Mary Ellen Duffy, MBA, FACMPE, CHBME 1
To crack down on the people and organizations who abuse the system and cost Americans billions of dollars each year. Detroit: 2013 brought charges in fraud schemes billing more than $380 million. Health Care Fraud Prevention and Enforcement Action Team Stephen Parente, a professor of health finance at the University of Minnesota who has studied medical billing extensively, estimates that 30% to 40% of hospital bills contain errors The Access Project, a Boston-based health-care advocacy group, says it's closer to 80% 2
Live your compliance plan Continually train staff and providers Expect errors Actively look for errors Remediate Determine how to prevent in the future Do not become complacent! 3
CYA: Document, document, document Keep a billing source binder or electronic file Who, when and how were you told What is the expert s credentials Is your information current? Obtain certification Attend seminars CMS listserv MLN Matters MAC and RAC listservs CMS Open Door Forum Payor newsletters Professional societies Specialty billing publications http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/fy15-work- Plan.pdf 4
Physicians Place-of-service coding errors Ophthalmologists Inappropriate and questionable billing Anesthesia services Payments for personally performed services Diagnostic radiology Medical necessity of high-cost tests Imaging services Payments for practice expenses Physical therapists High use of outpatient physical therapy services Sleep disorder clinics High use of sleep-testing procedures Questionable billing of Chiropractic and Ambulance services Random EP Meaningful Use audits Do you pay Overhead expenses? POS 11 Office YES POS 22 - Hospital outpatient NO POS 24 ASC NO Be sure to add and delete practice locations with Medicare and Medicaid 5
Prevent billing for items or services not actually rendered Prevent billing for items or services not actually documented Prevent billing for medically unnecessary services Prevent upcoding Prevent inappropriate balance billing Prevent duplicate billing Prevent inadequate resolution of overpayments To prevent unbundling Ensure the integrity of billing information Ensure the confidentiality of PHI Prevent misuse of providers identification numbers Follow provisions of reassignment of benefits Properly use CPT modifiers Prevent incentives that violate anti-kickback statute Prevent violations of the Stark self-referral law Avoid insurance only arrangements 6
Proportionally apply discounts and professional courtesy to patients and payors Ensure procedure and diagnosis coding are based on medical documentation Avoid the employment of sanctioned individuals AMA Medical necessity: Health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician or other health care provider.. According to section 1862(a)(1)(A) of the Social Security Act, Medicare will not cover services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The best way to stay within the bounds of medical necessity is to think of each element of the history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. Be careful of EHRs coding Follow NCDs and LCDs 7
Sec. 6402 of the ACA: Obligation to report and return overpayments within 60 days of identifying overpayments CMS: A person has identified an overpayment if the person has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment Overpayments are not found money Offset rationalization Federal law allows OIG/DOJ to prosecute any overpayments not just Medicare and Medicaid The federal threshold for refunds is $0.01 MI Unclaimed Property filing Credit balances can cause Accounts Deceivable Be sure to verify the legitimacy of the credit balance 8
CCI (Correct Coding Initiative) Edits CCI edits are updated every January, April, July, and October References: Such as Flashcode, Supercoder Specialty newsletters PA, NP, CNS services odirect bill o Incident To Surgery Assistant osome services are not reimbursed for assistant surgeon services (identified by co-surgeon indicator "0" osome services are reimbursed for assistant surgeon services only if documentation supports medical necessity (identified by co-surgeon indicator "1" Modifier 50 Inappropriate use: Reporting this modifier when performing the service on different areas of the same side of the body. The BILAT SURG indicator is 0, 2, or 9. When removing a lesion on the right arm and one on the left arm. Use the RT and LT modifiers. On a procedure code that is described as bilateral or unilateral or bilateral in its CPT description. Do not report a bilateral procedure on two lines of service appending modifier 50 to the second line of service. 9
Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure Appropriate use: Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed. Use Modifier 25 with the appropriate level of E/M service. The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010, or 090 days. Acceptable use: An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.) Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service. 10
Unacceptable use: A physician other than the physician performing the procedure. Documentation shows the amount of work performed is consistent with that normally performed with the procedure. Acceptable use: Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances. Documentation indicates two separate procedures performed on the same day by the same physician Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury) The following statements are false: I can always use this modifier when I did not plan the procedure. I can always use this modifier when the diagnoses are different. I can never use this modifier when the diagnoses are the same. 11
Acceptable use: Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits. Use Modifier 59 when there is NO other appropriate modifier. Use Modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service Unacceptable use: Code combination not appearing in the NCCI edits Submission of E/M Codes Submission of weekly radiation therapy management codes (CPT 77427) The NCCI tables lists the procedure code pair with a modifier indicator of "0" Documentation does not support the separate and distinct status Exact same procedure code performed twice on the same day Multiple administration of injections of the same drug If a valid modifier exists to identify the service Acceptable use: Append modifier 24 to the E/M procedure code. Use on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician during the 10 or 90 day postoperative period. Use modifier 24 on the E/M if documentation indicates the service was exclusively for treatment of the underlying condition and not for postoperative care. 12
Acceptable use: Use modifier 24 on the E/M code when the same physician is managing immunosuppressant therapy during the post-operative period of a transplant. Use modifier 24 on the E/M code when the same physician is managing chemotherapy during the post-operative period of a procedure. When the same physician provides unrelated critical care during the post-operative period. Unacceptable use: Do not use when the E/M is for a surgical complication or infection. This treatment is part of the surgery package. Do not use when the service is removal of sutures or other wound treatment. This treatment is part of the surgery package. Do not use when the surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. Unacceptable use: Do not use unless the medical record documentation clearly indicates the E/M was unrelated to the surgery. Do not use outside of the post-op period of a procedure. Do not use on the same day as a procedure. 13
OIG Advisory Opinion finds insurance only billing may violate anti-kickback Statute OIG has long taken the position that routine waiver of copayments constitutes an illegal kickback, which is a felony Routine waiver of copayments is a violation of the terms of private insurance company plans and can serve as a basis for a recoupment audit Can be seen as an act of collusion to defraud the insurance carrier The waiver must be based on a good faith determination of the patient s financial need Do not be apply routinely Consistently apply your hardship determination process and document your efforts May ask for check stubs, copy of income tax form or other methods to determine Can write-off 100% of the charge or a % discount Written policy no exceptions Cannot be extended to gain referrals would violate anti-kickback statute 14
http://exclusions.oig.hhs.gov/ http://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and- Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html Medicare Provider Utilization and Payment Data: Physician and Other Supplier 15
2014 2012 Medicare Dr 1 Dr 2 2,749 99201 0 0 99202 29,460 109 36 99203 244,575 74 166 99204 781,627 1 0 99205 318,610 0 0 1,377,021 184 202 2014 Medicare Dr 1 Dr 2 99201 0.20% 0.00% 0.00% 99202 2.14% 59.24% 17.82% 99203 17.76% 40.22% 82.18% 99204 56.76% 0.54% 0.00% 99205 23.14% 0.00% 0.00% 100.00% 100.00% 100.00% Cloning Auto populate fields Check one box for all Template misuse Wrong patient Testing records not scanned Billing before records are locked/signed 16
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Run an E&M/CPT volume report for same time period Verify level of coding based on documentation & medical necessity Verify coding meets LCD Self report/contact attorney 18
WPS What is your percentage of claim denials? MGMA states 4% or less acceptable Are you raising a red flag? Are you adhering to the LCD? C.S. Lewis 19
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The Whistleblower is entitled to a maximum of 25% and a minimum of 15% of any funds recovered by the Government as a result of the verdict or settlement. Damon Clinical Laboratories, Inc. fraudulently billed Medicare, Medicaid and CHAMPUS by bundling medically unnecessary tests not knowingly ordered by doctors. The Government recovered $83,700,000 and Jeanne Byrne, one of three whistleblowers, received $9,000,000. Understand that everyone is a potential whistleblower Code of Conduct: Require employee to come to supervisor first Listen [ I tried to tell them ] Keep the potential Whistleblower in the loop Investigate Take action 21
http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-securityguide.pdf Your Practice & the HIPAA Rules Understanding Patients Health Information Rights Understanding EHRs, HIPAA Security Rule & Cybersecurity Meaningful Use Core Objectives that Address Privacy & Security Sample 7 Step Approach for Implementing a Security Management Process Breach Notification, HIPAA Enforcement, & Other Laws Faxing PHI Email & PHI Cell phones & PHI Laptops & PHI Office security 22
HIPAA Omnibus Rule: Patient right to restrict certain disclosures of their PHI to health plans. The right applies only when a patient pays for a healthcare item or service out-of-pocket and in full. Psychotherapy or Substance Abuse notes 23