Transcript Presentation Title

AMERICAN OSTEOPATHIC
ASSOCIATION
DEPARTMENT OF SOCIOECONOMIC
AFFAIRS
Indiana Osteopathic Association
December 2, 2011
Socioeconomic Affairs Staff
• Yolanda Doss, MJ, RHIA, Director, Division
of Socioeconomic Affairs
• Sandra Peters, Assistant Director, Clinical
Practice Outreach
• Kavin Williams, CPC, CCP Health
Reimbursement Policy Specialist
• Michele Campbell, CPC, Coding &
Reimbursement Specialist
Yolanda Doss, MJ, RHIA
Responsibilities include:
– Helping to secure reimbursement for
osteopathic services
– Securing the acceptance of osteopathic
credentials
– Addressing Medicare issues
– HIPAA compliance
– Fraud and Abuse
Compliance
Objective:
• To provide information related to the required
framework; the rules of the road for successful
reimbursement
– Recognizing and avoiding fraud and abuse
potholes
– Knowing the governing regulations:
Medicare, Medicaid, False Claims Act,
HIPAA, and Stark
– Understanding your contractual obligations
Fraud and Abuse
• Fraud is the intentional deception or
misrepresentation that an individual knows
to be false or does not believe to be true. It’s
the knowing that this deception or
misrepresentation could result in some
unauthorized benefit, such as
reimbursement under the Medicare program
Fraud and Abuse
• Abuse are provider practices that are
inconsistent with sound fiscal, business or
medical practices (coding and billing)
resulting in unnecessary costs to Medicaid
or Medicare programs including
reimbursement for services that are not
medically necessary or that fail to meet
professionally recognized standards of care
Combating Fraud and Abuse
• Defining fraudulent activities
Billing
Diagnosis
Claim forms
Payments
Kickbacks
Charges
Misrepresentation Non-covered services
Gang visits
Medicare provider
numbers
Combating Fraud and Abuse
• Co-payments and
deductibles
• Home health care
• Suspect practices
uncovered
– Free space or equipment
– Training (Free)
– Income guarantees
– Payments
Combating Fraud and Abuse
Enforcement of the Statutes
– Department of Justice (DOJ)-Federal laws
– Office of the Inspector General (OIG)HHS
– Medicaid Fraud Control Units & State
Attorney Generals
Combating Fraud and Abuse
• Department of Justice (DOJ) and Health and
Human Services (HHS) Health Care Fraud
Prevention and Enforcement Action Team
(HEAT)
• A targeted criminal, civil and administrative
effort
• The joint initiative was announced May 2009
Combating Fraud and Abuse
• The operations are now in eight areas:
Tampa, Baton Rouge, Brooklyn, Detroit,
Houston, Los Angeles, Miami and Chicago.
The first phase of this effort began in 2007
• Chicago was most recently added in
February of 2011.
Combating Fraud and Abuse
• The HEAT is ON
• These are examples of reports that are now
regularly published by HHS and the DOJ:
• 2011.04.14: Miami Doctor Convicted in $23 Million
Medicare Fraud Scheme
• 2011.04.14: Two Owners of Miami-Area Mental
Health Care Corporation Plead Guilty to
Orchestrating $200 Million Medicare Fraud Scheme
Combating Fraud and Abuse
• On March 10, 2010, the White House released a
Presidential Memorandum Regarding Finding
and Recapturing Improper Payments
• Memorandum for the heads of Executive
Departments & Agencies
• Subject: Finding & Recapturing Improper
Payments
Combating Fraud and Abuse
• Reclaiming the funds associated with
improper payments is a critical component of
the proper stewardship and protection of
taxpayer dollars, and it underscores that
waste, fraud, and abuse by entities receiving
Federal payments will not be tolerated
Combating Fraud and Abuse
• Therefore, I hereby direct executive
departments and agencies to expand their
use of Payment Recapture Audits, to the
extent permitted by law and where costeffective. …
• Today, to further intensify efforts to reclaim
improper payments, my Administration is
expanding the use of "Payment Recapture
Audits," which have proven to be effective
mechanisms for detecting and recapturing
payment errors
Combating Fraud and Abuse
Transparency through oversight
• Recovery Audit Contractors (RAC)
• HEAT
• Federal Payment Recapture Audits
• Private Payer Audits
Combating Fraud and Abuse
• OIG Sanctions list for September 2011
– 352 entities or individuals
– 9 Physicians
– 2 DOs
The Best Defense is a Good Offense!
The Compliance Program
• Five Tips to Avoid Government Scrutiny as
provided by Foley and Lardner, LLP
Attorneys Lisa M. Noller, Judith A. Waltz
and Heidi A. Sorensen
– Monitor Claims Submissions and Payments
– Develop and Follow a Written Compliance Plan
– Conduct Due Diligence on Employees and
Contractors
– Consult With Outside Counsel
– Assume a Criminal Investigation is Under Way
(if contacted by the HEAT)
The Compliance Program
• The United States Sentencing Guidelines
were amended in November 2010 to allow
for the reduction in a recommended
sentence if a defendant could demonstrate
the existence of an effective compliance
and ethics program.
Seven Key Elements
1. Reasonable compliance standards and
procedures
2. Designation of a corporate officer
3. Due Care in delegation of authority
4. Effective training and education programs
5. Monitoring, auditing and reporting systems
6. Consistent enforcement and discipline
7. Responding to offenses with corrective
actions
Seven Key Elements
1. Reasonable compliance standards and
procedures.
– Begin by meeting with office managers to
obtain their perspective in their areas of
responsibility (staffing, scheduling, billing)
– Analyze the practice and the legal
standards applicable, which it must comply
with
– Assess existing policies and procedures
– Develop an employee “Standard of
Conduct” to promote compliance
Seven Key Elements
2. Designation of a corporate compliance officer
– Overseeing and monitoring the implementation of
the program
– Reporting on a regular basis and establishing
methods for improvements
– Periodically revising the compliance program in light
of changes or needs of the practice
– Developing, coordinating and participating in an
educational training program focusing on the
elements of compliance to ensure that they are
appropriate
– Ensure employees and management are
knowledgeable and comply with the standards
Seven Key Elements
– Ensure that National Practitioner Data Bank and
Cumulative Sanction Report have been checked with
respect to all employees and medical staff. The OIG
report may be found on the Internet at
http://oig.hhs.gov. The website also includes a list of
monthly disbarred contractors
– Develop policies and programs to encourage the
reporting of suspected fraud and other improprieties
without fear of retaliation
– Handling investigations, inquiries by employees, and
overseeing, monitoring and auditing of practice
compliance operations.
– Correcting problems with the compliance program
Seven Key Elements
3. Due care in delegation of authority
– A practice should use due care in
delegating substantial authority to
individuals whom the organization knows,
or should know, through the exercise of
due diligence, have a propensity to
engage in illegal and/or unethical activities
– Current employees
– New applicants
Seven Key Elements
4. Effective training and education programs
– Summarizing fraud and abuse laws and the
applicability of the False Claims Act (31
USC 3729) both civil and criminal provisions
of the Social Security Act (42 USC1320a-7a
and 1320-7b), criminal offenses concerning
false statements relating to health care
fraud (18 USC 1347), the Federal antireferral laws (42 USC 1395nn), and the
Federal anti-kickback laws (42 USC 1320a7b(b))
Seven Key Elements
– ACA amended the language of the Antikickback statute to state that a person “need
not have actual knowledge of this section or
specific intent to commit a violation of this
section.” (Ignorance of the law is no
excuse)
– Civil Monetary Penalties (CMP) law revised
– Knowingly making or using false record or
statement material to a false or fraudulent
claim for payment by a federal health care
program (up to $50,000 per violation)
Seven Key Elements
– Document the training
– Compliance as an element of a
performance evaluation appraisal
5. Monitoring, auditing and reporting
systems
– Checks and balances
6. Consistent enforcement and discipline
– Warning – Reprimand – Probation
– Demotion – Temp. Suspension
– Discharge/termination of employment
– Restitution – criminal prosecution
– Self reporting
Seven Key Elements
7. Responding to offenses with corrective
actions
– “Reasonable steps” including modifications
to a compliance program to prevent and
detect violations of law
Know the Rules – Have the Answers!
Rules and Regulations
• The Centers for Medicare and Medicaid
Services: http://www.cms.hhs.gov
Rules and Regulations
• Health Insurance Portability and
Accountability Act (HIPAA)
• Transaction regulations
– Protected Health Information (PHI)
– Covered entities
– Business associates
• Privacy and security
Rules and Regulations
• Health Information Technology for Economic
and Clinical Health Act (HITECH Act), part of
the American Recovery and Reinvestment
Act (ARRA) of 2009
• The HITECH Act created higher fines for
HIPAA violations, which were issued in the
recent Cignet Health case.
Rules and Regulations
• HHS Imposes a $4.3 Million Civil Money
Penalty for HIPAA Privacy Rule Violations
• HHS explained in a statement that Cignet
Health refused to respond to OCR's demands
to produce the records and failed to
cooperate with OCR's investigations of the
complaints and produce the records in
response to a subpoena. February 22, 2011
Rules and Regulations
• Security Breach Notification regulations
– On August 19, 2009 HHS issued the Interim
Final Rule
– These regulations attempt to clarify and
provide guidance on the definitions outlined in
the HITECH Act
– Currently awaiting the updated Privacy and
Security Regulations due out by the end of
the year.
Rules and Regulations
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Security Breach Notification definitions
What is a Breach?
Exceptions to notification
Timeliness of notification
Content of information within the notification
Actual or Substitute notification etc.
Rules and Regulations
• The Stark Law prohibits referrals of patients
for Designated Health Services (DHS) if the
physician (or physician’s immediate family
members) has a “financial relationship” with
the entity providing the services
• Knowing when exceptions apply is key (i.e.
certain in-office ancillary services,
compensation arrangements, rentals and
leases of equipment or office space.) 42 CFR
§ 411.357
Rules and Regulations
• ACA has new requirements for Physician
–Owned Hospitals and in-office ancillary
services
• The exceptions are increasing in
limitations, and will require increased
reporting and documentation to HHS
providing a detailed description of
ownership
Rules and Regulations
• Patients have to be notified that they can
seek the DHS elsewhere
• It must be in writing
• They must be provided a list of alternate
suppliers to furnish the service
Rules and Regulations
• Hospitals utilizing the Rural or Whole Hospital
exceptions must submit an annual report to
HHS containing detailed descriptions of
ownership
• This exception was extended until December
31, 2010. The exception will be
grandfathered in but;
• There may be no increase in capacity, or
increase in physician investment percentage
after March 23, 2010
Rules and Regulations
• New regulations will be published by January
1, 2012
• Hospitals continuing to use the exception
must submit an annual report containing a
detailed description of ownership
• There will be additional standards for
determining if the ownership or interest is
“bona fide”
Understanding Your Contract
(don’t have blinders on!)
Contractual Relationships
• In signing the Managed Care Organization
(MCO) contract, physicians are not only
agreeing to follow all the rules listed and
accept all the risks involved; the
physicians are also agreeing that they are
aware of and understand everything in the
contract
Contractual Relationships
• Six Steps that Should be Taken before Signing
Any Contract
1.Investigate the MCO
2.Analyze the terms of the contract
3.Obtain and review all relevant documents,
especially those which are referred to in the
contract
4.Ask questions and or negotiate to clarify the
contract
5.Assess administrative and financial impact on
the medical practice
6.READ the final agreement, then sign. No
matter how tedious. Also, no contract should
be signed without legal review
Top Ten Compliance Risks For 2011
• Compliance Risk Number 1: Increased “HEAT”
Activity and Enforcement: Perhaps the greatest risk to
consider in 2011 is the increase in targeted health care
fraud enforcement efforts by the government’s Health
Care Fraud Prevention and Enforcement Action Team
(HEAT).
• Compliance Risk Number 2: Zone Program Integrity
Contractor (ZPIC) / Program Safeguard Contractor
(PSC) / Recovery Audit Contractor (RAC) Audits of
Medicare Claims: As you already know, private
contractor reviews of Medicare claims are big business –
one ZPIC was awarded a five-year contract worth over
$100 million.
Top Ten Compliance Risks For 2011
• Compliance Risk Number 3: Electronic Medical Records:
Unfortunately, some early adopters of Electronic Medical
Records (EMR) software are now having to respond to
“cloning” and / or “carry over” concerns raised by ZPICs and
Program SafeGuard Contractors (PSCs).
• Compliance Risk Number 4: Physician Quality Reporting
Initiative (PQRI) Issues: Under the Health Care Reform
legislation passed last March. PQRI was changed from a
voluntary “bonus” program to one in which penalties will be
assessed if a provider does not properly participate. As of
2015, the penalty will be 1.5% and will increase to 2.0% in
2016 and subsequent years.
Top Ten Compliance Risks For 2011
• Compliance Risk Number 5: Medicaid Integrity
Contractors (MICs) and Medicaid Recovery Audit
Contractors (MDRACs): In recent months, we have
seen a marked increase in the number of MIC inquiries
and audits initiated in southern States. Notably, the
information and documentation requested has often
been substantial.
• Compliance Risk Number 6: HIPAA / HITECH Privacy
Violations: Failure to comply with HIPAA can result in
civil and / or criminal penalties. (42 USC § 1320d-5).
Top Ten Compliance Risks For 2011
• Compliance Risk Number 7: Increased Number of Qui
Tams Based on Overpayments: Section 6402 of the recent
Health Care Reform legislation requires that all Medicare
providers, (a) return and report any Medicare overpayment,
and (b) explain, in writing, the reason for the overpayment.
• Compliance Risk Number 8: Third-Party Payor Actions:
Third-party (non-Federal) payors are participating in Health
Care Fraud Working Group meetings with DOJ and other
Federal agents. Over the last year, we have seen an increase
in the number of “copycat” audits initiated by third-party payor
“Special Investigative Units” (SIUs).
Top Ten Compliance Risks For 2011
• Compliance Risk Number 9: Employee
Screening: With the expansion of the
permissive exclusion authorities, more and more
individuals will ultimately be excluded from
Medicare. As we have seen, HHS-OIG is
actively reviewing whether Medicare providers
have employed individuals who have been
excluded.
Top Ten Compliance Risks For 2011
• Compliance Risk Number 10: Payment Suspension
Actions: Last, but not least, we expect the number of
payment suspension actions to increase in 2011. In late
2010, Medicare contractors recommended to CMS that
this extraordinary step be taken against providers in
connection with a wide variety of alleged infractions.
Reasons given for suspending a provider’s Medicare
number included, but were not limited to: (1) the provider
failed to properly notify Medicare of a change in location,
(2) the provider allegedly engaged in improper billing
practices, and (3) the provider failed to fully cooperate
during a site visit. http://www.zpicaudit.com/2011/01/topten-health-care-compliance-risks-for-2011/
Socioeconomic Affairs Staff
Contact Information:
• Yolanda Doss, MJ, RHIA Director
(312) 202-8187 phone
(312) 202-8487 fax
[email protected]
• Sandra Peters, MHA Assistant Director, Clinical Practice
Outreach
(312) 202-8088 phone
(312) 202-8388 fax
[email protected]
• Kavin Williams, Health Reimbursement Policy Specialist
(312) 202-8194 phone
(312) 202-8494 fax
[email protected]
• Michele Campbell, Coding and Reimbursement
Specialist
(312) 202-8182 phone
(312) 202-8482 fax
[email protected]
Questions & Answers