consistent with coverage. Information is often requested to validate the following: Site of service (often reimbursement varies) Medical necessity and appropriateness of the diagnostic and/or therapeutic services provided Accurate reporting that services were provided at the level claimed

21 General Principles of Documentation Physician orders should be documented before a service is performed An addendum should be dated and timed the day the information is added to the medical record and not dated for the date the service was provided A service should be documented when it is provided in order to maintain an accurate record (timeliness) Confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and law

22 Compliance Everyday compliance you should have this in place right now: PREVENT DETECT CORRECT Don t Forget The RACs are here!

23 Actual RAC Letter Solo Practitioner CMS has retained Connolly Healthcare to carry out the RAC program in the State of Texas..This letter is to notify you that Medicare has made an overpayment to you in the amount of $ Identification of overpayments associated with E/M services ( ) billed without modifier 25 on the same date of service pulmonary diagnostic procedure ( )

24 Effective Compliance Program Elements U.S. Federal Sentencing Guidelines and relevant Compliance Program Guidelines include the following requirements: Establishing compliance standards (policies and procedures) Assigning senior management oversight responsibility Using due care when assigning responsibility to an employee (I.e., screen employees for past offenses) Conducting effective training and education Establishing reporting and monitoring mechanisms Enforcing standards and disciplining violators Responding to violations to prevent future offenses

25 Preventive Medicine Implement a Compliance Plan Employee Background Checks Annual question on Employee Evaluations inquiring as to: Illegal conduct Unethical conduct Fraudulent conduct Require signature Exit interview forms requesting similar information Spot Check on billing/medical record information Audit 10 records per year per provider (non-statistical sample)

26 Preventive Medicine Implement a document retention and destruction policy Require signed attendance sheets for all relevant training (on-site, carrier, teleconference) Require initials on all Carrier Notices Require all employees to access the CMS MedLearn site Only maintain documents as to the steps actually undertaken NOT what you THINK the government would like to see

27 Preventive Medicine Establish a Coding Compliance Committee Meet periodically or annually to Approve policies and procedures Review findings and results from audits Focus on problem areas, and Determine actions that need to be taken

28 Other Compliance Points HIPAA OSHA Stark Below Market Rents Human Resources (EEOC, Overtime, TWC)

29 Final Thoughts Be Proactive, not Reactive Implement a compliance plan Put policies, procedures and systems into place Train, educate and inform all staff View HEAT Provider Compliance Training Webcast Modules at_modules.asp

30 Final Thoughts Whether you are an employee or an employer ALWAYS, ALWAYS consult legal counsel prior to any communications with government agents.

31 Questions & Answers Reed Tinsley, CPA

Medicare Fraud. Programs supported by HCFAC have returned more money to the Medicare Trust Funds than the dollars spent to combat the fraud.

Medicare Fraud. Programs supported by HCFAC have returned more money to the Medicare Trust Funds than the dollars spent to combat the fraud. Medicare Fraud Medicare loses billions of dollars annually in fraud an estimated $60 billion in 2012 alone. In addition to outright criminal activity, the Dartmouth Atlas of Health Care (which studies