Eliminating the Fear of Private Payer Audits

Transcription

1 Eliminating the Fear of Private Payer Audits Presented by: Jaime Leyden, CPC, CPC-H Jodi Smith, CPC Objectives Identify various payer departments that conduct audits Discuss why private payers conduct audits Identify reasons audits are conducted Identify types of audits/reviews Discuss ways to respond to audits (and ways NOT to respond) 1

2 Disclaimer The information presented is only intended to be a general summary and not intended to take the place of any law, statutes, regulations, policies or procedures of any governmental or private entity. Please review specific laws, statutes, regulations, policies, procedures or any other material referenced herein or available elsewhere for a full and accurate understanding of their contents. The information presented herein is general information, and is believed to be correct, but may be incorrect or outdated. As the medical field is constantly changing, please check with your individual regulatory, compliance, and / or legal advisors before taking any action based on the information presented. The information presented herein is representative of the presenter s opinion only, and is not the official view of Aetna Health Care. Departments that Audit Special Investigations Unit HEDIS (Healthcare Effectiveness Data and Information Set) Quality Assurance Medical Payment 2

3 Common Types of Provider Audits Retrospective medical record review Prospective medical record review Compliance audit Automated review Overpayment identification/extension Why do we do what we do? Definitions Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Health Plan. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Health Plan, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between fraud and abuse depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. 3

4 General Fraud Early pressure from providers or covered persons for payment. Threats from providers or covered persons on filing complaints with state agency/attorneys or contacting the president of the company. Misspelled medical terminology or terminology in layman s terms. Medical services billed on Saturday, Sunday or Holidays. Alteration of bills dates, charges, diagnosis, white-out, different color ink. All bills are photocopies no original bills. Provider/Pharmacy Fraud Frequent telephone inquiries on claim status. Assertive providers who demand same day claim payment and/or special handling. Pressure for rapid claim payment. Threats of legal action, filing complaints with State agency or contacting the President of the company. A provider who voluntarily supplies more information than requested. Medical services billed on Saturday, Sunday, or Holidays. A large number of members from one group going to the same facility or same providers. Multiple claims for the same prescription fill were paid. Prescriptions filled or refilled for a time period longer than that allowed by the Plan or applicable regulations. Refills billed exceeds the number authorized by the Prescriber. 4

5 Member Fraud Alteration or fabrication of bills dates, charges, diagnosis, white-out, different color ink. White-out, strike-over, cut and paste inserts, or erasures are present on the bill. Routine services on a Sunday. Large bills are marked PAID. Unassigned billings that are normally assigned, such as large medical charges. Misspelled medical terminology or terminology in laymen s terms. Bills are photocopies no originals available. The insured s address on the claim is the same as that of the provider of service. Handwritten bills. Charges do not total correctly on bills. Member has multiple providers prescribing drugs known to have high street value or known to be abused for recreational use. Eligibility Fraud Different names or address of dependents and covered person. Use of aliases or multiple spellings of names. Unusual number of claims on dependent children. History of claims on spouse with a different name. Discrepancy in other information. No assignment of benefits, especially on large claims or billings. 5

6 Foreign Claim Fraud Claims are for large amounts, such as several thousand dollars. Absence of documentation or medical records. Excessive periods of hospitalizations. Extensive treatment for minor injuries or illnesses. No medical follow-up in the U.S. after serious illness or injury abroad. Other Areas of Provider Abuse and Suspected Fraudulent Activities Nature of services, procedures &/or supplies provided not consistent with provider specialty/licensure Dates that services/treatments were rendered Condition treated or diagnosis made Identity of the provider or recipient of services, procedures or supplies Undisclosed waiver of co-payments or deductibles in schemes to remove the patient from the billing process Deliberate performance of unwarranted/non-medically necessary services solely for financial gain Misrepresentation of diagnosis/procedures for financial gain Unbundling Upcoding Repetitive or excessive tests, supplies, drugs and treatments High number of corrected claims Physician to pharmacy claim mismatch 6

7 Staggering Statistics Federal prosecutors filed a record number of health care fraud cases last fiscal year, perhaps reflecting the greater emphasis the government has placed on combatting the crime costing taxpayers billions of dollars per year. According to Justice Department statistics obtained through a Freedom of Information Act request by a Syracuse University-based nonprofit group that tracks federal spending, staffing and enforcement activities, prosecutors pursued 377 new federal health care fraud cases in the fiscal year that ended in October. That was 3 percent more than the previous year and 7.7 percent more than five years ago. Cases that made headlines FBI: Doctor told healthy patients they had cancer in 'shocking' fraud scheme Cancer clinic owner accused of administering medically unnecessary chemo August 08, 2013 The owner of a Michigan oncology center has been charged with health care fraud for administering chemotherapy to patients who never had cancer as part of a Medicare fraud scheme that was worth as much as $35 million and may have contributed to a patient's death. Farid Fata, who founded the Rochester Hill-based Michigan Hematology Centers in 2005, is accused of submitting fraudulent claims for chemotherapy treatments, PET scans, and several cancer and hematology treatments on behalf of cancer patients who did not require them. 7

8 Cases that made headlines For the latest round of arrests, Strike Force agents identified suspects in Baton Rouge, Brooklyn, Chicago, Detroit, Houston, Los Angeles, Miami, and Tampa. The scams included: Los Angeles: Three people fraudulently billed Medicare for about $9 million for durable medical equipment, HHS asserts. The scheme allegedly included illegal payments to patient recruiters, who then bribed Medicare beneficiaries to share their information; and physicians and medical clinics, who prescribed medically unnecessary power wheelchairs, which they sold to the defendants for illegal kickbacks. Detroit: In one $12 million scheme, three people pretended to be doctors and signed prescriptions for drugs and other documents related to psychotherapy. Miami: In one $20 million case, three individuals bribed Medicare beneficiaries for their Medicare information, which was used to bill for fraudulent home health services. The lead defendant allegedly used his share of the funds to buy "multiple luxury vehicles," HHS reports, including two Lamborghinis, a Ferrari, and a Bentley. Provider Fraud/Abuse Lead Generation Tips from Members, Employees, Provider Staff Data analytics Anti-Fraud software Government, media and law enforcement 8

9 Tips in Responding to an Audit If you receive a medical record requests for 2 audits from the same payer, contact the payer and ask if they can combine. When pulling the charts/medical records, review for accuracy. If corrections are needed, follow appropriate steps for making amendments to the records and/or claims. If you disagree with a denial or overpayment notice, submit industry acceptable research showing your viewpoint. Preventive Measures Have a compliance plan and follow it Make sure it includes auditing your workflows, coding processes routinely (i.e. annually) Stay current with coding rules Know your resources Utilize the OIG Work plan 9

10 Documentation is Key We all know the old adage if it isn t documented, it didn t happen but overdocumenting doesn t increase the medical necessity of a service. All documentation should be relevant to the service provided. Consistently documenting to meet a Level 4/5 E&M code is a good way to earn an audit Appealing an audit As a provider, you have the right to appeal an audit. Ask for what criteria, guidelines, coding references etc were used Request a peer to peer review. This can be from the coding staff to the physician who reviewed the audit 10

11 AAPC Code of Ethics Commitment to ethical professional conduct is expected of every AAPC member. The specification of a Code of Ethics enables AAPC to clarify to current and future members, and to those served by members, the nature of the ethical responsibilities held in common by its members. This document establishes principles that define the ethical behavior of AAPC members. All AAPC members are required to adhere to the Code of Ethics and the Code of Ethics will serve as the basis for processing ethical complaints initiated against AAPC members. AAPC members shall: Maintain and enhance the dignity, status, integrity, competence, and standards of our profession. Respect the privacy of others and honor confidentiality Strive to achieve the highest quality, effectiveness and dignity in both the process and products of professional work. Advance the profession through continued professional development and education by acquiring and maintaining professional competence. Know and respect existing federal, state and local laws, regulations, certifications and licensing requirements applicable to professional work. Use only legal and ethical principles that reflect the profession s core values and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee. Accurately represent the credential(s) earned and the status of AAPC membership. Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests. Adherence to these standards assures public confidence in the integrity and service of medical coding, auditing, compliance and practice management professionals who are AAPC members. Failure to adhere to these standards, as determined by AAPC's Ethics Committee, may result in the loss of credentials and membership with AAPC. Source: Qui Tam anyone? April 25, 2013 CMS on Wednesday proposed increasing the maximum reward for reporting Medicare fraud to $9.9 million in an attempt to encourage more whistleblowers to come forward. Related: CMS enlists patients to combat Medicare fraud The proposed rule would increase the reward given to whistleblowers from 10% to 15% of the first $66 million of the final amount collected. It also would allow CMS to deny Medicare enrollment to providers who are "affiliated with an entity that has unpaid Medicare debt, deny or revoke billing privileges for individuals with felony convictions, and revoke privileges for providers and suppliers who are abusing their billing privileges." In a statement, HHS Secretary Kathleen Sebelius said that the proposal "is a signal to Medicare beneficiaries and caregivers, who are on the frontlines of this fight, that they are critical partners in helping protect taxpayer dollars." 11

12 Resources charged-in-medicare-fraud-schemes ng_signs.htm Doctor-told-healthy-patients-they-had-cancer-in-bizarrefraud-scheme How to Reach Us Jaime Leyden, CPC, CPC- H [email protected] Jodi Smith, CPC [email protected]

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