Physician Practice: Avoiding the Other F Word Fraud, or Identifying Your Risks in Coding and Billing. G2N, Inc. Honest & Healthy Bottom Lines

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1 Physician Practice: Avoiding the Other F Word Fraud, or Identifying Your Risks in Coding and Billing

2 CPE Certificates This webinar qualifies for 1 CPE credit. Please complete our short survey of 8 questions that will appear at the end of the webinar in order to receive your certificate. Your certificate will be ed to you.

3 Disclaimer This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 3

4 Rosie Donovan, RHIA, CCS-P Client Partner for G2N, Inc. G2N provides coding, documentation audits and other revenue cycle consulting services. 4

5 Rosie Donovan, RHIA, CCS-P 33 years of physician practice experience in both multispecialty, independent and RHC ambulatory medical groups Focus on documentation and coding audits, compliance, and reimbursement BS from Saint Louis University RHIA, CCS-P credentialed by AHIMA AHIMA-Approved ICD-10-CM/PCS Trainer 5

6 Mission of G2N We work to ensure America s healthcare providers have honest & healthy bottom lines in order to continue to fulfill their mission of improving community health. 6

7 Agenda Review Fraud and Abuse -prevention -detection -compliance -what s new -areas of risk 7

8 Are you smarter than an OIG fugitive? 8

9 Polling? #1- Pre-assessment Select True or False CMS requires a fingerprint-based background check for certain enrollment applications. A. True B. False 9

10 Polling? #2 Pre-assessment Select the false statement. A. Medicare Carriers, FIs, MACs, CERT Contractors, and Recovery Auditors all conduct claim review. B. Medicare Carriers, FIs, MACs, CERT Contractors, and Recovery Auditors all conduct extensive investigations. C. The OIG, the DOJ, and PSCs/ZPICs all conduct extensive investigations. 10

11 Fraud and Abuse is a Serious Problem Most Medicare providers/contractors are honest $4.3 billion recovered in a single year (FY 2013) $19.2 billion in the last five years Highest 3 year average ROI in 17 year history of program 11

12 How much did these providers plead guilty to? Two owners of a home health care company that claimed to provide skilled nursing to Medicare beneficiaries pleaded guilty in connection with a Medicare fraud scheme in the amount of $. Each owner pleaded guilty to: 1 count of conspiracy to commit health care fraud, 1 count of conspiracy to pay kickbacks, and 16 counts of payment of kickbacks to Medicare beneficiary recruiters. Each owner faces a maximum sentence of 10 years in prison for the health care fraud conspiracy count, 5 years in prison for the kickback conspiracy count, and 5 years in prison for each kickback count. What is the dollar amount of this Medicare fraud scheme? 1. $500, $2.6 million 3. $5.2 million 4. $110 million 12

13 What is Fraud? FRAUD is making false statements or representations of material facts to: Obtain some benefit or payment for which no entitlement would otherwise exist, including obtaining something of value through misrepresentations or concealment of material facts 13

14 What is Abuse? Abuse describes practices that: Result in unnecessary costs, Are not medically necessary, Are not professionally recognized standards, and Are not fairly priced 14

15 How much did these providers repay? A DMEPOS supplier was paid $5,049 for a power wheelchair, Group 2 standard. The documentation did not support medical necessity according to the applicable National Coverage Determination (NCD) and Local Coverage Determination (LCD). Neither the diagnoses submitted nor the face-to-face evaluation received from the physician s office supported the inability to self-propel. No other valid rationale was offered as to why a power mobility device versus another mobility device was reasonable and necessary. How much of the $5,049 payment did Medicare recoup from this supplier? 1. Nothing ($0) 2. Half ($2,524.50) 3. All ($5,049) 4. Triple ($15,147) 15

16 Prevention Let s review Medicare Fraud And Abuse Laws Our prevention in the war against FRAUD & ABUSE 16

17 Most Familiar Laws False Claims Act Anti-Kickback Statute Physician Self-Referral Law Criminal Health Care Fraud Statute These laws apply to Medicare Parts A, B, C, D. 17

18 What is the FCA? The False Claim Act: Protects the Federal Government from overcharges or being sold substandard goods or services Imposes civil liability on any person who knowingly submits, or causes to be submitted a false or fraudulent claim 18

19 What is the Anti-Kickback Statute? The Anti-Kickback Statute: Prohibits knowingly and willfully - Offering, paying, soliciting, or receiving remuneration to induce or reward referrals of items/ services reimbursable by a Federal health care program Kickback examples: Cash for referrals Free rent or below fair-market value rent for medical offices Free clerical staff Excessive compensation for medical directorships 19

20 What is the Stark Law? The Physician Self-Referral Law: Prohibits referring Medicare beneficiaries for: Certain designated health services To an entity in which the physician (or an immediate family member) has: An ownership/investment interest, or A compensation arrangement Exceptions may apply 20

21 What is CHCF? The Criminal Health Care Fraud Statute: Prohibits 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; In connection with the delivery of or payment for health care benefits, items or services 21

22 Improper Payment Detection Medicare receives 4.8 M claims per day CMS Office of Financial Management estimates that each year Medicare FFS program issues >$36.0 B in improper payments Medicaid program issues >$14.4 B in improper payments Most improper payments can only be detected by a human comparing a claim to medical documentation 22

23 Detection Let s review the entities that exist in our detection of improper payments or fraud &abuse 23

24 Recovery Audit Program Goal: Detect improper underpayments and overpayments Who? Recovery Auditors How? Post-payment claims review Many target reviews Restructured? Legal burden and appeals backlog 24

25 RAC Reviews Automated reviews Based on clear policy on overpayment Based on medically unbelievable services No timely response rec d in response to request Complex reviews Request for selected Medical Records Notice of on-site review of records GOOD CAUSE required OIG finding, data analysis 25

26 The Others MAC Medical Review Departments CERT Comprehensive Error Rate Contractors PERM Payment Error Rate Measurement Contractors 26

27 Dual Purpose Entities Detection with Investigation: PSCs/ZPICs/MEDICs OIG DOJ HEAT 27

28 PSCs, ZPICs, MEDICs Identify cases of suspected fraud and abuse Refer cases of suspected fraud to OIG Refer cases of suspected abuse to: Medicare Contractor, and/or OIG May take concurrent action 28

29 OIG Office of Inspector General: Protects Audits, investigates, inspects Excludes and penalizes 29

30 Polling? #3- Question 3: Select the correct answer. The OIG Provider Fraud Hotline phone number is?: A CMS-TIPS B HHS-TIPS C OIG-TIPS D DOJ-TIPS 30

31 DOJ Department of Justice Investigates fraud and abuse in Federal Government programs Partners with the OIG through HEAT 31

32 HEAT Health Care Fraud Prevention and Enforcement Action Team Multi-agency team of federal, state and local investigators Help prevent waste, fraud, and abuse in the Medicare and Medicaid Programs, and Crack down on fraud perpetrators who abuse the system Reduces health care costs and improves the quality of care Highlights best practices by providers and public sector employees Builds upon existing partnerships between the DOJ and OIG Maintains the Stop Medicare Fraud website 32

33 Compliance?

34 Compliance Role Encourage an environment of self-monitoring, detection and resolution of problems Encourage a culture of integrity and transparency Encourage development and revision of policies and procedures to enhance compliance Continuous awareness of coding/billing changes 34

35 In a Nut Shell

36 Compliance Plan Audit & Education Documentation Coding Billing 36

37 Why Compliance? Government oversight gathers momentum... On average $7.20 ROI for every dollar ($1.00) spent on detection and enforcement of - Fraud -Waste - Abuse 37

38 Compliance Acronyms RAC Recovery Audit Contractor MIC Medicaid Integrity Contractor ZPIC Zone Program Integrity Contractor These are the new Sheriffs in town, they have found Medical Practices to be quite lucrative targets. Their targets include privacy, coding, documentation and billing. 38

39 The Game Plan

40 Review It Audit: - Documentation - Coding - Billing 40

41 Sync It Your review should identify those areas where you are compliant! 41

42 Gap It Your review should identify those areas where gaps exist between what You are doing and what You should be doing 42

43 Don t Fake It We believe in honest and healthy bottom lines. You should too! Therefore, everything should be reported as you find it. No credit should be given for what may have been intended or meant to be done If a discrepancy is identified do something! 43

44 Fix It Create an Action Plan: - Education - Communication - Monitoring - Follow-up 44

45 Enforce It -Designate a Compliance Officer -Maintain written compliance standards -Train all team members -Conduct audits -Make open communication a POLICY -Respond to offenses & take corrective action -Publicize guidelines -Enforce disciplinary standards 45

46 Tools of the Trade Data mining What s in your Toolbox? Comparison data available Bell Curve Analysis Modifier utilization RVU analysis Claim rejections LCD/NCD/Payer policies-rac website Coding Resources OIG Work plan 46

47 What s new?

48 CERT Task Force August 2013 MACs announce Launch educate providers on costly claim denials and billing errors to Medicare goal is to collaborate on innovative educational products reduce the national payment error rate, as measured by the Comprehensive Error Rate Testing (CERT) program independent from the Centers for Medicare & Medicaid Services (CMS) CERT team and CERT contractors Participating Contractors Cahaba Government Benefit Administrators, LLC/J10 CGS Administrators, LLC/J15 First Coast Service Options, Inc./J9 National Government Services, Inc./J6 and JK Noridian Healthcare Solutions, LLC/JE and JF Novitas Solutions, Inc./JH and JL Palmetto GBA/J11 Wisconsin Physicians Service Insurance Corporation/J5 and J8 48

49 Health Care Fraud in the News! WASHINGTON- May 13, 2014 Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that a nationwide takedown by Medicare Fraud Strike Force operations in six cities has resulted in charges against 90 individuals, including 27 doctors, nurses and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $260 million in false billings. 7 th national take down by Strike Force, part of HEAT The crimes charged represent the face of health care fraud today doctors billing for services that were never rendered, supply companies providing motorized wheelchairs that were never needed, recruiters paying kickbacks to get Medicare billing numbers of patients. The fraud was rampant 49

50 Current Risk

51 Employees Whistleblowers Physicians Former employees Non-qualified staff; Incident to services Unskilled coders/billers Midlevel Providers 51

52 Unbelievable Volume Physician bills level 4 and 5, 95% of time OIG report 1700 Physicians identified 1700 Physician NPI list- available High frequency of claims 52

53 EHRs OIG Report Documentation vulnerabilities identical documentation across services Cloning Copy & Paste Templates 53

54 Modifiers Billing for service in global that are considered part of Global Package Use of Modifier 25 to unbundle E&M from procedure on same day-every visit Use of Modifier 59 when not warranted or due to claim edit for modifier- used without understanding purpose 54

55 Incorrect Coding-Billing Wrong procedure code billed but higher RVU Wrong number of units Wrong ICD-9 diagnosis code- medical necessity met per policy not per documentation E&M services billed at EVERY visit Documentation does not support what was billed 55

56 Claim submission errors Medicare News: Top Claim Submission Errors DESCRIPTION Non-covered charge/s. Charges exceeds fee schedule/maximum allowable amount or contracted/legislated fee arrangement. Duplicate claim/service. RESOLUTION Prior to performing or billing a service, ensure that the service is covered under Medicare. Please refer to the Centers for Medicare & Medicaid Services Internet Only Manual, , Chapter 16. Please check your Medicare Summary Notice for the additional remark codes as to why your claim has been adjusted. Please check claim status through the IVR to see if another claim was paid or is currently being processed. To prevent duplicate denials, allow us sufficient time to process a claim before submitting a second. Claim not covered by this payer/contractor. This denial indicates that the service is one that is processed or paid by another contractor. Examples of these types of service are: Durable Medical Equipment, hospice related services or Medicare Advantage. You must send the claim to the correct payer/contractor. The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This item or service is not covered when performed, referred or ordered by this provider. Claim/service lacks information which is needed for adjudication. Prior to submitting a claim, please ensure all required claim information is reported. To verify the required claim information, please refer to chapter 9 of the A/B Reference Manual. This non-payable code is for required reporting only. This code is for informational/reporting purposes only. 56

57 ROI OIG estimates it recovers $16.70 for every $1 it spends on fraud and abuse activities CMS reports its efforts yield $8.10 for every $1 spend on fraud and abuse activities Justice Department officials report recovering record breaking $4.3 billion in healthcare fraud FY2013: 137 cases filed, 345 individuals charged, 234 guilty pleas and 46 jury trial convictions 57

58 Overpayments Return Medicare and Medicaid overpayments an overpayment must be reported and returned within 60 days after the date on which the overpayment was identified At risk of being alleged to have violated the False Claim Act - knowing and improper failure to return the overpayment 58

59 Common Fraud & Abuse Billing for service not rendered Misrepresentation of nature of item or service Off label use Failure to return erroneous payments Improper financial relationships/referrals Medical Directorships/Consulting/advisory boards False statements on enrollment applications Billing services under another s NPI 59

60 Reimbursement Opportunities?

61 Achieve It A Compliance Plan that works for you and the whole group, might even help with better reimbursement! -Clean claims -Faster Payment -Lower AR -Decrease DRO 61

62 Where are you in the process? 62

63 Polling? #4- Where are you in your Compliance planning? Been there, done that. Well on my way. I think I can. Where do I begin? 63

64 The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement and policy making. B. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

65 Resources

66 Resources CERT A/B MAC Outreach & Education Task Force: CMS- Improper payment rate: CMS Provider Compliance: Network-MLN/MLNProducts/ProviderCompliance.html Stop Medicare Fraud: OIG- Compliance: OIG- EHR and E&M Services: 66

67 Questions?

68 For More Information Rosie Donovan, RHIA, CCS-P G2N, Inc

69 CPE Certificates This webinar qualifies for 1 CPE credit. Please complete our short survey of 8 questions that will appear at the end of the webinar in order to receive your certificate. Your certificate will be ed to you.