The Business of Optometry

Transcription

1 The Business of Optometry Carl H. Spear, OD, MBA, FAAO April Jasper, OD, FAAO Optometry is a Business A Five Year Picture Would you recommend your children go to Optometry School? Total U.S. Vision Care Industry Sales in 2007: $34.3 billion Total U.S. Vision Care Industry Sales in 2013: $35.6 billion Change 2007/20013: +4.6% Patient Volume/Competition Big Disclaimer Source: US Dept. of Labor, US Dept. Health, Education & Welfare, and Review of Ophthalmology Select Conditions are Diabetic Retinopathy, AMD, Glaucoma, and Cataracts 5 1

2 WIFM? Horror Stories Medicare and Medicaid Audits and the New World EHR/Meaningful Use Audits Other Regulatory Audits HIPAA OSHA ACA Impact on Small Business CMS Audits and the New World Unemployment and Labor Claims ACA Changes Its all about the $$$$$$$$$$$$$$$ IPhone Camera Not approved Device 45K payback Medicaid Audit 90K fine Missing Images Why Does it Matter? The Challenges of Technology: My reason was $90,000 Efficiency Patient education Data storage HIPAA Data recovery Data transfer Connectivity Workflow Medical Necessity Audit protection Most Frequently Asked Question: It Depends: How often can I order Visual Fields or OCT or Photos? 1. Do you want to get paid? 2. Do you want to keep your payment when audited? 3. Do you want to take best care of the patient? Copyright 2014 Distinctive Strategies and Leadership LLC All Auditors Decide Based on: 1. Medical Necessity as documented in Chart: LCD s (Local Carrier Determination) and PPP s (Preferred Practice Patterns) Document Need based on Change 2. Frequency of Utilization Only applies if no change Rights Reserved 2

3 "MEDICAL NECESSITY Frequency of Utilization Accepted standards of medical practice to restore or correct a functional deficit based upon Medicare Manuals, National and Local Coverage Determinations (NCD/LCD), CAC professional guidelines and peer reviewed research Use a variety of codes to minimize audit risk Example of Utilization Category 1 Category 2 Series 1 Series 2 Series 3 Series 4 Series 5 What You Need To Know Zeiss connects to your instruments Call Somebody Data Management is Key Recovery Billing and Coding Interpretation and Report Timely Response Other Non-ZEISS Instruments View Patient Data in Lanes Manage Data FORUM Glaucoma Workplace Interactive Guided Progression Analysis (GPA) A - Baseline visual fields B - Glaucoma Hemifield Test C - Current visual field D - GPA / Deviation from Baseline (Event Analysis) E - GPA Alert F VFI plot: Visual Field Index Display of the Trend (3-5yrs) under current conditions (Trend Analysis) G - VFI Bar: Remaining useful vision H - Rate of Progression / Significance A F H B G C D E 3

4 CMS History Health Care Finance Administration (HCFA) 1977 Renamed Centers for Medicare and Medicaid (CMS) 2001 Largest Department in Health and Human Services (HHS) The Following Federal Regulations ALL apply to you if you take Medicare Federal False Claims Act (FCA) Fraud Abuse Civil Monetary Penalties Law (CMPL) Monetary Physicians Self Referral Law Anti Kickback Statute Terminology 101 Terminology 101 "MEDICAL NECESSITY - Accepted standards of medical practice to restore or correct a functional deficit based upon Medicare Manuals, National and Local Coverage Determinations (NCD/LCD), CAC professional guidelines and peer reviewed research. "Utilization - The amount, frequency, and duration of services that must be defined as reasonable under accepted standards of practice. Accepted standards of practice is established by CMS/MAC/ RAC/ZPIC/OIG whom will consult practicing professionals, state and national associations and peer review board data in developing utilization criteria. CMS- Centers for Medicare/Medicaid Services MAC- Medicare Administrative Contractors multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. RAC- Recovery Audit Contractor- The RAC's detect and correct past improper payments so that CMS and Carriers can implement actions that will prevent future improper payments ZPIC- Zone Program Integrity Contractor OIG- Office of the Inspector General Office Inspector General Enforcement Arm OIG Work Plan Penalties 3 times amount of overpayments $10,000 per claim Example: 25 claims overpaid by total of 20K. What is the penalty? 310K 4

5 Medicare Fraud Here are examples of Medicare fraud: Billing for services or supplies that were not provided Altering claim forms to obtain a higher payment amount Billing twice for the same service or item Billing separately for services that should be included in a single service fee Misrepresenting the diagnosis to justify payment Continuing to bill for services or items no longer medically necessary Billing non-covered services or items as covered services Ordering unnecessary lab tests Refusing to bill Medicare for covered services or items Using another person's Medicare card to obtain medical care Soliciting, offering, or receiving a kickback, bribe, or rebate (for example, paying for referrals of patients) Waiving co-insurance or deductible!! Using unethical or unfair marketing strategies, such as offering beneficiaries free groceries or transportation to switch providers Repeatedly violating the participation agreement, assignment agreement, or limiting charge Medicare Abuse Here are examples of Medicare abuse: Excessive charges for services or supplies Routinely submitting duplicate claims Improper billing practices such as: Exceeding the limiting charge Billing Medicare at a higher fee schedule rate than for non- Medicare patients Routinely submitting bills to Medicare when Medicare is not the beneficiary s primary insurer Collecting more than 20 percent coinsurance or the deductible on claims filed with Medicare Breach of the Medicare participation or assignment agreements Claims for services that are not medically necessary publications/archives/workplan/2015/fy15- Work-Plan.pdf OIG 2015 Work Plan OIG 2014/2015 Work Plan Evaluation and Management services inappropriate payments Medicare Incentive Payments for Adopting EHR Security of Devices Containing HPI Patient Portal 5

6 Protocols and Checklists Create Review the LCD/NCD Consistency Efficiency Accuracy Empathy Fundus Photography SCODI Co-Management Transfer of Care Billing Dates Other testing Distinction in Eye Care by Solving our Patients Problems Who is a Glaucoma Suspect? Glaucoma Suspect AAO Protocol The clinical findings that define a glaucoma suspect are characterized by one of the following in at least one eye in an individual with open anterior-chamber angles by gonioscopy. Taken from p.18 POAG suspect AAO PPP Diagnosis Criteria for POAG WHERE Do I Find The AAO PPP? Evidence of optic nerve damage from either, or both, of the following: Optic disc or retinal nerve fiber layer structural abnormalities Reliable and reproducible visual field abnormality considered a valid representation of the subject s functional status Taken from AAO PPP POAG 6

7 ders.nsf/docscat/jurisdiction-11-part- B~95KVN87406 Diagnostic Test Compliance INTERPRETATION AND REPORT OF SPECIAL TESTING SERVICE Patient Name: John J. Smith Date of Service: 01/01/14 Type of Service: Fundus Photography-(92250) order (365.01) Results: Baseline Study of Optic Nerve Findings and Implications: OD CD ratio.6 /.6 well perfused 360 degrees. OS CD ratio.6 /.85 notch 5-7 o clock Impact on Plan OD: moderate risk for progression. Serial evaluation at 1 year. OS: high risk for progression. Serial evaluation at 6 months. Signature of Physician Staff and HR Social Media Webpage Facebook Twitter Other Staff Dirty Little Secrets Department of Labor OSHA 7

8 Solution Texting PHI Photos Hot Rod Example Distracted Doctoring Surgery Text HIPAA Solution Medicare.Gov Physician Compare Medicare.Gov Physician Compare Solution NPS: Tell your own Story 8

9 EHR EHR audits EHR EHR and MU Request will come from Figliozzi & Company Keep Copy of Report Card for 6 years Keep Copy of Submission Receipt Need Certification number for EHR Response required within 2 weeks of receipt of letter Entities deemed ineligible are responsible for returning all incentives to CMS Can we use a scribe and still qualify for MU? Any licensed healthcare professionals and credentialed medical assistance, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant. Solution Jim Tate RESOURCES Guidance/Legislation/EHRIncentivePrograms/Par ticipation-timeline.html RESOURCES