Data Analytics and Compliance Effectiveness

Transcription

1 Data Analytics and Compliance Effectiveness Julie Nielsen, Berkeley Research Group Stephen Sullivan, O Melveny & Myers HCCA South Atlantic Regional Conference Orlando, FL February 7, 2014 This presentation does not constitute legal advice. If you have questions regarding any transaction, please consult with inside counsel, who may confer with outside counsel depending on the facts. Discussion Topics What is data analytics and why is it important? Trends in the government s use of data and impact of new regulations Key challenges and considerations when using data for compliance monitoring 2/7/

2 What is Data Analytics? Data Analysishas been defined as, the process of systematically applying statistical and/or logical techniques to describe and illustrate, condense and recap, and evaluate data. [1] Why is data analytics important in health care? Improve clinical effectiveness Quality of care Outcomes Readmissions Patient safety Patient satisfaction Reduce costs and increase operational efficiency and financial performance Monitor compliance and mitigate enforcement and litigation risks Source: [1] accessed January 8, /7/ Where is Data Analytics Heading? Historically, the government has used a pay and chase approach to detecting fraud, waste and abuse using data analytics on limited and disparate data sets This is all changing Big Datais a popular term used to describe the exponential growth and availability of data, both structured and unstructured Structured data examples: claims, enrollment, payroll Unstructured data examples: , documents, social network posts Predictive modelingis a statistical process by which historical data is analyzed to determine the likelihood of a future event; examples include: Determine a patient s risk of developing a specific medical condition and beginning preventive care to offset that risk Identifying patients who are more likely to be non-compliant with medications Identifying patients with a greater likelihood of readmission Catching a greater percentage of fraudulent or wasteful claims pre-payment and settling legitimate claims more quickly 2/7/

3 Where is the Government Heading? Data Collection EHR incentive payments Encounter data collection from Medicare Part C and Medicaid managed care plans CMS integrated data repository Joint public/private fraud prevention collaboration Fraud, Waste and Abuse Detection and Prosecution Expansion of the False Claims Act Expansion of the Anti-kickback Statute 60-day repayment obligation on overpayments Increased funding for anti-fraud efforts RAC program expansion to Medicare Parts C and D and Medicaid Requirement to use predictive analytics 2/7/ How is the Government Getting There? 2/7/

4 Example: OIG Work Plan for 2013 Hospitals Same day readmissions Compliance with Medicare s transfer policy Duplicate graduate medical education payments Physicians Noncompliance with assignment rules and excessive beneficiary billing Error rate for Incident-to Services performed by non-physicians Long-term care Use of atypical antipsychotic drugs Questionable billing patterns for Part B services Medicare Part C Sufficiency of documentation to support diagnosis under risk adjustment program CMS oversight of data quality and accuracy Note: 2014 Work Plan is scheduled to be released in January /7/ Compliance and Enforcement Trends Medicare Parts A & B Kernan Hospital (2011): False Claims Act complaint alleging that a hospital engaged in systematic upcoding by (a) pressuring and leading physicians to diagnose patients with malnutrition (e.g., by placing purportedly improper sticky notes in patient charts) and (b) causing coders to suspend their independent coding judgment (e.g., by utilizing coding software that allegedly led coders to select the most severe form of malnutrition regardless of physicians documented specificity) Physician Medicare Payments: January 2014 notice in the Federal Register that CMS will make case-by-case determinations as to whether exemption 6 of the Freedom of Information Act applies to a given request for amounts paid to individual physicians 60-Day Overpayment Rule: For Medicare Parts A & B, CMS has proposed: 10-year look-back period Duty to take affirmative investigative action related to potential overpayments Timely and reasonable inquiry E.g., compliance hotline complaints create an obligation to timely investigate the matter 2/7/

5 Compliance and Enforcement Trends Medicare Parts C & D Janke (2010): $22.6M false claims settlement following allegations that the defendants submitted codes for Part C reimbursement that were not supported and failed to look for erroneous diagnoses or delete codes upon learning that they were inaccurate Attestation Requirements: e.g., annual requirement that MAOs certify their risk adjustment data is accurate, complete and truthful (based on best knowledge, information and belief) (42 C.F.R (1)) Medicare Managed Care Manual: An effective program to control [Fraud, Waste and Abuse (FWA)] includes policies and procedures to identify and address FWA at both the sponsor and downstream or related entity levels in the delivery of Parts C and D benefits. CMS Proposed Guidance: [I]f an MA organization or Part D sponsor has received information that an overpayment may exist, the organization must exercise reasonable diligence to determine the accuracy of this information, that is, to determine if there is an identified overpayment. 2/7/ Challenges and Considerations 2/7/