William Rusty Huseman 3733 University Blvd. West, Suite 305-A Jacksonville, FL 32217

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1 William Rusty Huseman est, 1

2 Audit & Compliance Audit Who can audit your practice? What to expect? What to do if you are audited? Compliance 2 What you MUST have in place now! What you SHOULD have now!

3 Who can audit your practice? Third Party Payors Florida Board of Medicine/Osteopathy Agency for Health Care Administration Medicare (CMS) Office of Inspector General Office of Civil il Rights States Attorneys Office 3

4 Third Party Payors Commercial Plans: AvMed, United, Blue Cross, etc. Authority to audit is contractual 4 Language g might include: Payor may, with reasonable notice inspect... Provider must cooperate with Plan to insure appropriate utilization and continued payment You will be given notice and you must comply or be subject to termination Contact a healthcare attorney as soon as you receive notice

5 Third Party Payors What to do if you are audited. 5 Pay careful attention to the notice letter and provide only what is requested Make two (2) copies of each chart; one to Payor and maintain i the exact copy in secure place for future reference Such post-payment payment audits are rare by comparison to Medicare/Medicaid. Attorney should engage independent auditor to determine, before submission, whether a problem exists. (Attorney-Client Privilege may attach)

6 Florida Board of Medicine and Osteopathy Authority is statutory t t Audit is physician specific You will receive notice of complaint filed against your license You must immediately contact your commercial med-mal mal carrier If you are self-insuring, immediately hire an experienced health care attorney who represents physicians before regulatory Boards Regulatory Boards have the power to suspend, fine and revoke your license Do not respond on your own... Ever!!! 6

7 Agency for Health Care Administration Medicaid idf Fraud d&ab Abuse HIPAA Violations Health Care Clinic registration violations Laboratory violations 7

8 Agency for Health Care Administration AHCA can come in with or without t notice With notice in form of post-payment payment audit Contact healthcare attorney immediately Attorney should conduct independent d audit to determine if irregular billing exists Copy everything in file for the independent audit Make 2 copies of file, 1 for attorney and an exact copy kept in confidential file After the independent audit, attorney should submit the charts with a cover letter. 8

9 Agency for Health Care Administration Without notice concern is fraud Immediately call healthcare attorney Check credentials of investigators Only one person should speak with investigator i If possible, close practice and send all employees home Take pictures of everything the investigators are looking at If possible, restrict their access to other areas of the practice 9

10 Medicare (CMS) RAC Audits (Recovery Audit Contractors) Post-Payment Payment Audit Will receive notice and demand for charts Immediately call healthcare attorney Perform independent d review utilizing i Attorney- Client privilege where possible Medical decision making is key Ultimately, documentation in the medical record will help with appeal Provide only what is requested after seeking advice from counsel 10

11 Medicare (CMS) ZPIC Audits (Zone Program Integrity Contractors) Primarily focused on individual physician or billing group This audit has fraud implications Cases of fraud are referred to Office of Inspector General Immediately call healthcare attorney Close practice and send staff home Say nothing until your attorney comes or at the very least, have attorney talk directly with OIG Agent. 11

12 Office of Civil Rights Complaints related to HIPAA 12

13 Office of Civil Rights Complaints related to HIPAA Will receive notice for unauthorized disclosure of PHI Immediately hire a healthcare attorney Investigate complaint Make sure internal investigation of complaint contained in written HIPAA Compliance Plan IF PI Attorney involved, likely to face complaint by BOM/BOOM No private right of action under HIPAA AHCA/OCR can fine breaching party 13

14 Office of Civil Rights Complaints related to HIPAA If fraud is involved, OIG will investigate Immediately hire a healthcare attorney Verify credentials of Agent Make sure internal investigation of complaint contained in written HIPAA Compliance Plan Person committing fraud is afforded due process rights including 5 th & 14 th Amendment rights Criminal sanctions likely Definitely referred to BOM/BOOM 14

15 State Attorneys Office Related to Fraud, Deceit, Abuse, Battery, Drug Diversion, etc. Immediately hire a healthcare attorney who, unless they practice criminal law, should refer the matter to criminal attorney Close practice and send all employees home If incarcerated, find covering physician until the matter is resolved Will result in BOM/BOOM complaint 15

16 Compliance Why implement a compliance program? Sound clinical/business practice 16 Identify and stop problems early Discourage employee qui tam actions Federal sentencing guidelines mitigate criminal fines Minimize risk of permissive exclusion of provider Avoid imposition of comprehensive corporate integrity agreement by OIG Limit it corporate director liability

17 Compliance What Compliance Plans are required? 17 HIPAA Privacy and Security Plan Must be in writing Every office must have a copy Must include HITECH elements Red Flag Rules Written Compliance Plan required by 12/31/2010 Requires you to protect t the identity of every customer Requires you to identify areas where identity theft is possible Requires education of staff and response to breach

18 Compliance What Compliance Plans should you have? 18 Written Medicare/Medicaid compliance plan Must be reviewed periodically Must provide evidence of following the plan Requires continuous education of staff Used as mitigating factor if investigated Corporate Compliance Plan Policy & Procedure Manual Employee Manuals OSHA Compliance Plan Radiation Compliance Plan CLIA Compliance Plan Billing Compliance Plan (EMR determination)

19 Questions? 19