Post on 21-Jun-2018
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved1
Medicare Compliance Hiding in Plain Sight .
Florida Physical Therapy Association September 26, 2015
Course Objectives
1. Understand best practice documentation that incorporate payer requirements as well as APTA defensible documentation
2. Understand the Medicare program initiative that are targeting review of therapy practices including the OIG, DOJ, FBI and other CMS fraud investigators
3. Understand the CMS requirements for establishing a skilled maintenance program and providing skilled maintenance therapy
4. Understand when therapy is not medically necessary or covered by Medicare and how to properly complete an ABN, as well as accept cash for therapy services
5. Know how to effectively implement a compliance program with monitoring and auditing, as well as a risk assessment of and how to incorporate the APTA Code of Ethics
Rehab Market Factors
• Consolidation
• Private practice with 3rd party capital/equity
• Movement of SNFs “outward”
• ACOs
• Hospital Networks
• Closed insurance networks
• “Joint” demonstration program
• The value of compliance
• Amount incremented to $1940 for each cap PT & SLP cap and OT cap
• Therapy caps exceptions process in place through 3/31/2017
• Therapy caps permanently apply to: Private practice, group practice
Rehab Agencies, CORFs, HHA & SNF (Part B)
Critical Access Hospitals
• Therapy caps do not apply to PPS Hospitals unless mandated
Therapy Caps – 2015
• You can keep using the 59 modifier until CMS issues specific instructions re: new X{EPSU} modifiers.
• X{EPSU} modifiers developed in the place of 59 modifier, XP modifier (used to indicate a different “practitioner”) is not appropriate to use [at this time] …therapy disciplines as CMS uses the therapy modifiers —GN, GO, or GP —
• For OP therapy.. you can continue to use the 59 modifier, rather than the X{EPSU} modifiers, to denote distinct therapy procedures until such time CMS issues future clarifying instructions.
Source: CMS Memo to Therapy Cap Coalition 11/12/2014
Modifier 59 for OP Therapy 2015 Therapy
2015 = $1940
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved2
Fine Print of Therapy Benefits
Medicare Benefits Brochure from Medicare.govMedicare Limits on Therapy Services from NancyBeckley.com
Resources:
Mixed Signals……
It is very important to recognize that most conditions would not ordinarily result in services exceeding the cap.
Resource: Medicare Claims Processing Manual, Chapter 5, Section 10.3
“”
In general, if your therapist provides documentaiton that your services were medically reasonable and necessary, you won’t have to pay for costs above the $1920 therapy cap limits
Resource: CMS Product No. 10988, Medicare Limits on Therapy Services 2014
“
”
DOCUMENTATION
• Baseline Measures
• Comparative Measures
• STG – LTG Progression
Objective Measures
POC PN#1 PN#2 D/C PN
Comparing PLOF to CLOF
– Independent in ADLs
• Better stated:– Stairs/steps
– Get in/out of SUV
– Don/doff garments
– Stand to cook meal at stove
– Sit to stand toileting
– Step into bath tub
– Comb/wash hair
– Light housekeeping (vacuum, dusting)
Current Level of Function
– Unable to perform ADLs
• Better stated:– “Prior to incident, patient was able
do all self‐care and toileting activities independently including……..
– Currently patient unable to…….
Prior Level of Function
Aligning Goals
Short Term Goals– Range of Motion
– Strength
– Endurance
Long Term Goals– Functional outcome ‐ why
Current Level of FunctionImpairments
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved3
Is this a new or acute problem? May need intensive focused care E.g. reduce pain and/or work on a specific
impairment or functional loss
Is this an old or chronic condition that needs retraining, or has had a change in condition? May need to update or modify program
Is this an exacerbation of a condition? May have to modify treatment, change
assistive devices as the condition deteriorates Are there other conditions (e.g. medical
diagnosis) that are the underlying problem?
Cognitive performance can impact care What is the beneficiary’s ability to retain
newly learned information (cognitive function)?
What is the beneficiary's ability to participate and benefit from rehabilitative services?
Reasonable & Necessary
Source: CMS Open Door Forum Slide Show 9/5/12
Treatment consistent w/nature/severity of illness/ injury Assessing Objective Measurable Gains for RehabLook at:
– Changes in the level of assistance required to perform functional tasks
– Changes in the types of functional activities/ tasks– Changes in the types of assistive devices– Improvement in rating of reported pain levels and changes in the ability to perform tasks given the reduction of pain
– (E.g. ‐ Ability to sit for a duration of time as a result of pain reduction)
Reasonable & Necessary
Source: CMS Open Door Forum Slide Show 9/5/12
Considerations:– Did the therapist consider the beneficiary’s goals?
– Were the therapist’s and beneficiary’s goals realistic based on the beneficiaries condition and,
– Did the therapist change goals/ treatment plan in response to improvement or lack of improvement in the beneficiary’s condition?
– Were there objective, measurable changes using standard scales and assessment tools?
– What was the beneficiary’s response to treatment?
Did this change over time?
Was it sustained?
Reasonable & Necessary
Source: CMS Open Door Forum Slide Show 9/5/12
• Comparative per Side (contralateral)
– Right
– Left• Comparative
– Evaluation
– 1st Progress Report
– 2nd Progress Report…..
– Discharge (Summary) Progress Report
Objective Measures
The “Problem”
The leading cause of payment errors for therapy services is "insufficient" documentation in the medical records. Documentation is often missing the required elements as outlined in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100‐02, Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230.
Source: CERT Task Force for Error‐Free Medicare Claims
Avoid CERT Errors
• Tips to improve therapy documentation:– Ensure the medical records submitted provide prove the service(s) was
certified and rendered. – Ensure the medical records provide justification supporting medical
necessity and that skilled services were needed. – Create a complete plan of care, making certain to include your legible
signature, professional identification (e.g., PT, OTR/L) and date the plan was established.
– Document when the plan of care is modified, including how it has been modified and why the previous goals were not met or could not be met.
– Confirm the plan of care is certified (recertified when appropriate) with physician/NPP legible signature and date.
– Clearly document, in minutes, the total time spent on timed‐code treatment only and the total treatment time (including timed and untimed codes) in the patient's record.
Source: CERT Task Force for Error‐Free Medicare Claims
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved4
UNDER REVIEW
Medicare Integrity Program
Specialty:
CBR
SMRC
Recovery Auditors
(RAC)
ZPIC
PSCCERT
MACs
Who is Reviewing & Auditing
Medical Review (MR) Program
CMS instructs contractors to use four parallel strategies to assist in meeting this goal:
1. Preventing inappropriate payments through accurate and effective enrollment of providers and beneficiaries;
2. Detecting program aberrancies through data analysis and on‐going medical review;
3. Making fair and firm medical review decisions enforcing local and national policies in accordance with Progressive Corrective Action (PCA); and
4. Coordinating activities and communicating information with internal and external partners, including other contractors, law enforcement agencies, and others.
CERT Program
• Comprehensive Error Rate Testing Program (CERT)
• Identifies and reports quarterly on “MAC” error rate
• Reviews a small selection of claims from all provider types to determine claims paid in error
• CERT notifies contractor of payment error and contractor collects from provider
• CERT used by other PI contractors to identify topics and areas of concern
• CERT publishes reports and contractors make reports available on their website
Recovery Auditors (RAC)
• Permanent CMS Program – 4 regions• RACs paid on % of errors $$• Automated reviews – claims analysis via automated data mining methodologies
• Complex reviews– DRG Validations– Medical necessity
• Mandate for Medicaid RACs– In addition to states that have Medicaid Integrity Programs
OIG 2015 Work Plan: Outpatient PT
Physical therapists—High use of outpatient physical therapy services– We will review outpatient physical therapy services provided by independent
therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary.
– Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, §1862(a)(1)(A).) Documentation requirements for therapy services are in CMS's Medicare Benefit Policy Manual, Pub. No. 100‐02, ch. 15, § 220.3. (OAS; W‐00‐11‐ 35220; W‐00‐12‐35220; W‐00‐13‐35220; W‐00‐14‐35220; W‐00‐15‐35220; various reviews; expected issue date: FY 2015)
Why this is important to all therapy under Part B, not just private practice
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved5
OIG: Spectrum Rehabilitation
• 100 claims reviewed: 83 not allowed
• $10,124 extrapolated to $3,112,501
• Errors:– Medicare Physician Certification Requirements Not Met
– Services Billed Under Incorrect Provider Number
– Treatment Notes Did Not Meet Medicare Requirements Services Not Medically Necessary
– Plan Did Not Meet Medicare Requirements
OIG: Illinois Physical Therapist
• 100 claims reviewed: 99 not allowed• $16,124 extrapolated to $634,837
• Errors:– Plan of Care Did Not Meet Medicare
Requirements– Treatment Notes Did Not Meet
Medicare Requirements– Untimely or Missing Progress Services
Not Medically Necessary – Physician Certification Did Not Meet
Medicare Requirements
OIG: Illinois Physical Therapist
• Plan of Care Errors• Goals not measurable
• Invalid or missing therapist’s signature
• Incomplete or no plan of care
• Treatment Note Errors• Missing specific skilled intervention
• Unsupported number of units billed
• Invalid therapist’s signature
• Billed code not in POC
Reference ‐ OIG/OAS: A‐05‐00010
OIG: Illinois Physical Therapist
• Services Not Medically Necessary• Overall documentation failed to support medical
necessity
• Physical therapy was repetitive with no evidence that skilled therapy services were needed
• Physician Certification Did Not Meet Medicare Requirements
– POC not signed by physician
– Physician certification not dated
– Untimely physician certificationReference ‐ OIG/OAS: A‐05‐00010
Zone Program Integrity Contractor
• Medicare Program Integrity Contractor
• Fraud investigators
• Different rule of “engagement”
• Work on “referral” or data analytics
• Recent rehab cases
– Change of address
– Can’t be in 2 places at one time – or can you?
45
Qui Tam Relators – “Whistle Blowers”
• Disgruntled employees• Former employees• Complaint
– Department of Justice– Office of Inspector General– Whistle Blower attorney
• Government decision– Enjoin all or part of complaint– Relator may also choose to advance on own accord
• Recent & past rehab relators
46
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved6
Case Study: OIG Finds Needle in Haystack
• The Case of the Excluded OT– Convicted for program‐related crime in Arkansas– Excluded from participation in federal healthcare programs– Working for Brookdale Senior Living – several management positions (2010 – 2013)
– Applies for reinstatement with Office of Inspector General (OIG)
• Denied as to timeliness• OIG does some further digging
– Brookdale employed her improperly, as she was excluded from participation
• Did not drill down on exclusions list as required
– Fine: $353,248 to settle False Claims Act violations
47
FIVE FACES OF FRAUD & ABUSE
The 5 FACES of Fraud & AbuseFalse Claims Act
Anti-Kickback Statute
Civil Monetary Penalties Law
Exclusion Statute
Stark
Source: HHS/OIG: “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse”.
Fraud & Abuse Laws False Claims Act (Civil 31 U.S.C. §§3729‐3733) (Criminal 18 u.S.C. § 278)
• Claims may be false if the service is not rendered to the patient, is provided but already covered under another claim, is miscoded, or is not supported by the medical record
• You can be punished if you act with “deliberate ignorance” or “reckless disregard” of the truth
• Intent not necessary
• For FCA violations, treble damages, plus $11,000 per claim
• Fines grow fast, each claim can be a separate ground for liability
State False Claims Acts
• Each state has an incentive to have a False Claims Act that meets federal requirements
• A link to check:
https://oig.hhs.gov/fraud/state‐false‐claims‐act‐reviews/index.asp
Fraudulent Billing
• Fraudulent billing results in a “false” claim to the Medicare or Medicaid program. Examples of fraudulent billing may include1. Billing for services that were never provided
2. Billing a patient for services, and the patient was never seen
3. Billing for services no longer medically necessary per the Medicare Statute
4. Up coding to a more expensive procedure to maximize reimbursement
5. Duplicate billing for the same patient
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved7
FCA ‐Whistleblowers
• The False Claims Act also provides a strong financial incentive to whistleblowers to report fraud
• Whistleblowers can receive up to 30 % of any FCA recovery
• Often whistleblowers turn out to be ex‐business partners, competitors, or even staff & patients
• Rehab examples…….
Anti Kickback Statute (42 U.S.C. § 1320A‐7B(B))
• Prohibits asking for or receiving anything of value in exchange for referrals of federal health care program business
• Asking for or receiving any remuneration in exchange for your referrals of Federal health care program business is a crime under the AKS
• The AKS applies to both payers and recipients of kickbacks. Just asking for or offering a kickback could violate the law.
• Violations can result in prison sentences and fines and penalties of up to $50,000 per kickback plus treble damages
• Additionally, exclusion from participation in the federal health care programs for violating the AKS
Anti Kickback Statute
• A kickback, or remuneration, can be anything of value. Kickbacks can include cash for referrals, free or reduced rent, excessive compensation for medical directorships, or tickets to major sporting events.
“In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime”. ‐ OIG
Anti‐Kickback Statute
• The Anti‐Kickback Statute is implicated when a rehab provider gives patients a financial incentive to come to their clinic for therapy:– For example routinely waiving co‐payment without regard for the patient’s ability to pay
• Co‐payments may be waived on a case‐by‐case basis based upon a financial hardship policy.
• The Anti‐Kickback Statute does not prohibit providing free or discounted care for uninsured patients.
• Safe Harbors
Civil Monetary Penalties (42 U.S.C. § 1320A‐7a)
• OIG may seek civil monetary penalties for a wide variety of abusive conduct, including presenting a claim that is false or fraudulent because it is for a medically unnecessary procedure
• OIG also may impose civil monetary penalties for violating the Medicare assignment agreement by overcharging or double billing Medicare beneficiaries
Source: HHS/OIG: “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse”.
Civil Monetary Penalties
• OIG may seek CMPs against any person who:– Presents or causes to be presented claims to a federal health care program
that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent.
– Violates the anti‐kickback statute by knowingly and willfully: (1) offering or paying remuneration to induce the referral of federal health care program business; or (2) soliciting or receiving remuneration in return for the referral of federal health care program business.
– Presents or causes to be presented a claim that the person knows or should know is for a service for which payment may not be made under the physician self‐referral or "Stark" law.
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved8
Exclusion Statute (42 U.S.C. § 1320A‐7)
• Under the Exclusion Authorities, OIG may exclude providers from participation in the federal health care programs.– Mandatory exclusions are
imposed on the basis of certain criminal convictions.
– Permissive exclusions are based on sanctions by other agencies.
• Check the exclusions database: http://exclusions.oig.hhs.gov/
Sanctions & License Ramifications
• Violations of healthcare laws by individual providers can lead to sanctions including being reported to the OIG's List of Excluded Individuals and Entities (LEIE) Database.
• Company policy should be to verify clinical staff credentials through this database, and other federal databases.
• State professional licensing boards can revoke a provider's license for violations of healthcare laws including fraud and abuse laws.
• Following exclusions, must apply for reinstatement.
STARK (42 U.S.C. § 1395NN)
• Physician Self Referral Law(s)
• Limits physician referrals when there is a financial relationship with the entity
– Is there a referral from a physician for a designated health service (DHS)?
– Does the physician (or an immediate family member) have a financial relationship with the entity providing the DHS?
– Does the financial relationship fit in an exception?
Special Fraud Alerts & Advisory Opinions
• Special Fraud Alert – pertaining to rehab: Rental of Space in Physician Offices by Persons or Entities To Which Physicians Refer.
• https://oig.hhs.gov/fraud/docs/alertsandbulletins/office%20space.htm
• OIG Advisory Opinion—relating to free transportation
SKILLED MAINTENANCE
Jimmo v. Sebelius Settlement
• On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius.
• Medicare mythical “improvement standard”
• Goal to ensure that
– claims are correctly adjudicated in accordance with existing Medicare policy,
– so that Medicare beneficiaries receive the full coverage to which they are entitled.
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved9
Medicare on Maintenance
Maintenance Program (MP)
“a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the
progress he or she has made during therapy or to prevent or slow further deterioration due to a
disease or illness.”
“Skilled” Maintenance
“..services …required to maintain the patient’s current function or to prevent or slow further deterioration
– are of such complexity and sophistication that…skills of a qualified therapist.. required to perform….procedure safely and effectively,
– the services would be covered physical therapy services.
“Skilled Maintenance”
• “….patient’s special medical complications require ..skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled,
– such services would be covered physical therapy services.”
Maintenance: At Conclusion of Therapy
• A patient with Parkinson’s disease is nearing the end of a rehabilitative physical therapy program and – requires services of therapist during the last week(s) of
treatment to determine • what type of exercises will contribute the most to maintain function or• to prevent or slow further deterioration of the patient’s present functional level following cessation of treatment. (MP vs HEP)
• …establishment of a maintenance program appropriate to the capacity and tolerance of the patient ..instruction of the patient or family members in carrying out the program, + ….reevaluations as may be required may constitute covered therapy….. because of the need for the skills of a qualified therapist.
CMS: Transmittal 179
Maintenance: Intermittent Review
• HX Multiple Sclerosis recent exacerbation : difficulties wheelchair transfers, maintaining LE ROM (increased spasticity muscle tone)
• Unable to walk…independent use of wheelchair…needs to be able to safely transfer in and out of wheelchair by herself or w/assistance of family member or caregiver
• After eval, (given patient’s overall medical and physical condition)
– skills of PT required to instruct patient and/or caregivers in proper techniques (see above) due to special medical complications from progression of MS
• When PT determines patient can carry out above safely and effectively, alone or with the assistance of caregivers, skills of PT are no longer necessary to furnish the skilledmaintenance therapy; and, the patient is discharged from PT.
CMS: Transmittal 179
Maintenance: Therapy by Therapist
• Patient has progressive degenerative disease– performing activities in maintenance program (established by
PT) with the assistance of family members.
• Program needs to be re‐evaluated to determine whether assistive equipment is needed and to establish a new or revised skilled maintenance program to maintain function or to prevent or slow further deterioration.
• Intermittent re‐evaluation of the skilled maintenance program would generally be covered: service that requires the skills of a therapist.
• Should the PT conducting the re‐evaluation determine program needs to be revised, these services would generally be covered.
CMS: Transmittal 179
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved10
NOT MEDICALLY NECESSARY
Ca$h and Compliance
• What’s not to like?
– Emerging trend
– Generating a lot of interest by private practice, even hospitals
– Enthusiastic grass roots movement and discussion via social media
– Industry acknowledged gurus, happy to share their unique “story”
– Many models: cash only, cash +, cash after
Ca$h and Compliance • Then of course, there’s Compliance!
– But I don’t take Medicare….– I heard there was a “secret” HIPAA clause– I looked at HIPAA, and I’m not a covered entity…– Doesn’t Medicare cover “wellness services”?– I’m also at ATC….can I “switch” practice modes?– The client didn’t tell me they were going to bill their secondary…
– The family is upset, and said they would report me to Medicare….
– I didn’t know that WASHINGTON had privacy laws and I had to report a data breach…
ABN – Compliance*
Ref: http://www.cms.gov/Medicare/Medicare‐General‐Information/BNI/ABN.html
ABN – Compliance* ABN Modifiers*
Modifier GA
• Waiver of Liability Statement on file
• Expecting “not medically necessary denial”
• Mandatory ABN is properly executed
Modifier GZ
• Item or service expected to deny as not reasonable or necessary
• No ABN obtained
• All claim line(s) with a GZ modifier “shall be denied automatically and will not be subject to complex medical review”
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved11
Effective Compliance ProgramSeven Elements
1. Policies and procedures2. Reporting and investigating3. Education and training4. Prevention and response5. Auditing and monitoring6. Responsibility/oversight7. Enforcement, discipline, incentives
http://www.ussc.gov/guidelines‐manual/2013/2013‐8b21
1. Policies, Procedures & Standards of Conduct
• Clearly written and describe expectations in detail
• Include detailed “code of conduct” and reporting
mechanisms
• Policies include compliance staff roles and responsibilities
• Readily available to all employees
• Reviewed by employees within 90 days of hire and annually
• Regularly reviewed and updated
Source: MLN: Provider Compliance Program Core Elements Checklist
2. Compliance Program Oversight
• Choosing the Compliance Officer:– Credible, integrity, high‐level personnel with control over the
organization
– Authority and resources to get the job done
– Should have no barrier to access; independent voice
• Who should the compliance officer report to?“The OIG believes that there is some risk to establishing an independent compliance function if that function is subordinate to the hospital’s general counsel, or comptroller or similar hospital financial officer”
– Owner, Governing Body and/or CEO
• Responsibility for Compliance Oversight
Source: Compliance Program Guidance for Hospitals OIG
http://oig.hhs.gov/compliance/compliance‐guidance/docs/Practical‐Guidance‐for‐Health‐Care‐Boards‐on‐Compliance‐Oversight.pdf
2. Compliance Program Oversight
• Develop and/or review policies and procedures that implement the compliance program
• Attend operations staff meetings
• Monitor compliance performance by operational areas
• Enforce disciplinary standards, ensuring consistency
• Implement system for assessment of risk
• Develop auditing work plan
• Review auditing and monitoring reports
• Coordinate with Human Resources
• Monitor consistency and effectiveness of corrective actions
Source: MLN: Provider Compliance Program Core Elements Checklist
3. Training & Education
• Conduct general compliance training to all employees, managers and supervisors that effectively communicates compliance program requirements, including the company’s code of conduct
• Conduct initial training for new employees at or near the date of hire
• Conduct annual refresher compliance training that re‐emphasizes the code of conduct and highlights compliance program changes
• Include compliance scenarios and/or investigations of non‐compliance
• Communicate compliance messages using training methods such as posters, newsletters, and Intranet communications
Source: MLN: Provider Compliance Program Core Elements Checklist
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved12
4. Opening Lines of Communication
• Establish an “Open Door” policy established with compliance officer/committee
• Compliance staff answers routine questions regarding compliance or ethics issues
• Make several methods available for employees to report compliance issue (for example, in person, electronically, or by anonymous drop box or toll‐free hotline)
Source: MLN: Provider Compliance Program Core Elements Checklist
5. Auditing & Monitoring
• Auditing & Monitoring System
• Risk Assessment
• Monitoring & Auditing Work Plans
• Written Policies & Procedures: Response to Detected Offenses
Source: MLN: Provider Compliance Program Core Elements Checklist
Where are my risks?
REG
ULATO
RY Credentials
Practice act
Documentation
Therapy cap/MMR
Students
THIRD PARTY
Medical Review
LCD/NCDs
ICD‐9 / 10
PEPPER
Billing/Coding
Overpayments
INTERNAL Audit findings
HR issues
Billing trends/issues
Reports/Interviews
EMR issues
Policies and procedures
External Sources of Information
Consider the following when determining your compliance risk
• OIG Annual Work Plan
• Industry journals/periodicals
• CIA’s, Fraud Alerts, Advisory Opinions, etc
• Recent government enforcement activities
• RAC/MAC/CERT/ZPIC/CBR’s
• Compliance Program Guidance
• APTA, AOTA, ASHA Websites
• Compliance experts interviews
• NARA e‐news/work groups
• Regulatory and third party payer list serves/publications
• Press releases
Internal Sources of Information
Compliance
Chart Review
•Internal
•External
“Hot Line” or other
reported concerns
Recent audit results
Compliance Program
Effectiveness Reviews
Grape Vine
•Formal
•Informal
Auditing & Monitor: Setting up the Plan
• Based on risk assessment
• Routine items
• Should be caught concurrently
• Daily checks
• Discharge or triple checks
• Examples?
• Based on risk assessment
• Routine audits
• Special audits
• QA/UR – is this audit?
• Chart review – is this audit?
• Examples?
Monitoring Auditing
Daily BP checks vs. Annual Physical Exam
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
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Monitoring Activities
• All “hands on deck” approach
– Compliance empowerment
• Focus on contemporaneous items that can be corrected immediately
– Legible signature and dated note
– Adding minutes – and checking the 8 minute rule
– Was a progress report due today? FLR reporting?
– Should the KX modifier be appended today? Does the therapist agree? “Proof” of medical necessity
– Did MD return POC certification?
• Focus on due diligence related to excluded providers
– Licenses – all states
– OIG LEIE
– “Excluded in One, Excluded in All”
6. Corrective Actions
• Conducted in response to potential violations (for example, repayment of overpayments or disciplinary action against responsible employees)
Source: MLN: Provider Compliance Program Core Elements Checklist
7. Consistent Discipline
• Clearly defined disciplinary standards
• Describe expectations as well as consequences for noncompliant, unethical, and illegal behaviors
• Include sanctions for non‐compliance, failure to detect non‐compliance when routine observation should have provided adequate clues, and failure to report actual or suspected non‐compliance
• Reviewed with staff regularly (at least yearly)
• Dealt with timely and enforced consistently
Source: MLN: Provider Compliance Program Core Elements Checklist
Auditing & Monitor: Setting up the Plan
• Based on risk assessment
• Routine items
• Should be caught concurrently
• Daily checks
• Discharge checks
• Examples?
• Based on risk assessment
• Routine audits
• Special audits
• QA/UR – is this audit?
• Chart review – is this audit?
• Examples?
Monitoring Auditing
Monitoring Activities
• All “hands on deck” approach– Compliance empowerment
• Focus on contemporaneous items that can be corrected immediately– Legible signature and dated note– Adding minutes – and checking the 8 minute rule– Was a progress report due today?– Should the KX modifier be appended today? Does the therapist agree?
“Proof” of medical necessity– Did MD return POC certification?
• Focus on due diligence related to excluded providers– Licenses – all states– OIG LEIE– “Excluded in One, Excluded in All”
External Audit Process & Outcomes
• Create audit parameters and summarize in audit face sheet– Identify data, records and other information needed; who to interview?
• Findings: objective and subjective– Interpret the findings with respect to future risk
– Recommend action steps• Employee discipline process
• Training and education
• Re‐audit
• Under “privilege” discussion if appropriate
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
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Dash Board Examples
• Examples to get you going:– License verification
– OIG Sanctions check
– Compliance logs
– Compliance “hot line” calls
• Case Studies– Therapist forgets to renew license
– Therapist titles an email with “FRAUD” in subject line
License Verification
WA CA OR AZ CO NM
Checks 198 469 207 95 145 95
Verified 198 469 207 95 145 95
0
50
100
150
200
250
300
350
400
450
500
Volume
License VerificationLicensed Professionals
n = 1217
Note: Sample Data
OIG Sanctions
Checks Findings Rule Out
Jan 2,615 2,643 2,643
Feb 2,816 298 298
March 2,781 104 104
Apr 2,764 402 402
May 2,493 100 100
June 2,630 50 50
July 2,714 278 278
0
500
1,000
1,500
2,000
2,500
3,000
Volume
OIG Sanction ChecksJan‐June 20xx
Note: Sample Data
Compliance Hotline Calls
Note: Sample Data
3354
By Region
Region 1 ‐ 33
Region 2 ‐ 54
12
46
6
12
9 2
By State
WA 12
CA 46
AZ 6
OR12
CO 9
NM 2
ADR Requests
Note: Sample Data
RAC Non‐RAC Total
Patients 75 56 131
Claims 250 226 476
0
50
100
150
200
250
300
350
400
450
500
Volume
Additional Documentation Requests201X ‐ Prepayment & Postpayment Review
Compliance Investigations
Internal• Who?
• What?
• When?
• How?
External• Federal: DOJ, OIG, FBI
• State: MFCU, AG, MIC
• CMS: MAC, RAC, ZPIC, PSC
• Qui Tam Realtor
FPTA – September 26, 2015 Medicare Compliance: Hiding in Plain Sight
©Nancy Beckley & Associates LLC All Rights Reserved15
Risk Areas
• False Claims Act
– 60 Day Duty to Repay
– “Reverse False Claims”
• Medical Directors
Attorney‐Client Privilege
• Does your organization have an established policy to help determine when to conduct an audit under privilege?
• Understand the scope of the privilege.
Seven Deadly Compliance Mistakes
1. Failure to exercise due diligence is hiring excluded individuals
2. Failure to demonstrate P & P on billing, coding & documentation
3. Absence of training on preventing fraud & abuse4. Relying on unofficial sources rather than manuals &
regulations5. Believing an EMR ensures compliance6. Not following POC statutory certification requirements7. Providing inaccurate information to beneficiaries, ABN,
CASH, Medical necessity
Investing in Compliance
“It's high time that boards of directors, C‐suites, and investors begin to view a properly resourced and structured compliance function as no less than a non‐negotiable investment in their firm's license to operate, full stop.
“Compliance and culture should be treated as the twin drivers of individual behavior that they are, especially among those employees who can do the most damage from within.”
“The right time to staff up for that is before, not after, the scandal headlines go viral on Twitter.”
Ref: Donna Boehme
The Small Print
• Materials used in the presentation are copyrighted. References have been noted as to sources utilized.
• Use of materials/slides/information in this presentation may be granted for in house education at your facility, however written permission is required.
• Other use of these materials require the permission of Nancy Beckley & Associates LLC.
Contact Information
Nancy J. Beckley, MS, MBA, CHCPresidentNancy Beckley & Associates LLC
http://nancbeckley,com nancy@nancybeckley.com
414‐748‐4376
@nancybeckley
http://www.linkedin.com/in/nancybeckley