health care compliance association’s - hcca official site · health care compliance...

©2009 Practice Management Alternatives

Health Care Compliance Association’s

Managed Care Compliance Conference

1©2009 Practice Management Alternatives

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�Compliance creates the culture;

�The more employees, members and

providers understand the culture, the

easier for SIU b/c the bad actors are

more apparent;

�Compliance is the Mayor, SIU is the

Sheriff.


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�Fraud: • Is at the Claim level not the payment level.� FFS

� Capped

� Whatever

• Can be the individual provider, the provider’s billing company or the provider (facility, as in Part A) filing claims for the individual.

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� Upcoding� Unbundling� Services not rendered� Services not covered by provider-type� Kickbacks/bribe for referrals� Prescription forgery� Treating 67 of your plan’s patients in one day� Working everyday from May to December


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�Before • Detection

• Assessment

• Investigative Strategy

• Case Investigation

• Reporting

• Recommendations for resolution

�There is the context of contact w/ Providers

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�Various departments may be

communicating with Providers before,

during and/or after an audit from the SIU

Department.

�Sometimes this causes confusion for the

Provider who has been asked to provide

medical records.


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�Credentialing Department• Requests medical records

• Performs On-site visits

• Provides feedback

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�Quality Management Department• Requests medical records for Quality issues or

HEDIS reviews

• Requires explanation of issue in writing

• Provides feedback


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�Network Management Department• Is the Liaison between the Provider and HMO.

Many times will contact NM regarding any issue.

Provider assumes Provider Representative will

handle their “problem”.

• May need to visit with Providers regarding a

process issue such as obtaining authorization.

• May request information such as fee schedules

regarding a contract.

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�Claims Department• May request medical records

• May request additional documentation or

explanation regarding a service performed.

• May deny or recoup a claim

• Provide feedback to Provider’s claims inquiries.


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�The SIU• Many times the Provider is frustrated or

confused by various requests for information by

the time a SIU request is made.

• Medical Record Request

� Usually high volume of records

� Offer to help copy (usually they choose not to accept offer)

� Offer to pick records up, instead of mailing them (they

usually take you up on this one)

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�Focus is usually on government products

– requirement of state agency

regulations.

�What effect does focus have on other

products?


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�Detection of Fraud/Abuse/Waste

�Change Incorrect Coding Behavior� Inform

� Educate; and

� Audit

�Referral of intentional wrongdoing

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� Request Medical Records

� Keep It Simple

� Refer to Quality and/or Contract compliance requirements

� Include an Attestation Form

� *Samples if you write to us� Mail Certified/Return Receipt

� Mail all correspondence certified

� Attach to copies of letters for reference� Follow Up Records’ Request

� Phone call follow up

� Fax second request

� Copy of 1st request

� Copy of return receipt� Document all “conversations” with Physician and office staff

• Note reaction or comments to medical records request or follow up request

• Take note of “intent” or “wrong doing”

• Provider may be suspicious: “Are you looking for fraud?”

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� Internal referrals

�Claims edits and front-end software

�Provider profiling

�Onsite provider audits

�Pre-and post-payment review of claims

by others

�Training program


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�SIU chooses provider type to investigate

on a monthly basis.

�Use DHHS OIG workplan and industry

articles on fraud for profile ideas.

�SIU analyst “data mines” system for

claims.

�Desktop or on-site audits conducted.

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�Examples might include Evaluation & Management codes (E/M CPT codes 99214-99215)- high level office visits that are outside benchmarks.

�Emergency visits in addition to office visits (CPT 99058).

�Certain CPT and ICD-9 (Dx) code combinations.

�History


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�Upon determination of reasonable cause

to continue the probe, the initial

documentation necessary for effective

investigation is obtained.

�Valid sample based on probe

�RAT-STAT, or something else

supportable.


�Analysis of Medical Records –

• Set Standards – Critical

�Steps to Informing –

• Providing the Audit Results

• Tallying the Results

�Steps to Changing Behavior• Require Coding Accuracy

• Require a Corrective Action Plan

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Documentation

Requirement

Description of

Documentation Requirement

Score Date and Action to be Implemented

(completed by

Provider)

Legibility All entries are legible to individuals other

than the author, dated (month, day, and year), and signed by the performing

provider

100%

CPT Code Level The selection of evaluation and management codes is supported by the client’s clinical

record documentation.

CPT 99245 Office Consultation for a new or established patient which requires a

Comprehensive History, Comprehensive Examination and Medical Decision Making

of High Complexity. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend

80 minutes face-to-face with the patient and/or family

50%

Chief Compliant The history and physical documents the presenting compliant with appropriate

subjective and objective information

100%


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Documentation

Requirement

Description of

Documentation Requirement

Score Date and Action to be

Implemented

(completed by Provider)

Allergies Allergies and adverse reactions (including immunization reactions) are prominently

noted in the record

100%

Patient Identification

Each page of the medical record will include the patient’s name, ID number or record

number

50%

Possible Points 500

Audit Score 80%

Physician Signature

Date:

Please return to:

My or Your Health PlansAttn: Compliance Department

4801 Fly-by-Night HwyCambridge, MA

Cc: The Law Firm of

Dewey, Cheatham & Howe

To be completed by MYHP

Date Reviewed: _______________Approved: Yes No

Re-Audit Date: ________________

Auditor: ______________________

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�Provide Results in Writing - Sample

�Offer Education Assistance Always

�Offer/ Suggest/Require Audit Review –

based on audit scores

�Require Improvement Goals in areas of

low scores

�Follow through with a Corrective Action

�See what you’ve got =Case Assessment


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�Expanded record review +;• Complete the appropriate state referrals;

• Begin a case tracking search (it is important to

review the system for prior cases, related cases

or even similar cases which may help unravel

the puzzle);

• Review provider contracts;

�Review corporate records

�Complete database records searches,

where indicated;• Add’l searches should be approved ($)

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�The first element of an investigative plan is the statement of predication to establish why a case is being opened.

� It is critical to remember that every case can be different and strategy needs to be developed as such. That said, an experienced investigator should be able to identify the critical elements of each new case.


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�The assignment of an investigation means someone in the chain of command has decided that the allegation(s) of health care fraud may have merit.

�That decision implies that the investigation has been determined to have a reasonable chance to succeed.

� It is the investigator’s job to prove or disprove the allegations through the fact-gathering process.

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�Other important issues during

investigations:• Investigating medical specialties –

• Gathering and using evidence –

� Evidence can also include comparative claims data

that shows a provider’s aberrance with respect to his

or her peer group.

• Sources of Evidence –

• Nature of the evidence-gathering process –


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� Establishing and maintaining a chain of custody:• Inventorying the evidence• Keeping evidence clean and admissible• Potentially altered documents• Non-original items• Packaging the evidence

� Witness statements� Insurer participation in law-enforcement evidence

gathering� Interviews

• Gathering previously unknown facts• Developing information regarding matters under investigation

or to establish elements of a specific violation• Gaining leads in developing a case• Establishing a background of the source of information,

including motives for furnishing evidence.

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�Determine type of allegation

�Contact provider as indicated

�Obtain and review documentation

including medical records, and claim

reports.

�Review provider contracts

�Arrange onsite audits if indicated


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�OIG-OAS outline• Criteria – What should be;

• Condition – What is;

• Cause – Why the condition happened;

• Effect – The difference and significance between

what is and what should be; and,

• Recommendation – Actions needed for

correction.

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� Has the plan been able to recover

overpayments?

� Does the case warrant a criminal prosecution?

� Was the investigation in conjunction with law

enforcement?

� Does the US Attorney have a dollar threshold for

this type of case?

� Does the OMIG want to handle this case?


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�Provider Education

�Provider Education + Recovery of

overpayments.

�Education, recovery and surveillance.

�Education, recovery, surveillance,

focused medical review audit:• Larger recovery

• Potential referral to DOI, OMIG, AG.

� All the above is now evidence.

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�Providers are sent a “Findings letter”

and a recovery spreadsheet.

�The provider has time to respond.

�The provider may request a

hearing/meeting/re-audit.

�Final resolution decisions are made by

management.


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�Detect• Analytics; Profiling

�Assessment• Records review, probe audits, education,

surviellance.

�Strategy & Case Investigation• Serious information gathering

�Reporting & Recommendations• You can’t outsource the resolution.

Derek

Practice Management

Alternatives, LLC

[email protected]

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