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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



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



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)



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?



• 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



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



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


• 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


• 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



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



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.



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.



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.


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.




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”



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


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




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)


5. Auditing & Monitoring

• Auditing & Monitoring System

• Risk Assessment

• Monitoring & Auditing Work Plans

• Written Policies & Procedures: Response to Detected Offenses


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?


• Routine audits

• Special audits

• QA/UR – is this audit?

• Chart review – is this audit?

• Examples?

Monitoring Auditing

Daily BP checks vs. Annual Physical Exam



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)


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


Auditing & Monitor: Setting up the Plan


• Routine items

• Should be caught concurrently

• Daily checks

• Discharge checks

• Examples?


• 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



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



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 [email protected]

414‐748‐4376

@nancybeckley

http://www.linkedin.com/in/nancybeckley

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