could you survive a post payment audit 4 hours b&w.ppt · you and your peers in the same...

1

Could You Survive A

Post Payment Audit?

Success Strategies For

Practice Compliance

www.mybreakthrough.com

Audits Are About Money

• Post payment audits are a tactic utilized by government and private insurance payers to extract money previously paid to doctors.

• Insurance profitability experts believe that payment audits are as successful in building insurance companies’ profits as raising premiums or adding members.


How Payer’s

Scrutinize Payments

• Payers perform both prepayment claim reviews and post payment audits.

• Prepayment claim reviews use advanced technology similar to credit card fraud detection.

• They are less costly and labor intensive for payers than post payment audits.


Automated Prepayment

Claims Review Checks• National Correct Coding Initiative (NCCI)

• National Coverage Determination (NCD)

• Local Medical Review Policy (LMRP)

• Local Coverage Determination (LCD) Rules

• Inter-claim • Intra-claim• Cross-claim • Cross-batch

• Lifetime Duplicates• Date Range Duplicates• Un-bundling• Modifier Codes • E&M Codes• Visit Level• High Payments Per Day

• Unusual Procedures • Geographic Improbabilities

• And More…


Post-Payment Audits

• Post payment audits cost payers more because they require skilled personnel and cannot be automated.

• The advantage of manually performed vs. automated audits is a higher return to the payer.


What Triggers A

Post Payment Audit?

• Provider profiling

• Complaint by a disgruntled patient

• Complaint by a disgruntled employee

• Practice advertising

• Submission of claims for care of family members and/or employees

• Random selection


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Verification Letters

• There are a number of reasons why there may be an irregularity in a patient's response to a verification letter:

• The service may have been performed, but the patient's recollection of the service was faulty.

• Occasionally a physician has patients with the same name and a claim for payment may have been submitted under an incorrect patient name.


Audit Identification Report

• Once you are selected as the target of an audit, an Audit Identification Report is created.

• This report measures the degree of variance in total annual revenue between you and your peers in the same specialty and geographic area.

• The more successful your practice, the greater your chance of an audit.


Your Audit Ranking

• The variance between your annual revenue and that of your peers is what the payer expects to gain from the audit and results in your audit ranking.

• The claims paid to you that are most likely to fall outside of the standard distribution of your peer group are then targeted for audit.


How Are Audits Conducted?

• Request for and review of office notes and documentation

• Questionnaires to or interviews of patients

• Interviews of employees (current and former)

• Meetings or teleconferences with provider

• Undercover patient (rarely)


Examination of Supporting

Documentation

• An auditor reviews your documentation to see if it supports the claims paid to you.

• This is why it’s so important to have carefully managed documentation and office notes readily available for review.


Who Should Care About

Post Payment Audits?

• The risks of noncompliance have ramped up from returning money to the exclusion from government programs, loss of practice license and jail time for healthcare fraud.

• Malpractice and general liability insurance do not cover audit defense legal fees and costs.


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Who Can Be Audited?

• Any provider who received insurance payments regardless of in-network or out-of-network status.

• In-network: Right to audit stems from provider agreement.

• Out-of-network: Right to audit stems from case law, statutes and regulations.

• Cash practices are not exempt from compliance with the standard of care and documentation requirements.


What’s My Exposure?

• According to a recent Improper Medicare Payment Report, DCs have the highest provider compliance error rate in Medicare, filing claims incorrectly 30.6% of the time.

• Business Insurance Magazine estimates 5%-10% of all BCBS claims are paid incorrectly which is echoed by Aetna’s estimate of 11% payment errors.


Do I Have To Cooperate

With An Audit?

• In-network:

– You have a

contractual duty to

cooperate.

• Out-of-network:

– No contract to

govern the audit,

but risk of carrier

offsetting or

blocking other

claims.www.mybreakthrough.com

What Is Claim Offset/Block?

• Claim Offset:

– Offset future reimbursements on a particular patient until past overpayment on that patient is paid in full.

• Claim Block:

– Offset future reimbursements on all patients until past overpayment is paid in full.


What Will It Cost Me?

• The insurer reviews a limited sample (e.g., 20) of patient files and determines % of deficient files within the sample (e.g., 25%).

• Refund Extrapolation: the deficiency % is applied to the reimbursement paid by the insurer over the past 6 years (e.g., 25% deficiency x $1,000,000 receipts over 6 years = $250,000 owed).


What To Do If Audited?

• Cooperate with the audit – stonewalling will get you a more intense audit.

• Don’t volunteer information or talk substance with billing auditors.

• Never change your notes or chart.

• Ensure auditors get all of your supporting documentation.


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What To Do If Audited?

• Only send notes for the time frame being audited and do not send original, only copies.

• Minimize the risk of an audit in the first place by setting up a Compliance Program in your practice to ensure proper coding, documentation and compliance with laws and regulations.


OIG Compliance Program

• The Office of Inspector General (OIG) released the final Compliance Program Guidance for Individual and Small Group Physician Practices in 2000.

• Yet many practices have still not implemented this program of self-auditing.

• The final guidance can be found on the OIG website http://oig.hhs.gov


What Is Health Care Fraud?

• On the Federal level (US Code Title 18,1347)

• “Whoever knowingly and willfully executes, or

attempts to execute, a scheme or artifice to:

• Defraud any health care benefit program;

• Obtain, by means of false or fraudulent pretenses,

representations, or promises, any of the money or

property owned by, or under the custody or

control of, any health care benefit program, in

connection with the delivery of or payment for

health care benefits, items, or services.”


Four Specific Risk Areas



• The OIG has focused its investigations and audits on four specific risk areas:

– Proper Coding & Billing

– Ensuring That Services Are Reasonable & Necessary

– Proper Documentation

– Avoiding Improper Inducements, Kickbacks, & Self-referrals


Coding & Billing

Risk Areas• Billing for items or services not rendered

• Double billing

• Upcoding the level of service provided

• Billing for unbundled services

• Failure to properly use coding modifiers

• Submitting claims for equipment, supplies and services that are not reasonable and necessary

• Knowing misuse of provider identification numbers, which results in improper billing


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CPT® Procedure Codes

• There are over 7,500

CPT® codes.

• DCs use only 25-30

codes the majority of

the time.

• The CPT® codes you

use must describe the

services you perform

and be within your

scope of practice.


Clinical Documentation

• Using the correct code alone is not sufficient

• Careful clinical documentation is required and may be requested by the payer

• Lack of clinical documentation is the number one reason for denial of service by payers

• Most insurers live by this claim handling rule:

• “If it wasn’t written down, it wasn’t done.”


CMT Codes Review

Compliant Coding


CMT Codes

• 98940-3 the basic building blocks and best description of the DCs work.

• Most comprehensive physician code to describe chiropractic services.

• Basic service around which everything else is built.


Correct Coding

• Use the CPT® code that best describes the service you provided.

• Codes should not be interchanged and the type of service performed should match the definition of the CPT® code.

• If an adjustment is performed, the appropriate CMT code should be used.

• If an office visit is performed, the appropriate E/M code should be used.


Coding The CMT

• Full Spine Adjustment: The treating doctor should prioritize the level of adjustment and code for the primary area(s) of concern.

• 98940: 35%

• 98941: 55%

• 98942: 10%


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Proper Use of Timed

Treatment Codes

Compliant Coding


Many Standards

• There are three possible standards to which you can adhere.

• Best to know all of the rules first.

• Use the correct policies required by each carrier.


CMS Rules

• The first: CMS rules in their transmittal AB-00-14, published in 2000.

• The memorandum makes two key points relating to the counting of therapy units.

• The first is with respect to total treatment time and the second deals with how time is counted.


AMA Guidance

• The second: AMA delivers guidance through the CPT®

Assistant.

• Because the ACA participates in the AMA coding process, ACA looks to the AMA for guidance.

• Up to now, this guidance stated that DCs continue to use the 15 minute rule.


Individual Carrier Policies

• Third: Due to carrier agreements you have, certain policies may apply.

• Check all your provider agreements so you are up to date.


As Medicare Goes…

• The saying is: “As Medicare goes, so goes the Nation”.

• Because of this, your best policy is to be in line with Medicare policy, as few others are as stringent.


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The 8-Minute Rule

• The AMA has recorded in CPT® policy what is known as the 15 minute rule.

• In the past, DCs have been instructed by ACA to use this guidance.

• This has now changed!

• All providers now are guided to use the same 8-minute counting rules set forth by CMS.


Medicare Demonstration

Project

• The Medicare demonstration project currently underway allows DCs to bill for all services within their scope.

• These rules required DCs to meet CMS guidelines.

• Included was the guidance to use the 8-minute rule for measuring time.


Use the Medicare Guidance

• AB-00-14 published in

2000, guides when

and how many units

you are allowed to bill

for timed services

rendered.

• Use to determine how

many units apply

during your treatment

time.


Defining Pre- and Post-

Service Time

• The guidelines restrict therapists from counting pre- and post- delivery service time

• Report only the time spent in actual delivery of a therapeutic procedure.

• Exclude rest time, bathroom breaks, etc.


Document Actual Time

• CMS says that therapists should document the

beginning and ending time of treatment in the

clinical record.

• Therapists should document the start and stop

time of each treatment modality – or the

beginning and ending time of the treatment.

• Does this mean you must use a stop watch!?? Of

course not!

• Be diligent in listing appropriate time in your

documentation of timed codes.


Example: Ultrasound

• Generally, therapists spend time retrieving the ultrasound cart, gel, towels, and any other needed supplies.

• Then the therapist positions and drapes the patient, applies gel, and turns on the ultrasound machine and begins treatment.

• At the conclusion of the treatment, the therapist cleans up the patient, and returns the cart for use in the next treatment.

• CMS says that none of the setup or breakdown time spent by the therapist can be included in the time billed.


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Understanding Overlap

• Active care procedures may contribute to some overlap.

• Consider Post Isometric Relaxation (PIR) being performed for the purpose of improving flexibility.

• This is coded as 97110.


Understanding Overlap

• During the PIR, the therapist finds it necessary to work certain trigger point areas (97140-manual therapy) and then PIR continues.

• However, in this context, the manual therapy is an intraservice component of the Therapeutic Exercise.

• Don’t report separately, but include all service in the time billed.


Rest Periods

• The transmittal advises to exclude rest periods between sets.

• Published literature states that it’s reasonable to include 30 second rest periods between repetitions and/or 60-90 seconds of rest between sets.


Evaluation and Management

• Remember that pre-, intra-, and post-service E/M is bundled into the therapy code.

• If you perform a separately identifiable E/M service, add the assessment to the service.


Counting Units

Single CPT® Codes

• For the first unit of a time-based code to be reported, you must perform at least 8 minutes.

• It’s important to understand this is for a SINGLE CPT® CODE.

• Multiple services are counted differently.

• This is explained later in this presentation.


Counting Units

Single CPT® Codes

• If the procedure is greater than or equal to 23 min. but less than 38 minutes, bill 2 units.

• 3 units = 38 up to 53

• 4 units = 53 up to 68

• 5 units = 68 up to 83

• 6 units = 83 up to 98

• 7 units = 98 up to 113

• And so on…..


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Manual Therapy 97140

• The CPT® code 97140 requires that the physician or therapist must have direct, one-on-one patient contact when providing the treatment.

• 97140 covers: Mobilization, Manipulation; Manual Lymphatic Drainage; Manual Traction.

• The 97140 code has a time descriptor of 15 minutes so the actual time spent providing the service should be reported.

• You should count the time spent performing treatments that are part of the code 97140.


Manual Therapy

Single CPT® Code

• If Manual Traction is rendered for 7 minutes, and Soft Tissue Mobilization is rendered for 5 minutes during the same treatment session, report that the code 97140 was rendered for one unit.

• Since it’s all under one CPT® code, this is proper descriptive coding.


Counting Units

Multiple CPT® Codes

• If more than one CPT®

code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time.

• We’ll illustrate on the following examples exactly how this is to be counted.


Example 1: Multiple

CPT® Codes• A patient receives 8 min. of Manual Therapy, 97140; 17 min. of Kinetic Activities, 97530; and 10 min. of Therapeutic Exercises, 97110.

• The total therapy time is 35 minutes.

• Only two units of therapy time may be billed, despite the fact that three distinct services were performed, because the 38 minute threshold wasn't reached.

8

17

10

Total 35www.mybreakthrough.com

Pop Quiz:

Which Codes Are Billed?

• We know we did 35

minutes of total time.

• This falls into the “2

Unit” parameter.

• Because Therapeutic

Exercise and Kinetic

Activities were the

longest total time, we

bill one unit of 97110

and one unit of 97530.


Example 2-Multiple

CPT® Codes• A patient receives 5 min. of Ultrasound, 10 min. of Kinetic Activities, and six min. of Neuromuscular Re-education.

• The total treatment time is 21 minutes, but only one unit can be billed because the total treatment time falls below the 23 minute threshold.

6

10

5

Total 21www.mybreakthrough.com

10

Pop Quiz:

Which Codes Are Billed?

• We know we did 21 minutes of total time.

• This falls into the “1 Unit” parameter.

• Because Kinetic Activities had the largest total time, we bill one unit of 97530.

• Be sure you document all the services!


Ancillary

Services

Compliant Coding


Supervised & Constant

Modalities

• Modalities are divided into two types: Supervised and Constant Attendance.

• Different codes are used depending on the level of supervision.

• When the application of the modality does not require direct one-on-one patient contact, it is considered a SUPERVISED modality.

• When direct one-on-one patient contact is provided, it is classified as CONSTANT ATTENDANCE.


Supervised Modalities

• 97010-97028 do not require one-on-one contact by the provider.

• This means that therapists can apply the modality, but they don’t have to be directly working with patients on a one-on-one basis.

• Time is not a factor for supervised modality codes.

• Only one unit of a supervised modality can be billed per day, regardless of the number of areas treated.


Supervised Modalities

• 97010 Hot or Cold Packs

• 97012 Mechanical Traction

• 97014 Electric Stimulation

• 97016 Vasopneumatic Devices

• 97018 Paraffin Bath Therapy

• 97022 Whirlpool Therapy

• 97024 Diathermy Treatment

• 97026 Infrared Therapy

• 97028 Ultraviolet Therapy

• REMEMBER: Once per encounter!


Constant Attendance

Modalities

• Constant attendance modalities (97032 –97039) require direct one-on-one treatment.

• The constant attendance codes indicate application of a modality to one or more areas and includes a 8-minute time component.


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Constant Attendance

Modalities

• 97032 Electrical Stimulation

• 97033 Electric Current

• 97034 Contrast Bath Therapy

• 97035 Ultrasound Therapy

• 97036 Hydrotherapy


Therapeutic Procedures

Compliant Coding


Active Care

• Therapeutic Procedures are time-based codes.

• Billed in 15-minute units.

• The patient is active in the encounter.

• Require direct one-on-one patient contact by provider of the service.


97110 Therapeutic Exercises

• Develop one functional parameter: strength, endurance, range of motion, or flexibility

• Treadmill for endurance

• Isokinetic exercise for ROM

• Lumbar stabilization exercises for flexibility

• Stability ball to stretch or strengthen


97112 Neuromuscular

Re-education

• Used to describe those activities that affect proprioception

• Balance

• Coordination

• Kinesthetic sense

• Posture


97530 Therapeutic Activities

• Used when multiple parameters are trained including balance, strength, and range of motion.

• Must be related to a functional activity with direct functional improvement expected.

• Use Outcomes Assessment Tools.


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97150 Group Therapy

• When supervising more than one individual, for a service that requires direct supervision, use code 97150 for each patient.

• For example, if NMR is performed in a group setting, use code 97150 — do not use 97112 and 97150 at the same time.

• Billed once per session.


97124 Massage

• Massage is a passive procedure used for restorative effect.

• Used for effleurage, petrissage, and/or tapotement, stroking, compression, and/or percussion.

• An independent procedure from CMT and is considered separate and distinct.


97140 Manual Therapy

• Includes Soft Tissue and Joint Mobilization, Manual Traction, Trigger Point Therapies, Passive Range of Motion, and Myofascial Release.

• When billed with a CMT, must be in a separate body region.

• Requires a -59 modifier.


Less Than 8 Minutes

• The only situation that is not directly addressed in the CMS transmittal is a single CPT® code performed for less than 8 minutes.

• What if you performed Attended Electric Muscle Stimulation, for example, (97032) for only 6 minutes?

• Based on what we’ve learned, it seems we can’t bill this service at all!

• But wait…..


Less Than 8 Minutes

• Since there is not another timed based procedure to bundle this into, we recommend using the 52 modifier.

• This indicates a reduced service.

• Document the record that you performed the service for less than 8 minutes.


52 Reduced Services

• When less than 8 minutes of a timed code is performed, add the modifier 52 Reduced Services.

• Bill your normal fees for this service and document the record.

• If you did only 6 minutes of Myofascial Release or Trigger Point Therapy to a different body region in conjunction with a CMT, code the reduced services as 97140-52.


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CPT® Modifiers

Compliant Coding


CPT® Modifiers

• 25: Separately Identifiable Procedure

• 52: Reduced Services

• 59: Distinct Procedural Service

• 76: Repeat Procedure by Same Physician


25 Separate E&M

Procedure• The 25 modifier means “separately identifiable evaluation and management service by the same physician on the day of a procedure or service.”

• The 25 modifier is used whenever a procedure, such as physical therapy, is performed on the same day as a re-exam.

• Adding a 25 modifier to your 99211-4 re-exams to stop bundling.


CMS 1500 Form

D

PROCEDURES, SERVICES OR SUPPLIES

(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

99213

98940

25


52 Reduced Service

• When a procedure or service isn’t completed to its full extent, reported it as a reduced service.

• If you perform less than one 8-23 minute unit of a timed modality, add a 52 modifier to indicate that a reduced service was performed.


CMS 1500 Form

D



CPT/HCPCS MODIFIER

97110

98940

52


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59 Separate Procedure

• 59 is an important modifier; it is used to keep the

insurance company from bundling procedure

codes.

• It should be used whenever you bill manual

therapy, 97140, together with a chiropractic

adjustment, 9894X.

• 59 indicates a distinct procedure was performed.

• When 9894X and 97140 are billed on the same

day, they must be performed on separate areas of

the body, i.e. neck and lower back.


CMS 1500 Form

D



CPT/HCPCS MODIFIER

97140

98940

59


76 Second Procedure

Same Date of Service

• The 76 modifier is used to report “a second procedure, which has been previously reported or performed on the same day.”

• This modifier is used when a patient was seen in the morning and needed to come back in the afternoon for more care.


CMS 1500 Form

D



CPT/HCPCS MODIFIER

98940

98940 76


ACA Coding Solutions Manual

• New section on Fraud and Abuse, HIPAA Security, an expanded Medicare section, and new talking points.

• Updated ICD-9, HCPCS, and E/M chapters.

• Includes a free CD-ROM with forms and template letters to strengthen your

insurance appeals process.

• 1-800-368-3083









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Reasonable & Necessary

• Claims should be submitted only for services that you find to be reasonable and necessary in a particular case.

• Upon request, you must be able to provide documentation, such as a patient’s records and physician’s orders, to support the appropriateness of a service that you have provided.









Documentation

• The OIG places heavy emphasis on proper documentation.

• Whether you are appealing a denied claim or defending a lawsuit, your most important asset can be the medical record.

• The medical record must demonstrate all of the services provided to a patient and be completed timely, accurately, and thoroughly.


The 7 Principles Of

Good Documentation

1. Your records should be complete and legible.

2. The documentation of each patient encounter should include: the reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impressions, or diagnosis; plan for care; and date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic tests and other ancillary services should be easily inferred.


The 7 Principles Of

Good Documentation

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT® and ICD-9-CM codes reported on the CMS 1500 claim form or billing statement should be supported by the documentation in the record.


Routine Office

Visit

Documentation

Compliant Daily Soap Notes


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Quality Patient Care

• Why use SOAP Notes? Whether paper or

electronic, it makes sense clinically, legally,

ethically and financially.

• In order to determine appropriate benefits,

services billed to third party payers must be

accurately documented in the patient's record.

• This information is used to verify that the services

were rendered and to justify the medical

necessity, appropriateness and quality of care

provided.


Sample SOAP Note

(BTC Form 108)


Patient Demographics

• The following information must be included to create the perfect SOAP Note.

• Patient demographics and page number are required to be compliant.

• This information includes the patient’s Identifying Number, Name and Date of Birth.


Chief Complaints

• Record the patient’s primary, secondary and tertiary (or more) chief complaints obtained during the Initial Case History.

• Make sure your writing is legible and complete.


Date of Visit & Pain Level

• Record the date of the Office Visit.

• Document the patient’s pain level using a Numerical Rating or Visual Analog Scale for each chief complaint.

• Don’t reveal the patient’s previous pain level as it could influence the level they report today.


Subjective Complaint

• What is the patient complaining of?

• Subjective Complaints include those based

primarily on subjective findings such as pain,

sensory problems, discomfort, tenderness or

weakness.

• Be as specific as possible and try to record what

the patient says accurately, without

interpretation, quoting the patient’s own words.

• Example: “I feel better when I wake up in the

morning.”


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Symptoms, Activities,

& Home Care

• These entries are designed to focus on changes in the patient's Activities Of Daily Living.

• Include symptoms such as pain, spasm, tingling, and numbness.

• Report changes in physical activity such as physical restrictions and work limitations.

• Record any Home Care instructions such as ice, heat, exercise or bed rest.

• For example: “Patient can perform repetitive bending and lifting up to 30 pounds.” or “ Patient can sit at computer for 30 minutes.”


Objective Findings

• Diagnoses made in the absence of visible, palpable or objectively measurable physical abnormalities are more questionable than those with objective, clinically relevant findings.

• Lack of objective findings increases the chance of treatment failure and payment denial.

• Record the following objective findings: Observation, Palpation, Localization of Tenderness, Segmental Dysfunction.

• Example: “Palpation reveals reduced joint suppleness with decreased muscle spasms.”


Symptom Diagram

• Use a Symptom Diagram to record your objective findings.

• Mark the diagrams with abbreviations.

• T=Palpable Tenderness

• M=Muscle Spasms

• X=Trigger Points

• RM=Restricted Motion


Subluxation Level

• You are required to

document the level of

subluxation you find

during your pre-

adjustment

examination.

• Record the level of

subluxation or write

down the listing.


Assessment

• Record your assessment of the patient’s condition as Improved, Regressed, Approaching MMI or at MMI.

• Add any additional comments using your own words.

• For Example: “Mary’s condition has improved and she continues to make excellent progress toward full recovery.”


Phase of Care & Progress

• Indicate the patient’s

phase of care.

• Acute, Sub-Acute,

Rehab, Supportive or

Wellness

• Indicate the patient’s

level of progress.

• Slower, Faster, or As

Anticipated


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Treatment Plan

• A Treatment Plan includes the procedures completed that day with a plan for future care.

• Record any Ancillary Services and note the area and time applied.

• CPT® and ICD-9-CM codes must correspond.

• If you perform a soft tissue modality, be sure there is a soft tissue diagnosis.


Level of Adjustment

• Record the level of adjustment including spinal and extraspinal CMT.

• CPT® and ICD-9-CM codes must correspond.

• If you perform an extremity adjustment, be sure there is an extremity diagnosis.


Additional Plan/Goals

• Treatment performed without incident, Continue current treatment plan as prescribed, or Modify treatment plan.

• For example: “Concern about patient’s non-compliance regarding home exercise program. Recommended better follow through.”


Sign The Note

• Every service performed must be documented, so be certain that modalities and procedures aren’t forgotten.

• Therapy Assistants performing procedures incident to a doctor’s license should complete the SOAP Note and sign it.

• The supervising doctor must also review and over-sign the SOAP note.


A Great SOAP Note

• Picture your SOAP notes magnified 25 times and

shown to a jury in court.

• The SOAP note for each visit must stand on its

own and provide medical necessity for treatment

on that day without referring to past visits.

• A third party must be able to read your notes and

know why you are treating your patient!

• If not documented, the rationale for ordering

diagnostic tests and other ancillary services

should be easily inferred.









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Law Enforcement

• The second most common reason for law

enforcement actions arises from improper

inducements.

• The Anti-kickback Statute prohibits knowing and

willfully giving or receiving anything of value to

induce referrals of Federal health care patients.

• Examples of inducements include routinely

waiving coinsurance or deductible amounts

without a good faith determination that the

patient is in financial need.


Kickbacks, Inducements

& Self-Referrals Risk Areas

• Financial arrangements with outside entities to

whom you refer Federal Health Care patients

• Joint ventures with entities supplying goods or

services to your practice or patients

• Office and equipment leases with entities to

which you refer

• Soliciting, accepting or offering any gift or

gratuity of more than nominal value to or from

those who may benefit from your referral of

Federal Health Care patients


Creating Your

Compliance Program

Step-by-Step Implementation


What You Must Do

• Establish written policies and procedures

• Designated Compliance Officer

• Conduct training and education

• Conduct internal monitoring and audits

• Develop accessible lines of communication

• Enforce disciplinary standards

• Respond appropriately to detected violations


Follow These

Steps To Success

• Relax & breathe.

• Include the following information in your Compliance Policies & Procedures (BTC Form 700)

– Location of your Compliance Manual

– Explanation of your Policies and Procedures regarding records creation, destruction and retention, including the specific time period that you will retain records.

– Designate a Compliance Officer

– Location of an anonymous drop box for clear safe reporting of potential erroneous or fraudulent actions.


Time To Train Your Team

• Set aside one hour for uninterrupted team training.

• Have a copy of your Compliance Policies & Procedures for each team member in attendance.

• Instruct everyone that as you go along you will stop for any questions.

• All team members initial all pages, sign & return original document to the C.O..


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Create A Compliance Manual

• Remember, this is a public record.

• Use a 3-ring binder to house the contents of your

Compliance Manual

• Gather the materials, 3-hole punch them & place

them in the manual

• This is a living document.

• You must update this manual & reference it

quarterly and as needed to stay current.


Compliance Manual

Contents

• Policies & Procedures

(BTC Form 700 )

• Office Policy

(BTC Form 207)

• Job Descriptions

(BTC Form 924)

• Patient Satisfaction

Survey (BTC Form 509)


Compliance Related

Activities Manual Contents

• Create and maintain a Compliance Related Activities Manual (Private File)

• Use another 3-ring binder to house the self-audit/chart review & investigation information

• This manual must include:

• Minutes of Compliance Meetings

• Dates and Description of Educational Activities

• Claims Submission Audit Checklists

• Compliance Logs

• Audit of Top 10 Denials

• Audit of Top 10 Services Provided


Self-Audit/Chart Review

• The Compliance Officer determines the number of charts to be reviewed. (2-5 per payer class or 5-10 per physician.)

• Determine the practice demographics, by payer class i.e. Major Medical 50%, Cash 20%, Medicare 10%, PI 10%, W/C 10%.

• Go to the patient chart holding area & select the appropriate number of charts that represent your practice’s demographics.

• For example the above demographics for a 2 Physician Office could mean 20 total charts: 10 MM, 4 Cash, 2 Medicare, 2 PI and 2 W/C.


The Self-Audit Process

• The Compliance Officer schedules a date to perform a Baseline Audit.

• Supplies need to complete the audit:

– Selected Charts

– Copies of Claims Submission Audit Checklist (BTC Form 701)

– Copies of Quality Assurance Chart Review (BTC Form 705)

– Copies of Compliance Log (BTC Form 702)


Self-Audit Day

• Audit day should be uninterrupted.

• Review each Patient Chart for the 7 Principles of Good Documentation and 4 Specific Risk Areas.

• Review all billing for each Patient Chart.

• Make sure your audit includes a valid sampling of your top 10 denials & your top 10 services.

• Complete a Log of your Compliance Audit Activities including any errors encountered

• Take appropriate action to remedy the error(s) encountered. Remember, the 60 day clock has begun upon discovery of an error.


21

Quarterly Audits

• File all completed Audit Forms in your Compliance Related Activities Manual.

• File all Compliance Log Forms in the Compliance Related Activities Manual.

• Schedule any actions needed to resolve any errors encountered in a timely fashion.

• Schedule on your calendar the date for your next audit & your annual training – No less than once annually – Breakthrough Coaching recommends auditing quarterly.


Legal Counsel

• Your Compliance Program Manuals are legal documents with legal ramifications.

• Consult an attorney during the drafting of your Compliance Program.

• It is important to retain an attorney who is familiar with your state’s laws involved in the process.


Your Intent Counts

• To be convicted of fraud there must be a finding of intent.

• The existence of an effective Compliance Program is evidence that any mistakes were inadvertent.

• This is considered in determining the intent to commit fraud.

• Judges take this into account when handing down sentences.

• The existence of a Compliance Program can reduce fines by 60%.


Are You Confident That

• You could perform a documentation self-audit?

• You could perform a billing and coding self-audit?

• Your staff could pass a compliance training audit?

• That you could survive a payment audit if the call comes on Monday?

• If you answered no to any of the above – take action today!


Could You Survive A

Post Payment Audit?

Success Strategies For

Practice Compliance


could you survive a post payment audit 4 hours b&w.ppt · you and your peers in the same...

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