Transcript Document
Fraud, Abuse, and Waste
Gayle Lee, J.D
Sarah Miller
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Concerns with Fraud & Abuse
• Institute of Medicine (IOM) reported that $765 billion per year has been lost to fraud, waste, and abuse. ($75 billion due to fraud) • Overutilization of services • Increased costs for payers • Corruption of medical decision-making • Unfair competition • Harm to patient • Deter new students from entering a profession due to public perception
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Increase in Prosecutions
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Fraud and Abuse: The Players
• Centers for Medicare and Medicaid services, central, regional offices • CMS Contractors (MACs, PSCs, QICs, RACs, ZPICs) • CMS Office of the General Counsel (Stark regulatory authority) • HHS Office of Inspector General • Department of Justice • FBI • State Attorney General • State Regulatory Agencies (e.g. Licensing Boards)
MEDICARE AUDITORS
Who are they?
What do they do?
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Strategic Health Solutions (supplemental auditor) • “ Analysis of Medicare claims data between August 2012 and March 2013 identified provision and billing of therapy services that either stopped or delayed just under the allowed therapy cap.” • “Analysis of Medicare claims data for October and November 2012 identified a continuation in billing and payment for Outpatient Therapy Services during a period of time that healthcare facilities were inaccessible to the public as a result of power outages and flooding caused by Hurricane Sandy.” • http://www.strategichs.com/medical-review-results/
CERT 2013 Report
Improper Error Rate by State: Dollars in Millions
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PROGRAM INTEGRITY CMS STRATEGIES
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Strategies to Reduce Improper Payments
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Provider Enrollment
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• Physical Therapists in Private Practice (PTPPs) placed in moderate risk category.
• PTPPs must have a site visit prior to enrollment as of March 25, 2011.
• Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. (applies to those providers and suppliers that were enrolled prior to March 25, 2011).
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“Red Flags” in System for PT
• Medicare is performing predictive modeling using the following red flags: • Frequent use of the KX modifier (aberrent from the norm) • In a private practice setting, the billing is going under one PT provider number rather than each separate PT enrolling.
• Excessive Number of Codes billed per session
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How Far Back Can the Govt Go to Collect Overpayment ?
• Prior to 2013, for Medicare overpayments, the federal government and its carriers and intermediaries had 3 calendar years from the date of issuance of payment to recoup overpayment. This has been changed to 5 years based on provision in Taxpayer relief act.
• The 3 year statute of limitations does not apply to recovering overpayments made as result of false pretenses or fraud.
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Risk Areas for Physical Therapists
• Missing Certifications on plan of care • Billing for services furnished by Aides/Techs • Providing inadequate supervision • Billing for one-on-one codes instead of group therapy • Failing to comply with the 8 minute rule • Failing to comply with CCI edits • Submitting claims for services that provider knows are not reasonable and necessary
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
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Risk Areas for Physical Therapists
• Code Gaming • Unbundling (hot pack, dressings) • Upcoding (E-Stim, RUGs group) • Billing for excessive duration and frequency of services • Billing for services not furnished • Billing for student services • Documentation deficits or fraudulent modifications post denial or request for records • Signatures not legible • Use of stamped signatures
INTEGRITY IN PRACTICE CAMPAIGN
THE VIEW FROM PHYSICAL THERAPISTS
Survey Sampling
• Survey of 571 member and 300 non-member PTs
Primary areas of compliance concern for PTs: Survey Results • More changes to already complex Medicare requirements; • Stricter documentation rules as it relates to electronic health records (EHRs); • Keeping up to date with software improvements to EHRs and similar systems; and • Pressure to see more patients and efficiently manage their time.
4 Main APTA Campaign Objectives
1) 2) 3) 4) Show APTA as a leader and partner in the effort to eliminate fraud and abuse from health care and strengthen the good reputation of physical therapy in health care system Educate members, nonmembers, new professionals, and students so they can avoid pitfalls that invite more scrutiny & payment cuts; and focus on delivering value and quality in practice Advocate on behalf of PTs and the profession to reduce or prevent further burdensome regulation and oversight, and preserve freedom to practice Communicate our efforts and highlight solutions through every channel while showing buy-in from partner organizations who are key stakeholders in health care
24 P O L I C Y M A K E R S S AY
Physical therapists are leaders when it comes to preventing and limiting healthcare fraud. More than any other group they took this challenge seriously, and put into practice the best standards and innovative approaches. We should ask them for their opinion about how to handle the next challenge.
25 P H Y S I C AL T H E R AP I S T S S AY
I was starting to worry about more potential regulation, but my association put together an incredible program that completely put the issue to rest. Not only am I confident that I know what to do, I’m also so proud of how my profession is the leader on this issue for other health practitioners.
26 PAT I E N T S S AY
I have total confidence in my physical therapist’s commitment to ethical practice. When it comes to the complicated matter of payment for services, she has been completely upfront and provided helpful information to ensure that I understand what is appropriate.
How We’ll Meet Our Objectives
• Develop a CE Module to address PTs’ key concerns of reduced payments and burdensome regulations, defines fraud and abuse, and connects the dots between compliance and their concerns • Partner with other key health care stakeholders • Articles in
PT in Motion, Perspectives
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Blurbs in News Now, PT blogs, and a Social Media Blitz
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Direct Education to Students & New Professionals
How will we meet our objectives
• Create Tools for Advocacy: - Fact Sheets - Case Studies - Infographics - FAQs
Partner Engagement
• Participate in Choosing Wisely Campaign • Development of list of 5 “Don’t” practices • Collaboration with AOTA and ASHA on education and advocacy initiatives • Initial meeting held • Future plans to reach out to SNFs (NASL, AHCA), corporate providers, home health, and others
Partner Engagement
• Collaboration with law makers, regulators, private insurers and payers on the upcoming campaign • Have had discussions/meetings with CMS Program Integrity, Office of Inspector General, Department of Justice about campaign • APTA presented at the Federation of State PT Boards meeting in the fall; Federation included a full day of curriculum on fraud & abuse
Education and Outreach to PTs
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Educate PTs about key practices & tools to remain in compliance.
• Continuing education modules on compliance • Development of a microsite on integrity in practice to house information • Develop mechanisms to focus education on compliance toward students, new professionals, and clinical instructors
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Module: APTA Learning Center
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Navigating the Regulatory Environment: Ensuring Compliance While Promoting Professional Integrity
Presenters: Dr. Shantanu Agrawal MD; Dr. Anthony Delitto PT, PhD, FAPTA; Katherine Karker-Jennings, JD, MS; Ellen R. Strunk, PT, MS, GCS, Becky Clearwater, PT, MS, DPT http://learningcenter.apta.org/showCourse.aspx?cs=5 8152b38-1976-4641-9585-6c7a5259d128
Education and Outreach to PTs
• Promotion of CE module via: • Article in PT magazine published on integrity in practice • Article in PT perspectives for new professionals • Development and placement of ads in PT magazine, PT Perspectives • Use of social media • Promoting on List-serves • Outreach to bloggers
CHOOSING WISELY CAMPAIGN
5/6/2020
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“Five Things PTs and Patients Should Question” • Planned in partnership with American Board of Internal Medicine (ABIM) Foundation • Each participating specialty society has created a list of “Things Physicians and Patients Should Question” to make wise decisions about appropriate care
About the Initiative
Focus on Social Justice • Safety • Quality • Doing no harm • Eliminating waste • Medical professionalism
Who is Participating in Campaign
• More than 50 medical specialty societies are participating to date • 15 more specialties are scheduled to release lists in 2014 • Consumer Reports joined the campaign to provide resources for consumers and physicians to engage in conversations. • Planned expansion of the campaign to include non-physicians.
About the Campaign
• Focus of campaign is on safety, quality, doing no harm, and eliminating waste. This is part of medical professionalism.
• Each participating specialty society has created lists of 5 “Things Physicians and Patients Should Question” to make wise decisions about appropriate care • Worded as “Don’t Do This”
Guidelines for Inclusion on Lists
• Organizations can determine the methodology for creating their lists.
• Each item should be within the purview and control of the organization’s members.
• Practices should be used frequently and/or carry a significant cost.
• There should be generally-accepted evidence to support each recommendation.
• The process should be thoroughly documented and publicly available upon request.
Choosing Wisely Criteria
• • • Evidence-based Frequently done but not necessary Under your control as a physical therapist
Examples
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North American Spine Society
Don’t recommend bed rest for more than 48 hours when treating low back pain.
In patients with low back pain, bed rest exceeding 48 hours in duration has not been shown to be of benefit.
American Headache Society
Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.
Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a careful clinical history and an examination.
5/6/2020
American College of Rheumatology 44
Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
Data evaluating MRI for the diagnosis and prognosis of rheumatoid arthritis are currently inadequate to justify widespread use of this technology for these purposes in clinical practice.
American Academy of Family Physicians
Don’t screen adolescents for scoliosis.
There is no good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The potential harms of screening and treating adolescents include unnecessary follow up visits and evaluations due to false positive test results and psychological adverse effects.
5/6/2020
You Might Be Wondering…..
(FAQs)
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Do the items on the list have to be framed negatively?
i.e. “Don’t do ______” “Avoid ______”
Will the list be relevant to all areas of PT practice?
Is our list limited to 5 items?
How will the final list be developed?
APTA’s Choosing Wisely Process
• Transparent • Inclusive • Clearly Defined Methodology
Methodology
Wide call to all members for item suggestions Member workgroup to review items and narrow list based upon Choosing Wisely criteria All member survey to rank final items Final Board approval ABIM approval Scientific article timed with release of list
Questions
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