Transcript Audit Targets: Avoiding the Crosshairs

Audit Targets:
How to Avoid the Crosshairs
August 18, 2015
KELLY
WAYNE
H.GRAHOVAC
VAN HALEM
Sr. Consultant
President
TheThe
vanvan
Halem
HalemGroup,
Group, LLC
LLC
934934
Glenwood
Ave.
SE
Glenwood Ave SE
Suite
200
Suite 200
Atlanta,
GA
30316
Atlanta, GA 30316
(404) 343-1815
(404) 343-1815,
ext 113
[email protected]
[email protected]
DATA ANALYSIS AND DATA MINING
• Data Analysis is a process of inspecting, cleaning,
transforming, and modeling data with the goal of
highlighting useful information, suggesting conclusions, and
supporting decision making. Data analysis has multiple
facets and approaches, encompassing diverse techniques
under a variety of names, in different business, science,
and social science domains.
• Data mining is a particular data analysis technique that
focuses on modeling and knowledge discovery for
predictive rather than purely descriptive purposes.
CONTRACTORS CONDUCTING DATA ANALYSIS
• Medical Review (DMACs)
– Determine codes for widespread review
– Determine suppliers for provider-specific review
– Calculate error rates
• Recovery Audit Contractors (RACs)
– Identify issues for automated or semi-automated reviews
– Identify providers for complex review
• Zone Program Integrity Contactors (ZPICs)
– Identify, reduce, and prevent fraud, waste and abuse
– Identify targets for investigation
QUITE AN INVESTMENT
• Hewlett Packard – Awarded $149.8 million in contracts to
conduct data analysis and audit providers (ZPIC Zone 1 & 7)
• NCI Holdings – Awarded $189.3 million in contracts to
conduct data analysis and audit providers (ZPIC Zone 2 & 5)
• Contracts are all transitioning to UPICs so there is fierce
competition currently to show CMS a return on their
investments.
PURPOSE
• Identify areas of potential errors that pose the greatest risk
• Establish baseline data to enable the recognition of unusual
trends, changes in utilization over time, or schemes to
inappropriately maximize reimbursement
• Identify where there is a need for a LCD
• Identify where there is a need for targeted education
efforts
• Identify claim review strategies that efficiently prevent or
address potential errors (e.g., prepayment edit
specifications or parameters)
PURPOSE
• Produce innovative views of utilization or billing patterns
that illuminate potential errors
• Identify high volume or high cost services that are being
widely over-utilized
• Identify program areas and/or specific providers for
possible fraud investigations
• Determine if major findings identified by RACs, CERT, and
CMS represent significant problem areas in the DMAC’s
jurisdiction.
IMPORTANT
• Being an aberrancy does not mean you are doing anything
wrong
• If it's legitimate, and you are prepared, you have no need for
concern.
AUDIT TRIGGERS
• Highest Reimbursed Codes within a product category
– Compare common product categories and the
percentage of the total within the category that
bill out at the higher reimbursed codes
– E0260 vs E0255 or E0250
– K0004 vs K0001
– Upcoding
AUDIT TRIGGERS
• Multiple Mobility Products on the Same Day.
Identify providers have billed for both a wheelchair
(K0001 – K0007) and other mobility assistive
equipment, such as a cane (E0100 – E0105) or walker
(E0130 – E0149) on or around the same day.
• Same or Similar
AUDIT TRIGGERS
• Maximum Allowed Amount on Certain Codes
• Albuterol, they are allowed 465 mg/month (J7609 –
J7611).
• Urologicals allow 200 units per month (A4332,
A4351 – A4353).
• Identify percentage of their claims that meet or
exceed maximum allowed amounts.
AUDIT TRIGGERS
• Review refill policies to determine if suppliers are
sending the maximum allowed amounts on regularly
scheduled intervals to determine if services are
reasonable and necessary and the refill requests are
documented properly
AUDIT TRIGGERS
• Claims for High End Equipment. Identify providers
that provided power wheelchairs to a given patient.
Assume most patients would have received other
type of equipment such as a manual wheelchair or a
walker before needing a power wheelchair.
AUDIT TRIGGERS
• Diagnosis Code Data
• What diagnoses codes are you using?
• Medicare would not expect that your patient
population all have the same diagnoses for the
same equipment
• Medicare excludes diagnoses specific products
• Can get even more complex with ICD-10
AUDIT TRIGGERS
• Peer Analysis
– Medicare compares your data to other similar
suppliers
– Review utilization rates/guidelines
– Be prepared if you have high utilization with
specific equipment
AUDIT TRIGGERS
• Unbundling
– Base codes for certain products may include other
components that are not separately payable
– Wheelchairs
– Prosthetics
– Urologicals
AUDIT TRIGGERS
• Accessories
– Do all your patients who receive wheelchairs also
receive the same accessories consistently.
– Each separately billed code you intend to seek
reimbursement for must be medically reasonable
and necessary and documentation must support
that it is.
AUDIT TRIGGERS
• Inpatient claims
– Difficult to counter
– RACs run this algorithm all the time
– Make sure patients understand that you must be
contacted if they are admitted to a hospital or facility
– Check on this when doing refill requests or follow up
– Recent Update: RACs are limited to DME claims paid on or
after April 1, 2015.
AUDIT TRIGGERS
• Rule Changes
– Changes in rules can lead people to change
behavior in an effort to circumvent them
– Group II vs. Group III PMDs after capped rental
change
– Vents being provided to avoid capped rental or
competitive bid limitations
– Increases in billing for non-competitive bid items
AUDIT TRIGGERS
• High Dollar Volume Claims
– Medicare has identified supplier that submit high
dollar volume claims
– High dollar volume has been identified as $1000
– High focus on prepayment review
AUDIT TRIGGERS
• Cross-claims analysis
– Compare your claims data with that of other
provider types
– Is there a relationship with the referring
physician?
– Is the patient on home health (homebound)
– Inpatient claims
AUDIT TRIGGERS
• Location of provider, beneficiary, and referral
sources
– Medicare would expect that referral sources,
patients and suppliers are generally within close
proximity of each other
– Mail-order exclusion
AUDIT TRIGGERS
• Date of Death
– This algorithm is regularly run by various
contractors including MACs, RACs, and ZPICs
– These denials are "red-flag" denials for Medicare
AUDIT TRIGGERS
• Compromised HICNs
–
–
–
–
Medicare numbers sold on the black-market
Beneficiaries found guilty of fraud
HIPAA violations
Medical Identity Theft
AUDIT TRIGGERS
• Modifiers
– What modifiers do you use consistently?
– KX Modifiers
•Are you using this one properly?
– ABN modifiers
•Are you ABNs valid?
– Function-level modifiers
TARGET BUSINESS PRACTICES
• New Provider Analysis
– As a new provider is enrolled, their data is more
heavily scrutinized
– New providers are flagged based on various
pieces of data obtained during the enrollment
process and background checks
TARGET BUSINESS PRACTICES
• Referring NPI concentrations. Compare the referring
NPI field to identify situations in which some
providers may have a significant relationship with a
referring doctor because they account for a large
percentage of their claims.
PHYSICIAN RELATIONSHIPS
TARGET BUSINESS PRACTICES
• Multiple Suppliers
– Aggressive internet marketing and leadgenerating businesses
– Two or more suppliers billing for the same
supplies for the same patients at the same time.
DO
YOU
HAVE
LOW
BACK
PAIN?
TARGET BUSINESS PRACTICES
• Direct to Beneficiary Marketing
• While perfectly legal, CMS does not like this business
model
• Expects the physician to be the one initiating care,
not the patient or supplier.
• Manage lead generation services closely and discuss
referrals with physicians
• Often times, patients do not qualify
TARGET BUSINESS PRACTICES
• Orthotics
–
–
–
–
–
–
Back Braces
Knee Braces
Ankle Foot Orthotics
Multiple Orthotics on the same idea
“Arthritis Kits” or “Ortho Kits”
Are you familiar with the KX modifier requirements for
AFOs and Knee Orthotics?
TARGET BUSINESS PRACTICES
• Non-Invasive Ventilation
– Changes in technology and payment rules led to
significant volume increase
– CMS still views this product as a “life-saving” product
– Pricing category put the “life-saving” constraints on
coverage
• Continuous rental, Generous fee
– The CMS solution to increased availability for the
technology is to change the pricing category
• Remember the E0471
NIV
• “Point being that it is theoretically possible to increase
availability of non-invasive ventilation to a less seriously ill
group of patients but that comes at a cost…Many
manufacturers and suppliers want increased coverage but
want to retain the high fee and continuous rental status. In
Medicare as in so many areas of life you can't have your
cake and eat it too.”
• A LCD for this product is unlikely anytime soon.
NIV
• The NCD says vents are covered for respiratory failure due
to COPD and neurological diseases and the payment
category says that the patient has to be at the life
threateningly ill stage before the vent can be covered.
• There is no diagnosis code or specific lab test that allows
for automation of that coverage.
• It all rests on a clear discussion in the medical record that:
– (1) the underlying condition and
– (2) whatever evidence is appropriate for the condition
to show that without ventilator support the patient is a
real risk of death.
TARGETED BUSINESS PRACTICES
• Add-on payment for face-to-face examination for Power
Mobility Devices
– Medicare requires that the treating physician, when
prescribing a PMD, conduct a F2F to determine the
medical necessity and write a prescription
– To receive compensation, the prescribing physician can
bill for an E/M service and has the option of billing for
an add-on payment for the sole purpose of
documenting the need for the PMD.
SUPPLIER BENEFITS
• Audit preparation
– Minimize impact of intense regulatory oversight
• Maintains compliance
– Identify issues internally
– Implement immediate and decisive corrective actions if
necessary
• Streamlines organization and increases efficiency
• Informed management
• Improves internal communication
• Improves overall quality (care, billing, reimbursement, services)
SUPPLIER BENEFITS
• An informed supplier aware of their data has an advantage in
a competitive industry
• CMS only wants to do business with the most compliant of
organizations
– Accreditation
– Surety Bonds
– Competitive Bidding
– Intense regulatory oversight
• Number of suppliers declining while numbers of consumers
increasing = A BUSINESS OPPORTUNITY for the savvy supplier
TAKEAWAYS
• CMS only has access to the data you send them
• If you send the data, you should be conducting your own
analysis to identify aberrancies
• An aberrancy does not mean that fraud exists, but it means
you may be the target of an audit
• Be aware and prepared to explain your aberrancies
• Documentation is your only defense in an audit
• Be proactive in obtaining documentation
• Conduct regular risk assessments
• Don’t be scared. Be prepared.
Stay Connected
The van Halem Group - A Division of VGM Group, Inc.
@vanHalemGroup
The Details Matter – blog.vanhalemgroup.com
Kelly Grahovac, Sr. Consultant
101 Marietta St NW
Suite 1850
Atlanta, GA 30303
[email protected]
404.343.1815
www.vanHalemGroup.com