Building a Practice Compliance Plan

Presented by:

Shelley Garrett, CPC, CMC, CMOM, CMIS

OIG 2012

www.oig.hhs.gov

OIGPhysicians and Suppliers:

ComplianceWith Assignment Rules

Reviewing for Inappropriately billed in excess of amounts allowed by Medicare and to assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.

OIGPhysicians and Other Suppliers:

HighCumulative Part B Payments Reviewing for a high cumulative

payment defined as an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse.

OIGPhysician-Owned Distributors of

SpinalImplants

Reviewing to what extent to which physician-owned distributors (POD) provide spinal implants purchased by hospitals and analyzing Medicare claims data to determine whether PODs that have been identified in review are associated with high use of spinal implants. Congress has expressed concern that PODs could create conflicts of interest and safety concerns for patients.

OIGPhysicians: Place-of-Service

Errors Reviewing physicians’ coding on

Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed.

OIGPhysicians: Incident-To Services Medicare Part B pays for certain

services billed by physicians that are performed by non-physicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. We also found that unqualified non-physicians performed 21 percent of the services that physicians did not perform personally.

OIGPhysicians: Impact of Opting Out of

Medicare

Reviewing the extent to which physicians are opting out of Medicare and determining whether physicians who have opted out, are permitted to enter into private contracts with Medicare beneficiaries.

As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.

OIGChiropractors: Part B Payments for

Services Reviewing Medicare Part B payments

for chiropractic services to determine whether such payments were in accordance with Medicare requirements. Medicare chiropractors’ services include only treatment by means of manual manipulation of the spine. Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable.

OIGEvaluation and Management Services: Use

of ModifiersDuring the Global Surgery Period Reviewing the appropriateness of the use of

certain claims modifier codes during the global surgery period to determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements.

The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period.

Steps to a Compliance Plan

The OIG has established a list of

Seven key elements whenestablishing your

Compliance plan.

Step One…

Have a written policyand procedure manual

Step Two…

Designate a Compliance

Professional to oversee

the plan

Step Three…

Conduct an effective training

program

Step Four…

Provide an effectivecommunication program

Step Five…

Develop an internalmonitoring program

Step Six…

Enforce your standards with

a corrective action plan

Step Seven…

Promptly respond to issues

Keys to Success

Foster a Culture of Compliance

Be sure that policies are updated and user friendly

Make training a part of the job

Keys to successStay current

Be visible and approachable

Take appropriate corrective action

Conduct regular audits

Address Areas of Concern

Coding

Contracts

Quality of Care

False Claims ActThis act addresses any entity who submits or causes to be submitted a

claimfor services that are: Not rendered Miscoded Already covered under another

claim Not supported in the medical

record Violates Stark Law

Penalties

If a claim is submitted by an individual who "knows or should know“ (termed deliberate ignorance) that they are filing a false claim, civil sanctions may be imposed.

Penalties Civil sanctions may be as much as

$11,000 per claim ($50,000 for an anti-kickback violation) plus an assessment of up to three times the amount improperly claimed.

Each claim for payment could cause a separate penalty.

Qui Tam Suits Whistle blower suits pay 30% of

the recovered amount. Who are known whistleblowers:

Patients Patients family members Competitors Past and Present Employees Ex-Business Partners

Code of Conduct

Each compliance plan should begin with a

code of conduct.

All employees, physicians, and any member of practice oversight should be educated. As a record of education you should have a signed copy of acknowledgement on file.

Comprehensive Plan

Coding and Billing Compliance Plan

HIPAA

OSHA

CLIA

Training

Annual training should be conducted on all areas of compliance and a record of attendance should be kept and readily available.

Ongoing Training Keep up with changes and

communicate with all staff

New Employees need intense training and all employees need refreshers

Make sure all training complies with state and federal regulations.

Ongoing Training

Be sure that all employees know the compliance plan, as well as, who should be notified when an issue arrives.

If you are the compliance professional: Be approachable and always have a no retaliation policy.

Follow-up on Reports

Conduct investigation

Document the areas of concern and how the issue was resolved

Self report, when necessary

Policies to Keep in Mind

Patient Discounts

Routine Waiver of Co-pays/Deductibles

Attempt to collect policy Bad debt write-offs Discounts and processional

courtesies

Policies continued…

Coordination of Benefits

Medicare/MedicaidMedicare as a Secondary

PayerLiability or No-Fault Insurance

Policies…

Business Relationship

Stark LawPrivate ContractingPhysician Coverage

Arrangements

Policies…Documentation Guidelines

1995 and 1997Proper Documentation for

ConsultationsGlobal and Bundled ServicesCare Plan OversightScreening Services

What steps have you taken toward compliance?

Audit Program Establish a realistic audit schedule Decide if all audits will be done in-

house, if you will seek outside help, or will use a combination of both

Decide if you need additional auditing or training based on what you discover

Self report on your findings Implement corrective action to

promote compliance

Audit Program Random sample vs targeted Sample all types of service

provided Review the encounter form

(charge ticket) and EOB in addition to the medical record. This will help you locate missed charges or inappropriate payments.

Take the opportunity to begin proactive education approach to ICD-10

Shelley Garrettmycodingconsultant@yah

oo.com

Questions?