Inspections and investigations and audits what you really didnt know
Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical...
Transcript of Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical...
![Page 1: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/1.jpg)
Department of Health Care Services
Audits & InvestigationsMedical Review Branch
Agenda Item 5
BRD 5-1
![Page 2: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/2.jpg)
2
Healthcare Expenditures Industrialized Nations : % 2011 GDP
Canada10.91
USA17.98
Brazil8.90
Israel7.73
Australia9.03
Japan9.27
EuropeUK 9.32France 11.63Germany 11.06Sweden 9.36Switzerland 10.86
US GDP 2011 : $14 .9 trillionHealth care spending: $2.8 trillion
World Health OrganizationTotal expenditure on health as a % of Gross Domestic Product, 2011
China5.15
South Africa8.66
Fraud, Waste & Abuse19%
Thomson Reuters, 2009
Agenda Item 5
BRD 5-2
![Page 3: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/3.jpg)
Error
Incorrect Coding
Waste
Medically Unnecessary
Service
Abuse
Improper billing
practice
Fraud
Billing for unnecessary Services or Supplies not
Provided
Intentional Deception
Bending the RulesInefficienciesMistakes
Agenda Item 5
BRD 5-3
![Page 4: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/4.jpg)
$70 billion (2014)1 in 5 people covered
Agenda Item 5
BRD 5-4
![Page 5: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/5.jpg)
5
Agenda Item 5
BRD 5-5
![Page 6: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/6.jpg)
Agenda Item 5
BRD 5-6
![Page 7: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/7.jpg)
Agenda Item 5
BRD 5-7
![Page 8: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/8.jpg)
Agenda Item 5
BRD 5-8
![Page 9: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/9.jpg)
A con artist is a professional
A con artist needs a conduit
A con artist needs a victim to take the fall
A con artist doesn’t care about the harm
Agenda Item 5
BRD 5-9
![Page 10: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/10.jpg)
Focus on medicine
Not taught about business (e.g. Don’t sign a blank contract!!!)
The National Provider Identifier is like a credit card without a limit
Agenda Item 5
BRD 5-10
![Page 11: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/11.jpg)
Deficit Reduction Act of 2005
Program integrity is the practical concept that programs should be organizationally and structurally sound
Health care – programs efficient, effective, ethical Corollary: prevent fraud, waste & abuse
Agenda Item 5
BRD 5-11
![Page 12: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/12.jpg)
Medical and Audit staff
Pre-Enrollment Reviews Utilization Controls Sanctions Referrals Studies Compliance Audits Outreach
Agenda Item 5
BRD 5-12
![Page 13: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/13.jpg)
Medical Board
Pharmacy Board
Centers for Medicare and Medicaid
Department of Justice
Agenda Item 5
BRD 5-13
![Page 14: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/14.jpg)
Prevention Disclosure Knowledge is Power Stop unlicensed practice
Affordable, quality care
Best use of dollars
Agenda Item 5
BRD 5-14
![Page 15: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/15.jpg)
Agenda Item 5
BRD 5-15
![Page 16: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/16.jpg)
Agenda Item 5
BRD 5-16
![Page 17: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/17.jpg)
Agenda Item 5
BRD 5-17
![Page 18: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/18.jpg)
Identity Theft versus Identity Lease
Avoid Patient Harm
Close the Knowledge Gap
Agenda Item 5
BRD 5-18
![Page 19: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/19.jpg)
Professional Societies California Medical Association Webinars Partner with Centers for Medicare & Medicaid Residency Programs Journal articles Education materials
Patients Providers
Agenda Item 5
BRD 5-19
![Page 20: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/20.jpg)
Need to Reach a Wider Audience
Agenda Item 5
BRD 5-20
![Page 21: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/21.jpg)
3 one hour Interactive Webinars
Developed with Xerox (fiscal intermediary)
Free
Goal – Free Continuing Medical Education
Subject Matter Experts
Agenda Item 5
BRD 5-21
![Page 22: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/22.jpg)
Module I Impact of fraud, waste & abuse
Module II Prescribing & Referring
Module III Documentation & Internal Controls
Agenda Item 5
BRD 5-22
![Page 23: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/23.jpg)
Timeliness
Impact of prescribing
Videos/input from other experts
Welcome Medical Board support
Agenda Item 5
BRD 5-23
![Page 24: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/24.jpg)
Attitudes
Education
Benefit for the greater good
Agenda Item 5
BRD 5-24
![Page 25: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/25.jpg)
Agenda Item 5
BRD 5-25
![Page 26: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/26.jpg)
Agenda Item 5
BRD 5-26
![Page 27: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/27.jpg)
Agenda Item 5
BRD 5-27
![Page 28: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/28.jpg)
Agenda Item 5
BRD 5-28
![Page 29: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/29.jpg)
Agenda Item 5
BRD 5-29
![Page 30: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/30.jpg)
Agenda Item 5
BRD 5-30
![Page 31: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/31.jpg)
Agenda Item 5
BRD 5-31
![Page 32: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/32.jpg)
Agenda Item 5
BRD 5-32
![Page 33: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/33.jpg)
Agenda Item 5
BRD 5-33
![Page 34: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/34.jpg)
Agenda Item 5
BRD 5-34
![Page 35: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/35.jpg)
Agenda Item 5
BRD 5-35
![Page 36: Audits & Investigations Medical Review Branch · 05/02/2014 · Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1. 2 Healthcare Expenditures Industrialized Nations](https://reader031.fdocuments.net/reader031/viewer/2022011801/5ae808007f8b9aee078ef2c4/html5/thumbnails/36.jpg)
Agenda Item 5
BRD 5-36