Transcript Chapter 5 - Delmar

Chapter 5
Legal and
Regulatory Issues
Copyright © 2008 Delmar Learning. All rights reserved.
Guidelines and Regulations
• The health insurance specialist must
know about the different guidelines and
regulations for maintaining patient
records and processing health
insurance claims.
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Regulations
• Federal laws and regulations affect
health care in government programs
like Medicare, Medicaid, TRICARE, and
Federal Employees Health Benefit
Plans.
• State laws regulate recordkeeping
practices and provider licensing.
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False Claims Act
• Regulated fraud associated with military
contractors selling materials and gear to
the Union Army.
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False Claims Act
• Used by federal agencies
– Regulates the behavior of any contractor
that submits claims for expense to the
federal government for any program.
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False Claims Act
• Amended in 1986
– Increase in civil monetary penalties to
impose a maximum of $10,000 per false
claim
– Plus three times the amount of damages
that the government sustains
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Federal Anti-Kickback Law
• Protects patients from fraud and neglect
by curtailing the corrupting influence of
money on health care choices.
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Federal Anti-Kickback Law
• Violation of this law could result in:
– Five years in prison
– Fines up to $25,000
– Administrative civil money penalties up to
$50,000
– Exclusion from participation in federal
health care programs
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Utilization Review Act
• Facilitated ongoing assessment and
management of health care services
• Required hospitals to perform
continued-stay reviews
– To determine medical requirement and
appropriateness of Medicare and Medicaid
inpatient hospitalizations
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McKinney Act
• Provides health care to the homeless
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Vaccines for Children Program
• Provides free immunizations to all
children in low-income families
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PATH
• Focus was on two issues:
– Compliance with Medicare rules affecting
payment for physician services provided
by residents
– If level of service was coded and billed
properly
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CCI
• Developed by CMS to trim down
Medicare program expenditures by
detecting out of place codes on claims
and rejecting payment for them.
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HIPAA
• Mandated administrative simplification
regulations that govern privacy, security,
and electronic transaction standards for
health care information.
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SCHIP
• Health insurance program for newborns,
children, and youth
– Covers health care services such as
physician visits, prescription medicines,
and hospitalizations
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Centers for Medicare
and Medicaid Services
• Department of Health and Human
Services (DHHS) responded to the
nation's first bioterrorism attack
– Delivery of anthrax through the mail
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Medicare Prescription Drug,
Improvement, and Modernization Act
• Provides Medicare recipients with
prescription drug savings and additional
health care plan choices
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Medicare Prescription Drug,
Improvement, and Modernization Act
• Requires Medicare trustees to analyze
the combined fiscal status and warn
Congress and the president when the
fund exceeds 45 percent.
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Health Insurance
Portability and Accountability Act
• Improves portability and continuity of
health insurance coverage in the group
and individual markets
• Combats waste, fraud, and abuse
• Supports use of medical savings
accounts
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Health Insurance
Portability and Accountability Act
• Long-term care services and coverage
• Unique identifiers for providers, health
plans, employers and individuals
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Record Retention
• HIPAA mandates withholding patient
records and health insurance claims for
at least six years
– Unless state law specifies longer
• Records are retained for two years after
a patient’s death
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Preventing
Health Care Fraud and Abuse
• HIPAA defines fraud as “an intentional
deception or misrepresentation”
• The difference between fraud and
abuse is individual’s intent
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Common Forms
of Medicare Fraud Includes
• Billing for services that were not
performed
• Misrepresenting diagnosis to justify
payment
• Unbundling codes
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Examples of Abuse
• Excessive charges for services
• Services not medically necessary
• Improper billing practices
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Examples of Abuse
• A person found guilty of fraud can face:
– Civil penalties of $5,000 to $10,000 per
false claim
– Imprisonment of up to 10 years
– Administrative sanctions
– Up to $10,000 civil monetary penalty per
line item on a false claim
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Steps to Identifying Risk Areas
1. Perform periodic audits to monitor
billing
2. Develop practice standards and
procedures
3. Designate a compliance officer
4. Conduct training and education
classes
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Steps to Identifying Risk Areas
5. Respond by investigating allegations
and disclosing to appropriate entities
6. Develop open lines of communication
– Have disciplinary standards and
enforce them
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Overpayments
• If reimbursed funds exceed the amount
a provider or beneficiary were supposed
to receive.
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Overpayments Include
•
•
•
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Payment based on a charge
Duplicate processing of charges
Payment made to the wrong payee
Payment made for a item not used
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Overpayments Include
• Payment during a period of
nonentitlement
• Payment for another entity who is not
the primary payer
• Payment made after the beneficiary’s
date of death
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Provider
Liability for Overpayments
• Providers are responsible for
reimbursement of overpayment when:
– Incorrect reasonable charge determination
– Provider received duplicate payments
– Receiving a payment after accepting a
assignment
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Provider
Liability for Overpayments
• Provider receives two payments:
– One from Medicare and another from a
workers’ compensation or automobile
carrier
• Provider was paid and did not accept
the assignment
• Provider furnished erroneous
information
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Provider
Liability for Overpayments
• Put in a claim for a services that were
not medically necessary
• Put in a claim for something that is not
qualified for Medicare reimbursement
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Provider
Liability for Overpayments
• Overpayment was made because of a
mathematical or clerical error
• Provider does not submit
documentation
• Billed under the one-time authorization
procedure
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National Correct
Coding Initiative (NCCI)
• Analysis of standards medical and
surgical practices
• Coding conventions included in CPT
• Coding guidelines made by national
medical specialty societies
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National Correct
Coding Initiative (NCCI)
• Local and national coverage
determination
• Review of current coding practices
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Unbundling CPT Codes
• NCCI edits determine appropriateness
of CPT code combinations
• NCCI edits are designed to detect
unbundling
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