1

Compliance Guidance for Physicians:

Keeping Your Practice Safe

AAPC

2013 Regional Conference

Presented by

Jean Acevedo, LHRM, CPC, CHC, CENTC

All rights reserved

Agenda

The 7 Elements

The new climate

Effectiveness

CMS demonstration

Grading your compliance program

Internal auditing and monitoring

Reporting

Education

2

The OIG’s Seven Elements

3

1. Conducting internal monitoring and auditing through the performance of periodic audits

2. Implementing compliance and practice standards through the development of written standards and procedures.

3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards.

4. Conducting appropriate training and education on practice standards and procedures.

5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities.

6. Developing open lines of communication to keep practice employees updated regarding compliance activities. Non-retaliation policy.

7. Enforcing disciplinary standards through well-publicized guidelines.

2

Identified Risk Areas

for Physicians

4

Proper coding and billing

Ensuring that services are reasonable and necessary

Proper documentation

Medical record

CMS-1500

Avoiding improper inducements, kickbacks and self-referrals

Coding and Billing

5

Upcoding, unbundling and improper use of modifiers

Misuse of provider’s identification numbers

Q6 (locum tenens) is not to be used to bill for services while you are waiting for Medicare to process the new doctor’s enrollment application.

Billing for:

Items/services not provided

Equipment, supplies and services not medically necessary

Non-covered services as covered

CBC, CMP, EKG as part of an “annual physical”

MAC’s LCD does not cover 76942; billed 76881 instead

Reasonable and Necessary Services

Local coverage determinations

Advanced beneficiary notice

Certificate of medical necessity

6

3

Medical Record Documentation

7

If it is not written - it did not occur

Document medical necessity

Complete, legible and signed!

Do you use scribes? How is that fact

documented?

If on an EMR

Copy & paste

Cloning

CMS 1500 Documentation

Match diagnosis to

documentation in

medical record

Match diagnosis with

procedure code

Identify secondary

insurance coverage

8

Inducements, Kickbacks and

Self-Referrals

Knowledge of or

willfully providing or

receiving anything of

value that can alter

medical decision

making resulting in

increased referrals or

utilization of services is

not permitted

9

4

Inducements, Kickbacks and

Self-Referrals

Claim induced by a kickback is a false claim

How does your State define an inducement, kickback or

self-referral?

Stark and self-referrals

Florida’s Patient Self Referral Act of 1992

FS 456.053

What does your state say?

10

All rights reserved

The New Climate

The New Climate: Whistleblowers

Support and encouragement of whistleblower cases

by leading prosecutors

Whistleblower web sites

Whistleblower support organizations

How-to books, checklists, advice

12

5

The New Climate: Whistleblowers

As of the end of 2012, there were more than 1200

federal qui tam cases under investigation, with no

decision as to whether the DOJ will intervene

Of these cases, over 800 involve healthcare fraud,

many against multiple defendants.

13

The New Climate: Whistleblowers

1/4/2013: $4.4M settlement – EMH Regional

Medical Center, Ohio

Unnecessary angioplasty and stent procedures

Former catheterization lab manager accused

hospital of doing procedures on patients with

insufficient blockage.

Received $661,000 award

14

The New Climate: ACA

Mandatory reporting, repayment, and explanation of

overpayments by “persons”

“Knowing” retention of overpayment beyond 60 days

is a false claim

With all its fines, penalties and whistleblower provisions

Mandatory Compliance Plans

First, nursing homes, later other providers

Mandatory reporting of overpayments

Mandatory review and follow-up

State requirements

NY Medicaid

15

6

All rights reserved

The New Climate:

Enforcement

Recent Cases – 2013

Salesman Admits Role In Bribes-For-Test-Referrals Scheme

Involving New Jersey Clinical Laboratory

Planned Parenthood Pays $4.3 Million To Settle Allegations Of

Unnecessary Medical Care, TX

Long Island Physician to Pay U.S. $388,000 to Settle False

Claims Act Allegations Related to Overbilling Medicare, NY

Seven Oncologists Charged With Importing Unapproved Drugs,

Ohio

Johnson City Physician Sentenced To Serve Two Years In Prison

For Unapproved Foreign Drugs, TN

Doctor Convicted in Kickback Scheme Involving a Philadelphia

Hospice, PA

Medical Clinic Director, CEO Plead Guilty To Health Care

Fraud, False Tax Return, Kansas

All rights reserved

Medical Clinic Director, CEO Plead Guilty To

Health Care Fraud

By pleading guilty, the Rysers admitted that they engaged in

fraudulent billing by “upcoding” and falsifying claims submitted to

insurers (including Blue Cross Blue Shield, Cigna, United Healthcare

and others, as well as government programs such as Medicare and

Tricare) in an effort to be paid more than the amount to which HCA

was entitled.

The Ryser’s scheme included: (a) billing for physician office visits

when Carol Ryser was out of town; (b) billing for physician office

visits when Carole Ryser had little or no involvement with the patient;

(c) billing for physician office visits when the patient contact was by

telephone call; (d) billing for physician supervised services when no

physician was on duty at the clinic; and (e) improperly billing for

consultation services.

The federal indictment describes six variations of billing fraud and

includes tables of claims demonstrating each type of billing fraud. For

those claims specifically included in the indictment, the total amount

billed on those claims was $359,168. The total amount that was

actually paid on those claims by health care benefit programs was

$51,789.

18

7

Medical Clinic Director, CEO Plead Guilty To

Health Care Fraud

Carol Ann Ryser, 76, and Michael Earl Ryser, 68, both of Mission

Hills, Kan., pleaded guilty before U.S. District Judge Greg Kays to

the charges contained in a June 26, 2012 federal indictment.

Carol Ryser owned Health Centers of America-Kansas City, LLC

(HCA), a medical clinic in Kansas City, Mo.. HCA purported to

specialize in the diagnosis and treatment of chronic diseases such

as Lyme disease, chronic fatigue syndrome, fibromyalgia, and other

auto immune diseases.

Carol Ryser, who was a medical doctor and the clinic’s medical

director, surrendered her medical license today as a condition of her

plea agreement. Carol Ryser may never again seek licensing to

practice medicine in the United States and she may never be

involved as an owner or employee (or in any other capacity) with any

medical clinic, hospital or other health care provider. Michael Ryser

was the CEO, chief administrator and vice-president.

19

Medical Clinic Director, CEO Plead

Guilty To Health Care Fraud

Under the terms of the 3/22/2013 plea agreements,

Michael Ryser will be sentenced within a range of 24

to 30 months in federal prison without parole.

Carol Ryser will receive a sentence of three years of

probation, including six months of home detention.

The Rysers must pay $51,789 in restitution to the

health care benefit programs that were defrauded.

20

21

Measuring Effectiveness……

8

CMS Compliance Effectiveness Pilot

3 year pilot

Ended early 2007

16 hospitals in the NE participated

84 hospitals applied

#1 Element: Communication

Communication across the organization re: auditing results and training

“Communication makes a difference.” Kimberly Brandt, Director, Medicare Program Integrity, HCCA Compliance Institute, April 2007

The more these 3 elements interfaced, the more there was an increase in the accuracy of claims 1. Communication

2. Auditing

3. Education

Outcomes of Raw Claims Data

When the contractor initiated action it was already

too late

Much less resources/$$ when the provider found an

issue & acted

Based on audit results

Based on the OIG work plan

Etc.

9

Outcomes of Raw Data

CMS would like contractors to provide semi-annual

data to providers very similar to what the pilot

participants received

CBRs in 2013

Little changes in the compliance program made big

differences.

Bottom line for the hospitals: Denied and rejected

claims decreased

Outcome: Education

Problem with documentation?

Web-based training does not work

1-on-1 training does work

Can decrease claims denial rate

Coding/Medical Necessity

Small groups work

1-on-1 intensive sessions work

By people who speak the same language

Physicians training physicians works best

Outcome: Auditing & Monitoring

All auditing results need to be communicated

throughout the organization

Then, training & staff education

Makes a difference if the organization makes a

commitment and emphasis on compliance

A culture of compliance

Commitment from the top people must be seen in

meetings/training.

Are your doctors/executive management present at annual

training? Compliance. OSHA. HIPAA

Important that the compliance officer “gets out there.”

10

Measuring Effectiveness

OIG’s Supplemental Compliance Program Guidance:

“Every effective compliance program necessarily begins

with a formal commitment to compliance by the hospital’s

governing body and senior management. Evidence of

that commitment should include:

Active involvement of the organizational leadership

Allocation of adequate resources

A reasonable timetable for implementation of the compliance

measures; and

The identification of a compliance officer and compliance

committee vested with sufficient autonomy, authority and

accountability to implement and enforce appropriate compliance

measures.”

28

Measuring Effectiveness – Policies &

Procedures

Documentation all employees have received Code of

Conduct, P&P?

Attestations

P&P are clearly written and relevant to day-to-day

responsibilities

Documentation of training at orientation

29

Measuring Effectiveness – Training

The OIG Guidance clarifies that education and training and

continual retraining of all personnel at all levels are

significant elements of an effective compliance program.

Updated compliance training materials used and maintained

Training is documented

Sign-in sheets with agenda

Specialized training

Coding and billing training

Coding rules

LCDs

Manager/Supervisor training

Treating each question/report confidentially

Non-retaliation against any employee asking a question/making a

report

Documenting and tracking questions and reports

When to report to Compliance Officer

30

11

Measuring Effectiveness – Monitoring

and Auditing

The OIG Guidance clarifies that the organization

should develop detailed annual audit plans

designed to minimize the risks associated with

improper claims and billing practices.

Conduct a risk assessment

Develop a tool

Keep it simple and practical

Determining your risk universe

OIG Work Plan

ADRs, Denials

Payer audits

Alerts, Bulletins received

AAPC Coding Edge!

31

Measuring Effectiveness – Monitoring

and Auditing

The OIG Guidance clarifies that the organization

should develop detailed annual audit plans

designed to minimize the risks associated with

improper claims and billing practices.

Audits

Determine parameters

Baseline, focused, ongoing

What to do with results

Education

Follow up audit

Repayment?

Let’s talk about this a bit….

32

Physician Compliance: Refunds

Medicare refunds should be made w/in 60 days of

discovery

Revised FCA – any $ not refunded become false claims!

But how to determine the full extent of the overpayment?

When does that 60-day clock start ticking?

How far back do you look? What is your “universe?” Add’l hour of infusion time billed but not documented: nurse

who misunderstood was only there for 3 months

Doctor billed a 99215 with every 99387 for 3 years

Check credit balances regularly – run reports, keep track

of accounts

Overpayment = refund or recoup

Credit balance may not = overpayment

12

Physician Compliance: Refunds

If your providers balk at paying back overpayments, show them the law!

18 U.S.C. § 669

Health care embezzlement applies to all payers (not just Medicare, Medicaid, other gov’t programs)

Keeping overpayments is a Federal crime

Biggest Compliance Program Failures

Identification of compliance risk areas and non-

compliance

No follow-up of identified issues

CMS is developing its own version of a FICO score

to be able to identify providers who may be/are at

risk for being out of compliance.

4/10/11, James Sheehan

2013 OIG Work Plan (next slide)

35

36

OIG Work Plan 2013: Review of Part A and Part B Claims

Submitted by Top Error-Prone Providers We will review Medicare Part A and Part B claims submitted by error-prone

providers to determine their validity, project our results to each provider’s

population of claims, and recommend that CMS request refunds on projected

overpayments. Previous OIG work illustrated a methodology for identifying

error-prone providers using CMS’s Comprehensive Error Rate Testing

(CERT) Program data. Using this methodology, we identified providers that

consistently submitted claims found to be in error over a 4-year period. In this

review, we will select the top error-prone providers on the basis of expected

dollar error amounts and match the selected providers against the National

Claims History file to determine the total dollar amount of claims paid. We

will then conduct a medical review on a sample of claims. Providers must

submit accurate claims for services provided to Medicare beneficiaries.

(CMS’s Medicare Claims Processing Manual, Pub. 100-04.) (OAS; W-00-13-35565;

various reviews; expected issue date: FY 2013; new start)

13

U.S. Attorney Spencer Turnbull*

“Compliance is more than just rules. It’s ethical

conduct and a culture of ethical conduct. The

question in a kickback case is not ‘can I do this,’

but ‘why am I doing this?’”

*Speaker, HCCA Compliance Institute,

Chicago, IL, April 2007

The Choices

38

Do nothing

Cross your fingers!

ADRs and Prepayment

audits

CIAs

Up to 5 years

Fines, penalties and jail time

Soon you will have no choice

May not have one now

Identify the right resource

Practice specific

More than just a book on the

shelf

A process that requires

commitment

Cost effective protection

Check your managed care

contracts –

They may require a

compliance program!

Back to where we started – 7 Elements

1. Conducting internal monitoring and auditing through the performance of periodic audits

2. Implementing compliance and practice standards through the

development of written standards and procedures.

3. Designating a compliance officer or compliance contacts to monitor compliance efforts and enforce practice standards.

4. Conducting appropriate training and education on practice

standards and procedures.

5. Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to

appropriate Government entities.

6. Developing open lines of communication to keep practice

employees updated regarding compliance activities. Non-retaliation policy.

7. Enforcing disciplinary standards through well-publicized guidelines

39

14

Useful Websites and Resources

www.stopmedicarefraud.gov/

OIG Work Plan, Exclusions List, Compliance

Guidance:

www.oig.hhs.gov

CERT Reports

www.cms.gov/cert

CMS Manuals (can’t live without them!)

www.cms.gov/manuals

Your Medicare Contractor

Compliance Toolkit for Physician Practices

www.aapc.com/toolkit

40

Jean Acevedo, LHRM, CPC, CHC, CENTC Acevedo Consulting Incorporated

561.278.9328

www.AcevedoConsultingInc.com