monitoring programs: what, when and how? physician ... programs: what, when and how? ... •...

Monitoring Programs:What, When and How?

Physician Practice / Medical GroupHCCA Upper Midwest Regional Annual Conference

September 16, 2011Eric D Anderson

Director, Corporate IntegrityHealthPartners

Scope of Monitoring Program

• OIG Compliance Program for Individual and Small Group Physician Practices– “Federal health care programs”– “does not have to be costly, resource-intensive or

time-intensive.”– Duty to “reasonably ensure that the claims

submitted to Medicare…are true and accurate.”– Element #1 of 7 – Auditing and Monitoring

• Sounds simple!

Scope of Monitoring Program

• A defined part of overall compliance program and risk-management continuum

• Monitoring Program• Compliance Officer/Committee Review, Approval and

Oversight• Leader and Provider buy-in and communication• Can only monitor against expectations. Are they

clear?• Which Payors / Departments / Sites?• Objectivity (re revenue functions)

What is “Monitoring?”

• On-going, embedded within an operational process• Concurrent with business operations• Intentionally less structured than auditing (no

professional standards)• May identify the need for an audit or further review

What should we monitor?• Baseline Assessment• Risk-based• OIG Guidance – documentations; coding/billing; reasonable

and necessary; improper inducements, kickbacks and self-referrals

• OIG Work Plan• Operational Risks unique to practice• Medicare Program Integrity Activity - RAC, CERT, ZPIC, MAC • Enforcement Actions – OIG, DOJ, MFCU• Medicare carrier/intermediary changes• Not just documentation, coding and billing

Methodology

• Ongoing and regular / annually• Define Objectives• Define Written Standards (policies)• Standard Operating Procedure – programmatic• Who should conduct monitoring reviews?• Retrospective or concurrent (pre-bill)

Methodology

• Sampling – “random” or random - avoid bias and statistical methodology;

• Sample size - 5 per payor or 5-10 per provider• Review • Establish scoring and thresholds• Calculating error rates• Documentation of services reviewed and findings• Coding “fix” or communication with provider to “fix”• Use other tools – E&M level distribution, outlier analysis,

denial analysis

What do we do with the results?

• Monitoring Program should have approved follow-up plan– Communication with providers– Communication with provider leadership– Training – Documentation and retention– Feedback to documentation and coding policy

decision-making

What do we do with the results?

• Corrective Action– Timely response – Claims hold– Follow-up reviews if indicated– Probe, audit or investigation– Repayment if retrospective review– Provider appeal process– Enforcing Disciplinary Standards (#7)

Special Risks to Monitor

• Third-Party Billing Vendor activity• Improper Inducements, Kickbacks and Self-Referrals

– OIG Special Fraud Alerts and Advisory Opinions• Advanced Beneficiary Notifications• Medicare Secondary Payor requirements• Timely Documentation – non-billable and “give less

weight”• Vendor Relations

Your bookmarks

• OIG Compliance Program Guidance • OIG Work Plan• CMS Physician Center• CMS Manuals and Transmittals• MAC/Carrier/Intermediary • Medicare Learning Network (MLN)• Medicare, OIG, DOJ, AHLA and other Listserves

Monitoring ProgramsWhat, When and How?

Hospitals

Kelli Meyer HCCA Upper Midwest Regional

Annual ConferenceSeptember 16, 2011

Allina Hospitals & ClinicsCompliance Director

Objectives Organizational scope Understanding your risks Integrity@ work

Regulatory Changes Ongoing billing challenges

Key Compliance Issues Large and complex and ever-changing

Hospital Hospital based clinics Specialty Care Ops

Why Monitoring?

Early identification of issues Collaboration

Resolution Corrective Action Plans

Audit outcome Successful outcomes

Fix Sticks

What Should be Monitored? Processes Identified through a compliance assessment Newly implemented systems

Services

Payors

Risk Areas Focused area of government oversight & scrutiny

Preventing & Detecting Crime Compliance Scorecard Measures Compliance

Effectiveness Identify Risk Areas Develop and Implement Changes to Address

Risk, or Deficiencies Identified in Audits Monitor Effectiveness of Changes Continued Focus on “doing the right thing—

each & every time”

What Methodology to Apply? Auditing OIG Guidance – documentations; coding/billing;

reasonable and necessary; improper inducements, kickbacks and self-referrals

Medicare Program Integrity Activity - RAC, CERT, ZPIC, MAC & PROBE

Medicare carrier/intermediary changes

Monitoring Tools Concurrent monitoring Retrospective monitoring

Hospital Risks:

Appropriate Level of Care Inpatient – outpatient – observation

National Drug Code Billing

Specific Medication Billing Units reported on claim

Mental Health Treatment plans completed

Medication Reimbursement Part A vs. Part B vs. Part D Ensuring correct place of service

Off—label Drug Use

Reimbursement Opportunities or bust

Controlled Drugs Identify most common drugs of abuse

Diversion trends – recreational drugs with a street value

Ensure sites are meeting all requirements of law (21 C.F.R. 13021.71(a) Effective controls and procedures are in place Reporting theft or substantial loss

Have safeguards in place to deter potential diversion Educate staff on simple steps to detect diversion Ensure sites are complying with government, regulatory and

company policy

Organizational Risks

HIPAA OCR Investigations Security

Data loss Privacy

High profile Proactive vs. reactive

Excluded Providers Education and Tracking

Focused issues and areas Compliance 360 tracking

Tools

Excellian Access Monthly Monitor

Department Manager: Monitor Date: Date of Access Monitor Report: Number of Employees Listed:

Screens Accessed

Employee Name

Number of

records accessed

Did employee

access their own

MRN

Appro-priate Yes / No

Did employee

access another

Lab Employee

MRN

Appro-priate Yes / No Encounter

Patient Level

Access Orders Only

History

Appoint-ment

Office Visit

Other--list

All Appropria

te Yes / No

Further Action/Investi

gation required

Tools cont.

Corrective Action Plan Monitoring

Clinic or Hospital: Monitoring Period: Monitored by: Criteria:

1. Review 20 charts for 3 consecutive months with above 95% accuracy for e/m level selection 2.

Send completed form to: Compliance Manager electronically via email.

Criteria Met? (Y or N)

CPT selected by Provider

CPT Reviewed by Coder

CPT Reviewed by

Educator

Comments Medical Record/Account

#

Patient Name/Initials Date of Service

1 2 3 4 5

Ensuring Site Accountability

Integrating Compliance Into Operations Monitoring should be your flashlight Ensure accountability remains with operations

Facilitating Effective Hand-Offs Say yes … But move to no Keep senior leaders updated Clarify roles and expectations

Ensure “Fix Sticks” Acceptable Standards Measure effectiveness Ongoing monitoring plan

Compliance Team Oversight Focused Audits Report findings Engage leadership in results Business unit scorecard

© 2008 Sinaiko Healthcare Consulting, Inc. Proprietary and Confidential 1

Health Plan Monitoring Techniques

Kelly A. NueskeManaging Director

[email protected]


What is Compliance?

C – CULTURE O – OPPORTUNITY M – METRICS P – PERFORMANCE L – LIABILITY I – INTEGRITY A – ACCOUNTABILITY N – NEGOTIATION C – CODE OF CONDUCT E – ETHICS


Health Plan Compliance ProgramsAssess at a Minimum

CMS & OIG Marketing / Sales Enrollment / Eligibility Quality of Care Medical Necessity Claim Adjudication and Payment Documentation and Coding Reimbursement HIPAA False Claims Act Medical Improvement for Patients & Providers Act (MIPPA)

Health Plan Key Financial Metrics

Medical Loss Ratio Admissions / 1000 Days / 1000 General and Administrative (G&A) Claims Reserves IBNR (incurred but not reported) Stop Loss


Medical Loss Ratio (MLR)

Key statistic in monitoring Health Plan performance Defined as the cost-ratio of benefits provided to

revenues received An MLR of 85% indicates the cost of health benefits

was 85%, while administration and profit were 15% Given concern over profitability, some states mandate

the MLR to restrict the level of administrative and profit margin to address the concerns that premiums cover the cost of health care benefits


Admissions and Days / 1000

These statistics are designed to monitor inpatient utilization

Target admissions/1000 and days/1000 vary by plan membership type; commercial, Medicare and Medicaid will vary given the very different composition of the membership


G & A

Refers to all general and administrative costs within the Health Plan

Standard financial methodology Generally Accepted Accounting Rules (GAAP) apply

Includes profit or margin depending on whether the plan is for-profit or non-profit


Claims Reserves

Amount of money set aside to pay all claims for services deemed payable

Another key statistic since forecasting utilization and its attendant cost is a difficult and highly complex task

A Health Plan’s Tangible Net Equity (TNE) is a way of determining a plan’s financial viability and an indicator of the adequacy of claims reserves

IBNR (incurred, but not reported) are claims for services which must be paid, but are not yet in the system and thus, not calculated in the current cost of services


Stop Loss

A specific dollar limit on the cost of services for individual patients

May be applied to physician services, but more often is a provision in payor/hospital contracts to limit the financial risk

Language in contracts set forth an amount of money per patient incurred at the compensation level in the contract; when the stop loss target is reached, payment reverts to another schedule or percentage of charges


Measurement Tools - HEDIS

HEDIS – Health Plan Employer Data and Information Set

Defined as a set of performance measures designed to provide specific guidelines for employer and governmental agencies aimed at improving the health status of covered lives; specific measurement sets change each year to yield report cards on these statistics


Measurement Tools – Star

Star system derived from the Patient Protection and Affordable Care Act of 2010 is another tool for evaluating performance in Medicare Advantage Plans

36 measures grouped in 5 domains– staying healthy– managing chronic conditions– health plan responsiveness and care– members complaints and appeals– health plan telephone service


Compliance Monitoring

Reports must have measurable metrics which also have business value

Compliance plan and audits must be current, well documented and reviewed by Board and regulators

Corrective action plans must be timely with resolutions clearly defined and implementation documented and reviewed for effectiveness

Use of dashboard for overview; acts as early warning system


Results and Reporting

Outcomes of Audits Responses to Regulatory Notices Issues related to Privacy and Security Compliance Reporting of Delegated Entities Reporting; Senior Management; Board; Regulators


Regulators Oversight Categories

Attestations; Monthly and Annual Requirements Call Center (volume, complaints, grievances) Data Validation; Monthly and Annually Consistent Reporting; may be monthly, quarterly;

biannually and annually External Quality Reviews; annual Hedis “Secret Shoppers” – CMS Complaint Tracking Module (CTM)


Dashboard

Examples of Components Sales and Marketing Appeals and Grievances Enrollment Member Services speed of answer; abandonment rate Pharmacy – coverage decisions; time frames


Sample Executive Dashboard


Sample Executive Dashboard (continued)


Progressive Monitoring Program

Establish a monitoring policy and procedure Operations responsible for monitoring; compliance

responsible for oversight of monitoring Identify monitoring activities based on RISK Reach agreement on acceptable accuracy thresholds

for each monitoring activity Progressive escalation for activities that do not meet

the acceptable threshold


Supplemental Information


Contracting Compliance

Health Plan contracts must conform to all statutory and regulatory requirements; an absence of processes to update new documents or conduct reviews of existing contracts and update as required constitutes a compliance failure

Inadequacy of the network in terms of executing contracts with sufficient numbers of required providers is a compliance breach

Absence of required language


Sales and Marketing Compliance

Perhaps, the single most vulnerable area, especially in Medicare programs

Compliance and/or alleged compliance violations in this area are focused on– Allegations of improper sales conduct by both internal and

external sales staff– Failure to license and/or train sales staff– Failure to conduct ride-alongs for sales staff– Breaches in terms of providing improper incentives– Contacting potential members without an appointment


Sales and Marketing Compliance (continued)

– Use of incentives beyond a dollar value of $15.00– Serving meals at Health Plan meetings– Enrolling a new member who requires a Health Care Power of

Attorney, but no signature was obtained

The list of potential violations is significant with detail provided in Chapter 3 of the Medicare Managed Care Manual

For commercial members, issues related to licensing sales staff also apply, as well as allegations of falsifying information on contracts


Sales and Marketing Compliance (continued)

Medicaid members are enrolled individually as well and allegations of improper sales incentives also constitute a breach– Falsifying information on applications – Use of improper incentives– Lack of adherence to state and federal marketing guidelines;

every state has its own set of requirements for Managed Medicaid


Provider Relations Compliance

Failure to monitor network adequacy; this responsibility is often shared with the Contracting function

Failure to train downstream providers in compliance Failure to respond to member complaints/grievances

that address a member’s access to service (hours of operation as an example),

Failure to enforce service standards such as booking lead time


Provider Configuration Compliance

Incorrect contract loading could result in failure to list provider’s information correctly; wrong address, telephone number

Improper fee schedule loading results in incorrect claims adjudication

Failure to correct errors in a timely manner Failure to load the proper effective date of a contract

or the proper effective date of a terminated contract


Claims Adjudication Compliance

Failure to update system to reflect current codes; retire out-dated codes

Failure to address unbundling Improper use of language on EOBS Failure to respond to members’ and providers’ inquires on

claims data Failure to pay, deny or pend claims within required time

frames Failure to adhere to timelines for appeals and grievances;

failure to pay interest when required


HCC Audits

Failure to secure correct records Failure to identify improper use of codes Unbundling Identifying patterns of fraud Identifying abuse


Member Services Compliance

Failure to act upon a member’s complaint or grievance within the stipulated time frames

Failure to document all inquiries with complete information and resolution

Call Center failure to answer calls within the required time frames

Failure to refer issues for resolution to appropriate departments


Information Technology Compliance

Failure to ensure system security to avoid HIPAA, hi-tech breaches

Lack of responsiveness to concerns that affect communication, such as phone systems, eligibility, utilization review, claims adjudication and member services

Failure to update policies and procedures on a timely basis

Failure to train staff on compliance issues


Health Services Compliance

For all members, the requirement to inform members of decisions on key service questions is crucial

With respect to Medicare, the rendering of an “organization determination” within required time lines may constitute a serious compliance breach

Failure to communicate decisions on required forms immediately is a breach of contract requirements

HIPAA breaches are a major risk area given the sensitivity of information in this department


Quality Compliance

Failure to monitor and act upon adverse indicators Failing Hedis/Star scores Failure to produce quality reports with processes and

outcomes clearly delineated


Pharmacy Compliance

Failure to adhere to approved formulary listings Failure to monitor drug interactions Failure to perform oversight of PBM Failure to develop/update policies and procedures Lack of adherence to mandated time frames


Vision Compliance

Lack of oversight of delegated entity Failure to train in compliance Failure to act upon complaints of network inadequacy

or extended time frames for accessing benefits


Dental Compliance

Failure to provide oversight Failure to train in Health Plan compliance Failure to monitor and act upon documented network

deficiencies Failure to ensure receipt of required reports on

utilization and cost data


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