Post on 25-Dec-2015
Derry, Nolan & Associates, LLC
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Physician Practice Compliance Program
Presented by
Barbara Derry, BSN, CMPE
Melania “Lani” Antonio, CPC
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Overview
• Common Compliance Risk Areas
• Compliance Program Development
Barbara Derry
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Common Risk Areas • None or irregular risk assessment• Physician employment/partnership agreements• Governing board, physicians & staff lack
awareness• Physicians not holding each other accountable
for coding & documentation accuracy• Disregarding employees’ concerns• Compliance policies, procedures & documents
not updated –
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Common Risk Areas • Physician business agreements – anti-kickback
statutes• Coding & claims submission & reconciliation
inaccuracies lead to claim denials & decreased revenue– demographic & insurance not correct– coding & documentation don’t link – Medical necessity rules not followed
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
A collaborative cooperative voluntary compliance program, led by physician leadership, promotes early detection, prevention & correction to minimize risks of healthcare fraud and abuse.
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Foundation for an Effective Compliance & Ethics Program (OIG’s 7 Elements)
1. Standard Policies & Procedures2. Oversight & Documentation Responsibility3. Education & Training4. Lines of Communication5. Audit & Monitoring6. Enforcement & Discipline7. Response & Prevention
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Getting Started↓ Physician’s agree on commitment to the
compliance program “culture” OIG’s 7 elements↓ Assign physician board oversight responsibility↓ Physician board designates compliance officer
for program oversight↓ Assign a compliance committee (C.C.) selected
from major departments↓ Conduct a risk assessment internal vs. external
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Self - Risk Assessment• Each organization will have different risk areas• Sets a compass for the organization to follow• Identifies:
policies, procedures and forms education & training audit & monitoring resources
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Compliance Committee Recommends Annual Goals
1. Develop a compliance program with physician leadership driving the process that promotes effectiveness & follows new sentencing guidelines:
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
New Federal Sentencing Guidelines• Encourages organizations to partner with
Federal government in crime control• Provides strong incentives for organizations to
self-police, self-report & cooperative in investigations of its own wrong doing
• Requires board and senior leadership to be knowledgeable about the content and operation of the program to prevent and detect violations – eliminate knowing & doing gap
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Compliance Committee Goals
2. Develop an effective communication system for communicating, reporting, correcting possible compliance violations
BoardKnowledgeable & Accountable
Compliance OfficerOversight
Documentation MaintenanceMonitoring & Auditing
Reporting
Compliance Committee
Development & Implementation
Physicians & Staff
Confidential Alert or Hot LineAvailable 24 hrs
Allows for AnonymityTimely feedbackDocument Action
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Development Effectiveness• A practical/simple approach to policies,
procedures and forms – communication tools• Resource tools:
OIG 2000 physician practice guidelinesOIG work plans Federal Sentencing GuidelinesMedicare Part B NewsCCI edits,
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Development Effectiveness• Provide education & training to board, providers and
staff to promote early detection, prevention & correction
• Substantiate & document awareness• Accurate outpatient billing – NO DENIALS• Audit activities focus on risk areas• Audit results & recommendations to board & senior
management• Follow through with corrective/disciplinary action
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Choose Subcommittees who become the working arm of the Compliance Committee
Typical Representation:• Education & Training • Claims Submission & Reimbursement• Audit & Monitoring• Others, as identified
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Major Duties of Subcommittees• Research, develop, write, present & amend policies and
procedures for compliance committee• Document progress of outstanding issues• Investigate risk areas via quality improvement efforts• Responsible for education & training (staff & physician)• Responsible for auditing processes to determine
effectiveness• Make recommendations for enhancement• Measure effectiveness
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Education & Training Subcommittee
Define organizational structure, governance & organizational chart
• Define “Core” policies most relevant to your organization – focused on “operationalizing” the compliance program
• Based on risk assessment results
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Policies May Include
1. Standard of Conduct
2. Confidentiality (Includes HIPAA)
3. Internal & External Communications
4. Conflict of Interest
5. Documentation Retention
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Policies May Include Cont’d
6. Self-Reporting of violations of laws/regulations – legal review
7. Physician contracting, Employment Agreements – legal review
8. Organizational contracting (vendors & payers) – legal review
9. Human Resources – awareness & consequences of non-compliance
10.Solicitation: Vendors/Gifts & Gratuities
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Policies May Include Cont’d
11. Marketing
12. Coding & Claims Submission
13. Claims Reimbursement & Reconciliation
14. Education and Training
15. Audit & Monitoring
16. Other policies as identified
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Example of Core Policy: Education & Training• Board, physicians, manager & staff review pertinent
policies & procedures • Sign appropriate policy acknowledgement forms• Take appropriate tests: providers, billing, non-billing staff• Determine physician & employee knowledge level by
achieving 95% accuracy rates• Additional training and testing for those with less than
95% score • Document training and scores• Provide annual education
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Provider EducationAccurate coding & documentation drives
reimbursement & prevents violationsCommon Problems
– under & over coding– default coding– lack of diagnosis specificity– lack of knowledge of Medicare’s national medical
review policies– inappropriate use of modifiers & unbundling services
deemed not medically necessary
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Optimal Physician Education & Training• Establish a physician leader to drive education
process• Conduct annual chart audit for each physician to
establish baseline of knowledge • Structure education based on those results• Avoid too generalized coding sessions
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Optimal Physician Education & Training• Be specialty-specific• Standardize fee-tickets & documentation
templates• Re-audit in 2-3 months to determine
effectiveness of training• No improvement--document & report
corrective/disciplinary action – 100% chart review, expense charged to provider or department
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Example of Partial Fee-Ticket for Ophthalmology with Diagnoses Linked to NCDs & LMRPs
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Example of a Standard Documentation Template
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Audit & Monitoring SubcommitteeFostering an atmosphere of continuous process
improvement• Follow CMS’s quality integrity program’s 4 elements
– risk assessment and problem identification– solution planning– solution implementation and– monitoring the success of the process
• Audit the highest risk areas• Profile physicians to identify outliers• Investigate all concerns, report findings, make
recommendations (e.g., education)
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Claims Submission & Reimbursement Subcommittee
Claims Submission Sub-Policies
OIG’s Work Plan– accurate codes: CPT, HCPCS, ICD-9– use of modifiers: 25, 26, 51 & 59– care plan oversight– incident to
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Claims Submission & Reimbursement Subcommittee
– medical necessity and ABN (GA modifier)– duplicate claims– disputed claims– unbundling– physician services at SNFs
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Claims Submission & Reimbursement Subcommittee
Claims Reimbursement Sub-Policies
OIG’s Work Plan– deductibles, co-payments & coinsurance– Bad debt & small balance write-offs– discounting of services– refunds
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
Claims Submission & Reimbursement Subcommittee
– charity care/financial aid application– Professional discounts/designated services– Third party billing payments– Denials, bundled and appealed charges
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program
To Summarize
Physician Practices that implement a culture that promotes and embraces compliance are more likely to have effective compliance programs & are better able to prevent, detect & correct problems
Derry, Nolan & Associates, LLC
Physician Practice Compliance Program Auditing & Monitoring
Melania “Lani” Antonio, CPC
Group Health Cooperative
Manager, Billing Guidelines Development
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Follow CMS’s quality integrity program’s 4 elements
– risk assessment and problem identification– solution planning– solution implementation and– monitoring the success of the process
• Audit the highest risk areas• Profile physicians to identify outliers• Investigate all concerns, report findings, make
recommendations (e.g., education)
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification
– Review Office of Inspector General (OIG) work plan and investigate current practice.
– Review coding activities throughout the organization and identify risk areas.
– Investigate all concerns and identify risk.
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Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health
Professionals• Billing Service Companies
– “We will identify and review the relationships among billing companies and the physicians and other Medicare providers who use their services. We will also identify the various types of arrangements physicians and other Medicare providers have with billing services and determine the impact of these arrangements on the physicians’ billings.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Medicare Payments to VA Physicians– “We will assess the validity of Medicare reimbursement for
services billed by physicians who receive remuneration from the Department of Veterans Affairs (VA) for the time the physicians reported as being on duty at a VA hospital. Physicians employed by VA may not bill Medicare for services rendered at other hospitals during the times they were on duty at a VA hospital. Our preliminary work has identified a number of VA physicians who received Medicare reimbursements totaling approximately $105 million for services rendered between January 1, 2001 and June 30, 2003. Using time reporting and payroll documentation from the VA, we will identify the services rendered while the physicians were reported as on duty at the VA hospitals and remunerated for such duty.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Care Plan Oversight– “We will evaluate the efficacy of controls over Medicare
payments for care plan oversight claims submitted by physicians. Under the Medicare home health and hospice benefits, care plan oversight is physician supervision of beneficiaries who need complex or multidisciplinary care requiring ongoing physician involvement. Reimbursement for care plan oversight increased from $15 million in 2000 to $41 million in 2001. We will assess whether these services were provided in accordance with Medicare regulations.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Ordering Physicians Excluded from Medicare– “This review will quantify the extent of services, if any, ordered
by physicians excluded from Federal health care programs and the amount paid by Medicare Part B. Under Federal regulation, physicians who are excluded from Federal health care programs generally are precluded from ordering or performing services for Medicare beneficiaries. During a current review, we identified a significant number of services that had been ordered by excluded physicians.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Physician Services at Skilled Nursing Facilities– “We will examine Medicare Part A and Part B claims with
overlapping services for skilled nursing facility patients and determine whether duplicate payments were made to either the physicians or the nursing homes for the same patient services. Physicians may bill Medicare only for the professional component of a service on behalf of skilled nursing facility patients. The technical component of physicians’ services is covered under the patient’s Medicare Part B stay in the skilled nursing facilities and should not be billed separately by the nursing home. Under an exception to this rule, nursing homes may receive Part B payments for both the professional and technical components of physicians’ services if both parties have an agreement under which only the nursing home may bill and receive these Part B payments.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health
Professionals• Physician Pathology Services
– “Our review will focus on pathology services performed in physicians’ offices. Pathology services include the examination of cells or tissue samples by a physician who prepares a report of his findings. Medicare pays over $1 billion annually to physicians for pathology services. We will identify and review the relationships between physicians who furnish pathology services in their offices and outside pathology companies.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Cardiography and Echocardiography Services– “We will review Medicare payments for cardiography and
echocardiography services to determine whether physicians billed appropriately for the professional and the technical components of the services. Like many physician services, cardiography and echocardiography include both technical and professional components. When a physician performs the interpretation separately, the modifier 26 should be used to bill Medicare for professional services.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Physical and Occupational Therapy Services– “We will review Medicare claims for therapy services provided
by physical and occupational therapists to determine whether the services were reasonable and medically necessary, adequately documented, and certified by physician certification statements. Physical and occupational therapies are medically prescribed treatments concerned with improving or restoring functions, preventing further disability, and relieving symptoms.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Part B Mental Health Services– “We will determine whether Medicare Part B mental health
services provided in physicians’ offices were medically necessary and billed in accordance with Medicare requirements. Payments for mental health services provided in the physician’s office setting accounted for approximately 55 percent of the $1.3 billion in Medicare payments for Part B mental health services in 2002. In a prior report, we found that Medicare allowed $185 million for inappropriate mental health services in the outpatient setting. We will also determine the financial impact of claims that do not meet Medicare requirements. ”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health
Professionals• Wound Care Services
– “We will determine whether claims for wound care services were medically necessary and billed in accordance with Medicare requirements. Medicare-allowed amounts for certain wound care services billed by physicians increased from approximately $98 million in 1998 to $147 million in 2002. We will also examine the adequacy of controls to prevent inappropriate payments for wound care services.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Coding of Evaluation and Management Services
– “We will examine patterns of physician coding of evaluation and management services and determine whether these services were coded accurately. In 2003, Medicare allowed over $29 billion for evaluation and management services. In prior work, we found that a significant portion of certain categories of these services is billed with incorrect codes resulting in large overpayments. We will also assess the adequacy of controls to identify physicians with aberrant coding patterns.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Use of Modifier -25– “We will determine whether providers used modifier –25
appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is a significant, separately identifiable service from such procedure or service. A provider reports such a circumstance by using modifier –25. In 2001, Medicare allowed over $23 billion for evaluation and management services. Of that amount, approximately $1.7 billion was for evaluation and management services billed with modifier –25. We will determine whether these claims were billed and reimbursed appropriately.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Use of Modifiers With National Correct Coding Initiative Edits
– “We will determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative edits. The initiative, one of CMS’s tools for detecting and correcting improper billing, is designed to provide Medicare Part B carriers with code pair edits for use in reviewing claims. A provider may include a modifier to allow payment for both services within the code pair under certain circumstances. In 2001, Medicare paid $565 million to providers who included the modifier with code pairs within the National Correct Coding Initiative. We will determine whether modifiers were used appropriately.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• “Long Distance” Physician Claims– “We will review Medicare claims for face-to-face physician
encounters where the practice setting and the beneficiary’s location were separated by a significant distance. While all beneficiaries may seek professional services for specialized consultation during leisure travel, those with ongoing illnesses requiring skilled care would be unlikely to travel long distances from home. We will examine these claims to confirm that services were provided and accurately reported. If warranted, we will recommend enhancements to existing program integrity controls.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals
• Provider-Based Entities– “We will determine the extent to which health care entities that
have been designated as “provider based” are in compliance with requirements for receiving this designation. In prior work, we found that hospital ownership of physician practices is widespread and that fiscal intermediaries are frequently unaware whether these hospitals are being treated as provider based or freestanding. Medicare and its beneficiaries may be paying excessive amounts for services inappropriately billed as provider based. We will also determine the impact on Medicare reimbursements of entities billing as provider based instead of freestanding.”
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
DOCUMENTATIONHandwritten or
dictated
Charges are manually entered
Charges are
interfaced
BILLINGSYSTEM
CHARGE
MASTER
INS COMPANYClaims
Processing
$$$
Charge Slip
Charge Slip
DOCUMENTATIONElectronic Medical
Record (EMR)
Provider assigns codes on the charge slip
Typically Non-provider staff maintains code set up in the Charge Master.
Provider assigns codesin EMR
Claim Reject
In some cases, Non-provider staff reviewscoding and makes
appropriate changes priorto manual entry.
Typically Non-provider staff reviewscoding and makes appropriate
changes prior to claim submission
Codes are referenced on the charge slip.
Codes are set up in EMR.
Non-provider staff may change coding in order for claim to be reprocess.
CODING
ACTIVITIES
Coders should review coding set ups for accuracy.
Coders should review & update codes.
Develop policies & procedures on appropriate
coding changes
Coders should review coding set ups for accuracy.
Develop policies & procedures on appropriate
coding changes
Develop policies & procedures on appropriate
coding changes
Derry, Nolan & Associates, LLC
Risk Assessment and Problem Identification Cont’d
• Investigate all concerns– Example:
• A pattern of increased denials.• During an exit interview, a staff member
provided concerns on a potential compliance issue.
Derry, Nolan & Associates, LLC
Integrity Cycle Report
Report #: 1 Date Initiated: __/__/__ Initiated By: {Staff Name}
Source: Compliance Line Employee interview or report
Audit result X Reimbursement or denial pattern
Other (specify):
Problem Identification (research conducted):
A pattern of increased Medicare denial on XXXX services.
Solution Planning and Implementation: Solution planning needs to encompass two areas: 1) resolution of the billing issue for XXX services; and 2) provide education and training
Action Responsible
Person
Date Completed
Comments
{Date} Review documentation Coder
{Date} Provider coding training Coder
{Date} Corrected claims Billing Staff
{Date} Compliance Subcommittee recommend a 2nd audit
Coder
Monitoring Plan:Coder will continue to audit XXXX services prior to claim submission until 80%-100% accuracy is achieved.Claims will not be re-submitted until coding and documentation match.
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
Auditing Effectiveness
Based on 4 Key Elements– Standardization– Communication– Quality– Tracking
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring• Standardization
– Develop an auditing manual for coders/auditors to use as a reference. Manual may include the following:
• Standard policy– Follow policy for provider E&M coding and documentation– Select number of charts (10) reviewed for each provider– Determine acceptable accuracy percentage– Determine number of failed chart audit sessions (3) prior to
disciplinary action of 100% chart review– Provide report to Compliance leadership team with
recommendations.• Guidelines
– Audit E&M by following 1995 OR 1997 guideline.– Should we follow only Medicare guidelines? How about
providers that do not see Medicare patients?• Auditing process
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Communication– Auditor/Coder to Auditor/Coder– Non-provider staff members (i.e. billing staff,
patient account, etc.) to Auditor/Coder– Auditor/Coder to Provider staff members (i.e.
physicians)
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Communication– Auditor/Coder to Auditor/Coder
• Eliminate opportunities for misinterpretations on processes and/or guidelines.
• Communicate new processes and/or guidelines.• Communicate opportunities for improvement.
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Communication– Non-provider staff members (i.e. billing staff,
patient account, etc.) to Auditor/Coder• Eliminate opportunities for misinterpretations in
coding/billing (i.e. usage of modifiers).• Provide feedback on coding/billing (i.e. claim
reject) that may need to be further reviewed and/or investigated (i.e. non-covered diagnosis).
• Provide feedback on coding/billing (i.e. claim reject) that may require provider education (i.e. usage of modifiers).
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Communication– Auditor/Coder to Provider staff members (i.e.
physicians)• Provide coding education in a group setting and/or one-on-
one upon completion of an audit.– Potential problem: Physician may not agree with auditor/coder.
» May request a second review by another auditor/coder.
» If provider still disagrees it is bumped up to the physician compliance leader to resolve and document action taken OR may have a policy that it is sent out according to the auditors recommendations.
• Provide follow-up coding education.• Provide open communication where the provider request
assistance in coding as needed basis.
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Quality– Audit the auditor/coder
• Identify coding errors– Provide additional training– Develop policy on how to address job performance
– Audit revenue cycle• Identify inaccurate coding changes• Improve operational processes• Provide additional training to new process• Re-audit to determine if changes were effective
Derry, Nolan & Associates, LLC
Physician Practice Auditing & Monitoring
• Tracking– Track all audits in a centralized location
• Excel• Access Database
– Report back to compliance officer the results and recommendations for improvement.