Steve Johnson, Director of Reimbursement Consulting CAC ... · ambulance services throughout the...

Presented by -

Amanda Ward, Esq., CAC, CACO, CAPO

and

Steve Johnson, Director of Reimbursement Consulting, CAC, CACO,

CAPO

www.pwwemslaw.com

5010 E. Trindle Road, Suite 202 Mechanicsburg, PA 17050

717-691-0100 717-691-1226 (fax)

[email protected] [email protected]

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2016

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Amanda Ward Attorney [email protected] Amanda Ward is an associate attorney at Page, Wolfberg & Wirth, LLC. She focuses on Reimbursement and Compliance issues and is a speaker at PWW’s signature abc3 conference series as well as other seminars and webinars. Amanda’s work for PWW includes representing private, public and nonprofit EMS agencies, billing companies and others that serve the nation’s ambulance industry. Amanda also helps to develop many of the firm’s articles, books, presentations and other programs that are widely used by EMS providers throughout the United States.

Prior to joining PWW, Amanda was the in house counsel and Compliance Officer for a large ambulance service where she created, implemented and oversaw the company’s first formal compliance program. Amanda has significant experience advising both public and private ambulance services and third party billing agencies concerning reimbursement and compliance issues. She also has experience reviewing claims and advising entities regarding best practices for reimbursement compliance. Amanda is familiar with the employment and contractual issues affecting the ambulance industry and is able assist ambulance services as they navigate those matters.

Amanda is admitted to practice law in California and holds a certification in healthcare compliance from the Compliance Certification Board. She graduated with honors from Millikin University in Decatur, IL with a degree in Marketing. Amanda is also a graduate of the University of Illinois College of Law where she was an Intellectual Property Moot Court competitor and editor.

Amanda is an avid Illini fan and lives in the suburbs of Chicago with her three children. She actively volunteers with various organizations in her local community including her children’s schools and the Junior League.

http://www.pwwemslaw.com/


2016

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Steven M. Johnson Director of Reimbursement Consulting [email protected] Steve began his career in the EMS industry in 1985, gaining valuable experience while serving as an EMT and later as Director of a municipal ambulance service in Minnesota. As an ambulance service manager, Steve established his expertise in areas of operations, billing and administration.

Steve also has significant EMS educational experience. He established and served as Training Coordinator and Lead Instructor for a State Certified EMS Training Institution for EMTs and First Responders.

Steve served on both the Rules Work Group and the EMS Advisory Council to the Minnesota State Department of Health.

He joined the staff of a large, national billing and software company, where he was a frequent lecturer at national events and software user group programs. For over seven years, Steve served as Director of a national ambulance billing service and was responsible for all aspects of managing this company, including reimbursement, compliance and other activities for ambulance services throughout the nation.

Steve served as founding Executive Director of the National Academy of Ambulance Coding (NAAC), overseeing all activities of the Academy, including the Certified Ambulance Coder program, the nation’s only coding certification program specifically for ambulance billers and coders.

As the Director of Reimbursement Consulting with Page, Wolfberg & Wirth, Steve is involved in all facets of the firm’s consulting practice. Steve works extensively on billing and reimbursement-related activities, performing billing audits and reviews, improving billing and collections processes, providing billing and coding training, conducting documentation training programs, and performing many other services for the firm’s clients across the United States.

Steve is also a licensed private pilot, and enjoys an active role in his church.

http://www.pwwemslaw.com/


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Questions During the Webinar

• Use the “Questions” feature on your GoToWebinar control panel

• Fax: 717-691-1226

Today’s Webinar:

To enter your CEUs log into your NAAC account at www.AmbulanceCompliance.com

Fall 2016- All NEW Content

Registration NOW OPEN!

www.abc360conference.com

Hershey 2016 Dates

October 18-19 October 17

October 15-17 October 15-16 October 15-16

Certifications

This Webinar covers the “big” items since the fall 2015

abc360 conference



Dates for Upcoming 2016 abc360

Update Webinars

• September 14, 2016 2 - 3pm

• December 14, 2016 2 - 3pm

Today’s Webinar

• ICD-10 Implementation Progress• New Medicare Payment Data• Recent Reimbursement and Compliance

News• The Final 60 Day Overpayment Rule• HIPAA Happenings• The Latest ACA Legal Challenge

MEDICARE AND REIMBURSEMENT UPDATE

2016 Ambulance Inflation Factor

• Negative 0.4%

MLN Matters Number: MM9412

Remember this?



AMA and CMSAnnounced ICD-10 “Flexibility”• “[For 12 months]. . . Medicare review

contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule . . . based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right [family of codes]…”

Only 3 months left in the “flexibility” window

Assessing Your Progress

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf

Some KPIs to Track

Coder productivity Volume of records coders return to

providers for more documentation

Requests for additional information from payers

Some KPIs to Track

Use of ICD-10 codes on prior authorizations and referrals

Denial of unspecified codesDenial of claims specifically related to

ICD codes used

Ask Staff About…

• Specific parts of their workflow that are slowed by ICD-10

• Areas where more or different tools or training might be helpful

• Where they see opportunities for improvement

• Coding situations that cause the most difficulty



Are We Getting What We Need?

• Look at clinical documentation for services provided before and after October 1, 2015

• Issues with documentation might be a result of insufficient training on ICD-10 coding concepts and guidelines

CMS Released CY 2014 Part B Medicare Payment Data

Let’s take a quick look at CY 2014 nationwide ambulance

data . . .

ALS1‐E33%

ALS1‐NE2%

ALS2<1%BLS‐E

19%

BLS‐NE45%

SCT<1%

National Ground Breakdown 2014

ALS36%

BLS64%

National ALS/BLS Breakdown 2014

ALS1‐E64%

BLS‐E36%

National Emergency Transport Breakdown 2014



ALS1‐NE5%

BLS‐NE95%

National Non‐Emergency Transport Breakdown 2014

Average Submitted Charges Nationwide 2014

• ALS1-NE $828.66• ALS1-E $963.00• ALS2 $1,166.71• BLS–NE $547.63• BLS-E $700.31• SCT $2,033.17• Fixed Wing $16,942.28• Rotary Wing $19,948.57

MAC HappeningsCycle 2 Revalidations. Here

we go again….

Cycle 2 Revalidation Program

• All providers and suppliers supposed to revalidate every 5 years

• CMS assigning revalidation due dates based on the last successful revalidation or the date of the initial enrollment e.g, if you revalidated in 2011 your new

revalidation date will be in 2016

Use CMS Revalidation Lookup Tool

• CMS has assigned due dates through fall 2016

• If you haven’t yet been assigned it will show “TBD”

https://data.cms.gov/revalidation



Cycle 2 Revalidation Program

• First set of due dates was May 31, 2016• CMS will notify providers or suppliers

by email within 2-3 months of their due date

• Data last refreshed on 7/5/2016• Next data refresh tentatively scheduled

for 9/1/2016

Submitting Revalidations

• Permitted to submit revalidations up to 6 months prior to the scheduled due date

• Revalidations can be submitted either on paper or by using PECOS online

• For more information: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html

If You Fail to Timely Revalidate

• Medicare billing privileges will be deactivated

• Will be required to submit a complete enrollment application to “reactivate”

• CMS said no payments will be made for services provided during the interim period

Did You Hear About the Misinformation from some of

the MACs?

We agree! And we want to help with an ALL NEW

session…COMPLIANCE UPDATE



OIG Updates Criteria it Uses to Determine Whether to

Impose Exclusion

http://oig.hhs.gov/exclusions/files/1128b7exclusion-criteria.pdf

IN OTHER WORDS… WHETHER OR NOT YOU END UP HERE

Remember…

• The OIG has the authority to exclude individuals and entities who engage in fraud or improper conduct

• It MUST exclude individuals and entities in certain circumstances like Conviction for patient abuse Felony conviction for healthcare fraud

But…

• But in all other situations it’s up to the OIG to determine if exclusion is warranted based on how likely it is that the individual or entity will engage in fraud or improper conduct again

The New Standard

• The OIG presumes that exclusion is necessary when fraud or improper conduct occurs unless the individual or entity can PROVE that exclusion is not necessary

The OIG Assesses Four Categories…



Based on the Assessment the Likelihood of Future Risk is

Determined

And Then a Penalty is Imposed Based on the Risk Level

1. Transports to dialysis facilities that potentially Never occurred Were medically unnecessary

2. Improper ALS-E payments

“We will examine Medicare claims data [for]”



Houston and Philadelphia Ambulance Moratoria Extended Again!

• Effective January 29, 2016 CMS extended moratoria for an additional 6 months

Are YOU Next on the Moratorium List?

Now You Can Predict It!

The Final 60 Day Overpayment Rule

• Published February 12, 2016

Effective:March 14, 2016



Enforces Two Provisions in the ACA

1. Providers and suppliers must report and return identified overpayments from Medicare and Medicaid within 60 days

2. Retaining an overpayment after the deadline constitutes a violation of the Federal False Claims Act (FCA)

Regulations Apply to…

• Medicare overpayments • CMS said it will issue other rules for

Medicaid overpayments Even without Medicaid-specific rules, you

still have a duty under ACA to return Medicaid overpayments within 60 days of identification

Definition of “Overpayment”

• Any funds a provider has received or retained from Medicare to which the provider is not entitled

Examples of Overpayments• Claims paid at a higher level of service

than is justified by the documentation

• Claims paid for transports performed or billed by an excluded individual

• Claims paid without a valid signature are overpayments

• Invalid or missing PCS forms

Identified

• A provider has identified an overpayment if the provider has, or should have through the exercise of reasonable diligence Determined that an overpayment has been

received, and Quantified the amount of the overpayment

42 CFR § 401.305(a)(2)

Reasonable Diligence

• Reasonable diligence is BOTH: Proactive compliance activities conducted in

good faith by qualified individuals to monitor for the receipt of overpayments Investigations conducted in good faith and in

a timely manner by qualified individuals in response to obtaining credible information of a potential overpayment



Here’s the Way it WorksYou determined

you’ve received an overpayment and

quantified it

You exercise “reasonable diligence”

You fail to exercise “reasonable diligence”

You have “identified” an overpayment

The overpayment is “identified” once you’ve determined

you’ve received it and you’ve quantified it

The overpayment is likely “identified”

when it was received

60 Day Time Frame

• When investigations are necessary, HHS says that the investigation should take at most 6 months from the receipt of the credible information

• Maximum time frame to complete the refund is 8 months - 6 months maximum for an investigation + 60 days to refund the overpayment

Best Practices - Investigation

• Where little or no investigation is required – report and return 60 days from date you discovered the issue

• If you need to investigate: Proceed with “reasonable diligence” Don’t take longer than 6 months to investigate Don’t take more than 8 months from discovery to

repay

Quantifying the Overpayment

• If actual amount can be readily determined, refund the actual amount

• In more complicated cases, like a two-step process:1. Probe sample2. Extrapolation

6 Year Lookback Period

• Overpayments must be refunded only if provider identifies the overpayment within 6 years of the date the overpayment was received

• When investigating potential overpayments – may need to go back 6 years!

Find Out More About the 60 Day Overpayment Rule by attending

• 2016 Compliance Update• ALL NEW session How to Navigate

the 60 Day Overpayment Rules



PRIVACY UPDATE

The Phase 2 HIPAA Audits are Underway!

Check Your Spam Filter!

• OCR will via email you• “If your spam filtering and virus

protection are automatically enabled, we expect you to check your junk or spam email folder for emails from OCR; [email protected].”

• 14 days to respond

Who’s Getting Audited?

• “Every covered entity and business associate is eligible for an audit.”

You Get a

HIPAA Audit

What if We Get Contacted?

• Must fill out audit pre-screening questionnaire online

• Will be asked for list of business associates

The Audit Protocol is Online

http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/protocol/index.html



Recent Advice on Patient Rights Patient’s Have a Right to Get Records Via Email

Even, Unencrypted Email And, you Can’t Do This Stuff…

You Can’t Make the Patient

• Physically come in to request PHI• Use a web portal to access their

records• Mail a request for records• Notarize an access request

When it Comes to Patient Access:



HEALTHCARE REFORM UPDATE

The Latest ACA Legal Challenge

• U.S. House of Representatives vs. Burwell• May 12, 2016 – U.S. District Court for

the District of Columbia • The court ruled that the federal

government cannot make payments to health insurers under the cost-sharing reduction program


• The cost-sharing reduction program provides a subsidy for certain eligible individuals who purchase coverage through the health insurance exchanges

• The ACA requires the payments, but Congress didn’t appropriate the funds

• The court ruled that the Executive Branch cannot spend funds unless appropriated by the Legislative Branch


• This case is working its way through the appeals process

• The court entered a stay of its injunction pending appeal, which means the government can continue to spend the funds – and insurers can continue to receive reimbursements – during the appeal

Questions

• Use the “Questions” feature on your GoToWebinar control panel

• Fax: 717-691-1226

Fall 2016- All NEW Content Registration NOW OPEN!

www.abc360conference.com

this

Certificate of Completionis presented as evidence of completion, by the Certified Ambulance Coder®, Certified Ambulance Compliance Officer™ or Certified

Ambulance Privacy Officer™ whose signature and Certification Number appear below, of the NAAC® approved Continuing Educationcourse entitled

2015-2016 abc360 Update Webinar Series Part 1 of 3

CEU Code: kGznFW

I hereby certify that I have completed the continuing education training as represented on this certificate.

Signed: ____________________ NAAC® Certification Number: ____________________

Jason J. LeetProgram Coordinator

07/27/16

Date of Training

Certificate is invalid without the signature and certification number of the attendee.

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Steve Johnson, Director of Reimbursement Consulting CAC ... · ambulance services throughout the...

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