Introduction 1/12/2015. Healthcare Reform Compliance and Audit Updates. Jon Weeding President CS EYE

Transcription

1 Healthcare Reform Compliance and Audit Updates Jon Weeding President CS EYE This material is designed to offer basic information for creating a compliant atmosphere in the small private practice. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This presentation is intended as an educational guide and should not be considered a legal/consulting opinion. CPT is a registered trademark of the American Medical Association. All rights reserved. Introduction The purpose of this presentation is to provide a basic understanding of how healthcare reform has increased funding for enforcement of existing laws, regulations and requirements of healthcare providers. Real world examples of increased audit activity in optometry, their triggers and results will be shared. This presentation will also demonstrate how the increased focus on compliance and audit activity, as well as changes in reimbursements, are affecting the way optometry must practice to fully participate in eye care moving forward. 1

2 IMPACT OF HEALTHCARE REFORM Federal Guidelines/Regulations affecting Healthcare Providers Why is compliance so important today The Age of Big Data and Claims Analysis Ongoing Audits: Compliance, HIPAA, Meaningful Use EHR Stimulus, CPT Profiles, Medical Record, Quality Control and Targeted Data Audits Examples and talking points Healthcare Reform is changing the way Optometry must practice MCO s, MA s, ACO s minimum requirements Standard of Care following medical guidelines Audit findings for optometry Positives?! The LAWS: Federal Regulations Federal and State regulatory agencies are safeguarding patients and the government against fraudulent or abusive billing practices. A few of the laws affecting healthcare: False Claims Act (1861) aka Lincoln Law Mail and Wire Fraud Act Criminal Health Care Fraud Statute (2010) Social Security Act 1935 OBRA (Omnibus Budget Reconciliation Act) (1987) Medicare Catastrophic Act (1988) (Repealed in 1989) HIPAA (Health Insurance Portability and Accountability Act 1996) BBA (Balance Budget Act 1997) BBRA (Balanced Budget Refinement Act of 1999) BIPA (Benefits Improvement and Protection Act of 2000) MMA (Medicare Prescription Drug Improvement and Modernization Act of 2003) DRA (Deficit Reduction Act of 2005) MMSEA (Medicare, Medicaid, and SCHIP Extension Act of 2007) MIPPA (Medicare Improvement for Patients and Providers Act of 2008) MPPRA (Medicare Physician Payment Reform Act of 2009 HITECH 2010 from ARRA 2008 (Health Information Technology for Economic & Clinical Health from American Recovery and Reinvestment Act 2009) PPACA 2010 (Patient Protection and Affordable Care Act) The Laws are not new but ACA has put teeth into the laws by funding audit activity. The education phase is over! We have entered the enforcement phase! 2

3 DRAMATICALLY INCREASED AUDIT ACTIVITY Operation Restore Trust returned $23 for each $1 invested. All Payers are expanding auditing contracts and personnel due to the proven financial benefit! $4+ billion in 2010, $6+ billion in 2011, $15+ billion in 2012 and $23+ billion in 2013 returned to CMS. Medicare, which was going bankrupt by 2014, is now funded beyond 2017 due in part to aggressive audit activity. Medicare Program Integrity Partners and Approaches Medicare Program Integrity Partners and Approaches We collect 9 to 17.5% on improper payments 3

4 Claims Analysis OIG Work Plan Targets Eye Care Eye care specifically targeted by OIG work plan focusing on 92xxx ophthalmic codes and 99xxx codes Ophthalmologists Questionable billing Billing and Payments. We will review Medicare claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during Evaluation and management services Inappropriate payments Billing and Payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities # 1 priority of OIG TO PREVENT FRAUD, WASTE AND ABUSE. Claims Analysis What Are Insurance Providers Looking At? Comprehensive, Intermediate Exams and Refractions 92002, 92004, 92012, and Diagnostic Testing 92020, 9208x, 9213x, 92250, Evaluation and Management Coding 99xxx Combination of Diagnostic Testing and 99xxx coding Diabetes, Glaucoma and Mac. Degeneration Medically Necessary Contacts Chronic illness - Risk Adjustments 4

5 Age of Big Data Medicare Claim Percent of Use Comparative Billing Report Compared clinic s usage with 2,149 other clinics (PTANs) in Peer Group of the specialty 41 Optometry. Compared usage over 12 months within the J5 MAC jurisdiction (4 states). Information from WPS Medicare Administrative Contractor Clinic Comparison CPT Usage Percent CPT Usage Percent % ,218 1% % ,432 21% % ,712 46% % ,661 31% % ,105 1% Claims Analysis Audit Results South Dakota Federally Funded Healthcare Audit Recovers $283,499 A South Dakota optometrist reached a settlement with the South Dakota Attorney General s (AG) Medicaid Fraud Control Unit (MFCU), and the U.S. Department of Health and Human Services (HHS), Office of the Inspector General (OIG). The optometrist will be shelling out $283,499 to resolve allegations he submitted false claims to Medicare, Medicaid and TRICARE, according to the South Dakota AG. This settlement was announced on October 1,

6 Claims Analysis Audit Results Mississippi Medicaid Audit Recovers $131,249 5,652 pages for 167 line item claims were reviewed. 20 of 167 did not establish medical necessity. Of the 147 that were deemed medically necessary, 62 were identified for up coding due to a lack of documentation to support the code submitted. 5 lacked the documentation to support the quality of care provided. Claims Analysis Audit Results California VSP Audit May 2014 Recovers $37,000 Flagged due to claims analysis. Medically necessary contact lenses. Unannounced, in person audit, pulled/printed 40 charts (2 included medically necessary CL) Specific plans followed, optical notes did not have enough specificity Recouped due to lack of adequate documentation VSP and EYEMED Audits have increased dramatically: Quality Control Audits call for reviewing all providers 1-3 years Targeted Audits in VSPs case, performed by Special Investigation Unit, unannounced and asking for records. Not random. Performed to prove you are in violation, not to see if you are. Recent VSP AUDIT Results in 2014: $62,000 VSP Recoupment $160,000+ VSP Recoupment Recent audit overturned and dismissed!! Claims Analysis Audit Results Minnesota Optometry Meaningful Use Audit: Downloaded popular HIPAA Compliance Manual and felt they were diligent about customizing it for their practice Failed MU audit with doctor # 1, audit soon followed for doctor # 2 and anticipated following with doctor # 3 $40,000 plus at risk Asking for recoupment of stimulus dollars based on lack of following a compliance program and providing proof that a security risk assessment has been performed 6

7 FREE CPT PROFILE TOOL Know how insurance payers see your practice For FREE CPT PROFILE HIPAA and COMPLIANCE AUDITS Based on findings from the HIPAA audits OCR is preparing for another round of audits starting in the Fall of Do you have a compliance officer and compliance manual? Have you performed a security risk assessment with implementation plan and completion dates? Do you have copies of records reviewed and mitigation plans to address any errors in documentation? HIPAA Enforcement Violation Penalty Max Calendar Year Did Not Know $100 - $50,000 $1,500,000 Reasonable Cause $1,000 - $50,000 $1,500,000 Willful Neglect (Corrected) $10,000 - $50,000 $1,500,000 Willful Neglect (Not Corrected) $50,000 $1,500,000 A Covered Entity (CE) or Business Associate (BA) may be liable for multiple violations of multiple requirements, and a violation of each requirement may be counted separately. A CE or BA may be subject to multiple violations of up to a $1.5 million cap for each violation, which would result in a total penalty above $1.5 million. 7

8 Lack of proof that a security risk analysis has been performed that outlines risks and shows effective action has been taken to address risks is the number one reason for EHR Stimulus Funding to be recouped during a Meaningful Use Audit. Excerpt from Meaningful Use Audit 2014 Centers for Medicare and Medicaid Services Document Request List - Eligible Professionals Medicare Electronic Health Record (EHR) Incentive Program Please provide all of the documents requested below by the due date. **Please separate your submissions by the item numbers listed below** (A) Item Number (B) Requested Documents 3 Core #15- Protect Electronic Health Information: Provide proof that a security risk analysis of the Certified EHR Technology was performed prior to the end of the reporting period (i.e. report which documents the procedures performed during the analysis and the results of the analysis). If deficiencies are identified in this analysis, please supply the implementation plan; this plan should include the completion dates. Tips & Complaints OIG Hotline Operations Whistle Blower Risks OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the US Department of Health and Human Services' programs. Your information will be reviewed by a professional staff member. Due to the high volume of information that we receive, we are unable to reply to submissions; however, we appreciate the information that you have provided. How to Contact the OIG Hotline Contacting the OIG Hotline is as easy as selecting from the following: I am NOT an HHS Employee I am an HHS Employee 8

9 Don t let your audit serve as the ultimate warning for all others! Act Now! MCOs, MAs, and ACOs Changing the way healthcare is delivered and paid for (fee-for for-service +) Driven by primary care provider and outcome based (huge incentives for saving $$) Managed Care Organizations (MCOs), Medicare Advantage Plans (MAs) and Accountable Care Organizations (ACOs) are requiring participants: Meet compliance standards (minimums) Provide best practices standard of care on disease management (follow professional medical guidelines) To implement electronic medical record system (E.H.R.) To have standardized reporting metrics To treat patients with chronic illness as an interdisciplinary team with team based care To communicate with other providers through electronic pathways MCOs, MAs, and ACOs Medicare Advantage Plans Funding based on lives covered Five Star (Stars) ratings Additional funding if percentage of sick patients is higher during a reporting period Risk adjustment audits Reducing provider panel size and focusing on: Compliant practices Practices following standard of care Practices reporting chronic illnesses on claim form PA MA plan targeted optometry as reason for dropping from 5 to 4 stars If they don t raise level to 5 stars, funding reduced such that they likely cease to exist 9

10 Standard of Care Following Medical Guidelines 1. Adherence to standard of care or best practices for disease management will help your practice standout in online reviews 2. Practices that follow standard of care will have an increased opportunity to participate with Accountable Care Organizations (ACOs) 3. Practices that follow standard of care generate more revenue and are more profitable than their colleagues that do not 4. Practices that follow standard of care reduce risk associated with profiling based on claims data analysis Standard of Care Following Medical Guidelines 1. Adherence to standard of care or best practices for disease management will help your practice standout in online reviews. Optometry is a specialty comprised of knowledgeable and patient care focused physicians. Audits of medical records has shown that, as a specialty, optometry is providing excellent care; however under coding or not following best practices standard of care is also prevalent. Adhering to proper coding guidelines and standard of care will enhance your revenue and improve your outcomes. Provider websites are increasingly showing information on doctor s fees, care and reviews. Some compare them on quality of care based on claims data. If you are following standard of care, it will show in the provider s review based on analysis of your claims data. Standard of Care Following Medical Guidelines 2. Practices that follow standard of care will have an increased opportunity to participate with Accountable Care Organizations (ACOs). ACOs are forming throughout the country, with over 500 now funded by either public or private sectors. Optometry needs to be at the table as these groups assign eye care providers for their covered members or risk being on the outside looking in. ACO participation may increase patient volume to your practice (a group practice in OH estimates receiving 400 additional patients per month based on their participation). Optometry practices that demonstrate they are compliant and following standard of care create a favorable addition to ACOs. 10

11 Standard of Care Following Medical Guidelines 3. Practices that follow standard of care generate more revenue and are more profitable than their colleagues that do not. As noted in # 1 above, our specialty has created an environment of under-coding and under-utilization rather than up-coding or over utilization and that can lead to increased medical legal liability due to limited diagnostic testing in line with standard of care, and under charging for services. Practices that diligently document and follow coding guidelines, as well as implement standard of care for frequency of visits and diagnostic testing, have shown increases of $30,000 or more annually. Standard of Care Following Medical Guidelines 4. Practices that follow standard of care reduce risk associated with profiling based on claims data analysis. As providers embrace the age of big data, their edits detect anomalies in billing patterns based on deviation from the norm. Practices that are following the standard of care for frequencies of visits and diagnostic testing typically follow the billing patterns of their peers and are less likely to stand out in a profile analysis, and are less likely to be identified for a target audit. Standard of Care Following Medical Guidelines As always, care should be taken to ensure that the services provided are medically necessary, are documented properly and aid in the management of disease or treatment of that patient. 11

12 Audit Findings Optometry audit findings: 1. Practice does not have compliant written policy and procedures 2. Practice has not completed a security risk analysis/assessment 3. Practice documentation of medical record is lacking 4. Practice is under coding on 99xxx codes 5. Practice is up coding on 99xxx codes 6. Standard of care is not being followed for diagnostic testing Audit Findings Optometry audit findings: 1. Practice does not have compliant written policy and procedures Required to be in electronic format Outlines the specifics of your organization Defines key officer roles and who fills key those roles Compliance, Privacy, Public Information and Security Includes updated privacy policy and business associates required from Omnibus ruling September Outlines practice standards, procedures and adherence to health care laws and regulations Describes record retention, privacy and security Audit Findings Optometry audit findings: 1. Practice does not have compliant written policy and procedures (continued) Provides auditing, benchmarking and monitoring of charts and claims Details and documents training and education Outlines communication and compliance reporting protocol Enforcement employment and employee discipline Should include the necessary templates, letters and documents necessary to meet HIPAA requirements Practice should also complete mandatory HIPAA and Fraud, Waste & Abuse training and testing annually 12

13 Optometry audit findings: Audit Findings 2. Practice has not completed a security risk analysis/assessment Required of all healthcare providers regardless of MU As part of each attestation Every 2-3 years or anytime significant changes are made Optometry audit findings: Audit Findings 3. Practice documentation of medical record is lacking Medical necessity not established with chief complaint Chief complaint and primary diagnosis don t match No written order for diagnostic testing No interpretation and report Not tying diagnostic test to management and treatment option Optometry audit findings: Audit Findings 4. Practice is under coding 99xxx exams Audit of records shows that if the physician had documented properly, the record would support a higher code Doctor performed the work and documented, but still billed a lower code (to be safe) Lack of understanding Medical Decision Making 13

14 Optometry audit findings: Audit Findings 5. Practice is up coding 99xxx exams Audit of records shows that the record would not support the higher code chosen (99214 most typical) Lack of understanding when to bill 92xxx versus 99xxx Lack of understanding Medical Decision Making Optometry audit findings: Audit Findings 6. Standard of care not being followed Underutilization leads to medical legal exposure Lack of understanding of guidelines Frustrating YES! Does it have to be.no! 14

15 HIPAA and COMPLIANCE AUDITS Based on findings from the HIPAA audits OCR is preparing for another round of audits starting in the Fall of The results of those findings will drive desk and field audits in Do you have a compliance officer and compliance manual? Have you performed a security risk assessment with implementation plan and completion dates? Do you have copies of records reviewed and mitigation plans to address any errors in documentation? Commitment to Compliance 15

16 Positives A solo optometry practice that implements compliance with standard of care, wellness/preventative plans, and proper coding, billing and documentation has seen increases in revenue of $30,000 to $100,000 in the first 12 months of doing so. As noted previously, proactively establishing your practice as compliant and following standard of care, and seeking participation in newly forming ACOs has led to an increase in patient volume. 16

17 Remember be a pig! Not a chicken! QUESTIONS? Healthcare Reform: Compliance and Audit Updates Jon Weeding President CS EYE 17