Transcript Compliance Strategies - Medical Group Management Association of

Compliance Strategies
For Physician Practices
Government Enforcement
Efforts
Healthcare fraud is the #2 priority of the
Department of Justice, second only to
terrorism and violent crime.
Government Enforcement
Efforts
The Obama administration said on February
11, 2013 that its efforts to combat fraud in
the Medicare and Medicaid healthcare
programs were paying off as the government
recovered a record $4.2 billion in fiscal 2012
from individuals and companies trying to
cheat the system.
Government Enforcement
Efforts
• The $4.2 billion recouped in fiscal 2012 from
those attempting to defraud federal healthcare
programs, including Medicare for the elderly and
Medicaid for the poor, was up from nearly $4.1
billion the year before.
• Over the past four years, enforcement efforts
have recovered $14.9 billion, more than double
the $6.7 billion recouped over the prior four-year
period.
Government Enforcement
Efforts
• For every dollar spent investigating
healthcare fraud over the past three years,
the government recovered $7.90.
• This was the highest three-year average
return on investment in the 16-year
history of the federal Health Care Fraud
and Abuse Program.
Government Enforcement
Efforts
On May 20, 2009, the HHS Secretary and
the Attorney General announced the
creation of the Health Care Fraud
Prevention and Enforcement Action Team
(HEAT), an interagency effort focused
specifically on combating health care fraud
Government Enforcement
Efforts
Since the HEAT Strike Force's inception,
operations in nine locations have charged
more than 1,000 defendants who
collectively have falsely billed the Medicare
program for more than $2.3 billion.
Government Enforcement
Efforts
The Patient Protection and Affordable Care Act
authorized additional tools to fight fraud,
including tougher eligibility screening for
Medicare providers, increased data sharing among
government agencies and greater oversight of
private insurance abuses.
http://www.healthcare.gov/news/factsheets/201
0/09/new-tools-to-fight-fraud.html
Healthcare Reform Law and Mandatory
Compliance Programs
 Congress for the first time has mandated that a
broad range of providers, suppliers, and
physicians adopt a compliance program
 The Healthcare Reform Law’s compliance
program mandates are divided into two
categories: (1) nursing facilities and (2) all other
providers/suppliers.
Healthcare Reform Law and Mandatory
Compliance Programs
 Right now specific implementation
deadlines for nursing homes but not the
others
 Expect provider/supplier compliance
program mandates to be issued on a
rolling, industry sector–specific basis
 DME & Home Health first?
What is an Audit?
• An audit is a review of medical claims submitted
to a government or private payer.
• Audits can be conducted due to:
– A random event
– A Qui Tam event
– Benchmarking event
• At times, it may be impossible to determine
what triggered an audit, but you must always be
prepared
Enforcement
A neurologist who owned and operated a Brooklyn,
N.Y. medical clinic, pled guilty to one count of
health care fraud for his role in a scheme to
defraud Medicare and other carriers.
Claims were submitted for services that were not
provided; billed for a level of service higher than
that which he performed; double-billed different
health care benefit programs for the same service
provided to the same beneficiary; and billed for
services purportedly performed when he was out of
the country.
Enforcement
On July 2, 2012, the DOJ announced that an
Arizona company with a chain of urgentcare facilities agreed to a $10 million
settlement. The company was accused of
billing Medicare and other health coverage
plans for unnecessary tests as well as
inflating billings, or "upcoding."
ER BILLING COMPANY AND PHYSICIAN
FOUNDER TO PAY $15 MILLION FOR
HEALTH CARE BILLING FRAUD
Billing company typically upcoded claims and
billed for services more extensive than those
actually provided by the physicians.
Enforcement
On September 19, 2012, one of the nation's largest forprofit hospital chains agreed to pay $16.5 million to settle
allegations that it gave financial benefits to doctors in
exchange for patient referrals. For example, the hospital
chain allegedly paid above-market rent amounts for office
space owned by a doctor group to help the group pay its
mortgage and to encourage the group to refer patients to
the hospital.
Enforcement
North Carolina internist accused of defrauding
federal healthcare programs — doctor accused of
knowingly submitted false or fraudulent claims to
Medicare and Medicaid for services that were
either never rendered, medical unnecessary or not
supported by proper documentation. Doctor also
allegedly submitted claims for patients who did not
qualify for medical services reimbursement.
•
Enforcement
On November 5, 2012, a Missouri-based healthcare
provider and hospital system agreed to pay $9.3 million to
resolve allegations that it violated the Stark Act and the
FCA by knowingly billing Medicare for services referred to
the provider by physicians that had a financial relationship
with the provider. The provider allegedly gave incentive pay
to approximately seventy physicians based on the revenue
generated by the physicians' referrals for certain diagnostic
testing and other services performed at provider-owned
clinics, and then billed Medicare for the services.
Enforcement
• California Oncologist sentenced to prison for billing for
cancer medications that were never provided.
• Maryland cardiologists convicted for inserting
unnecessary cardiac stents.
• Couple convicted of soliciting and receiving kickbacks, of
offering and paying kickbacks, and of conspiring to
violate the Anti-Kickback Statute. At trial, the
government introduced in evidence audio and video
recordings demonstrating that the couple made cash
payments to physicians for referring patients to their
imaging center
Enforcement
• An Illinois physician ordered medically unnecessary tests
for patients, used false diagnosis codes to justify the
tests, and then submitted claims for government
reimbursement. The government's evidence included
testimony that the defendant administered EEGs, EKGs
and other tests for an unusually high number of patients,
which was perhaps the trigger to a more detailed
government review of his practice. For his efforts, the
defendant was given a 2-½ year prison sentence.
• A New Jersey doctor was convicted of accepting cash
kickbacks in exchange for referring patients to a medical
diagnostic facility, and was caught when he accepted
payments from a cooperating government witness.
Health Care Fraud (18 U.S.C. § 1347)
It is a crime to knowingly and willfully execute (or
attempt to execute) a scheme to defraud any health
care benefit program, or to obtain money or
property from a health care benefit program,
through a false representation. This law applies
not only to federal healthcare programs but to
most other types of benefit programs, such as
commercial health insurance plans.
Health Care Fraud (18 U.S.C. §
1347)
Is it possible to move from an unintentional error
(civil penalty) to knowingly and willfully
committing criminal healthcare?
THE E/M CODING EXAMPLE
Conduct to Avoid
 Billing for services never provided to
patients.
 “Upcoding” - billing for more extensive
services than weren’t actually rendered.
 Falsely certifying that services were
medically necessary.
 “Unbundling” - billing for each component of
the service instead of billing an all-inclusive
code.
Conduct to Avoid
 Billing for non-covered services as if covered.
 Flagrant and persistent over utilization of
medical services with little or no regard for
results, the patient’s aliments, condition, or
medical needs.
 Consistent use of improper or inappropriate
billing codes, such as billing for the same
level of service or diagnosis code irrespective
of the services rendered in the individual
case.
What Enforcement Cases Should
Teach Physicians
• Assume the government will be reviewing
records of the tests administered to patients,
and ensure that all tests are medically
necessary.
• Periodically compare the quantity of drugs
utilized to the services rendered to ensure
that there is a reasonably relationship
between the two.
What Enforcement Cases Should
Teach Physicians
• Any offer to provide remuneration in exchange
for services or referrals should be a "red flag" for
fraud.
• Any activities that are handled by others should
be periodically examined -- preferably without
advance notice lest a criminal actor hide his/her
tracks -- to make sure that others are not
submitting false claims without
approval. Otherwise, you might be the next
physician whose education renders a lack-ofknowledge claim incredible.
Actual Letter From CMS
“You received this letter because recent
analysis of recent data shows you are billing
specific E/M services in percentages different
from your peers (nationally and state)……We
ask
that
your
review
your
billing
practices……We will continue to monitor your
claims submissions to determine if your
patterns of billing these services are more in
line with Medicare’s expectations.”
What Payors Want
Payors (including MEDICARE) require
reasonable documentation to ensure that
services provided are consistent with
coverage. Information is often requested to
validate the following:
 Site of service (often reimbursement varies)
 Medical necessity and appropriateness of the
diagnostic and/or therapeutic services provided
 Accurate reporting that services were provided at the
level claimed
General Principles of Documentation
 Physician orders should be documented before a service
is performed
 An addendum should be dated and timed the day the
information is added to the medical record and not
dated for the date the service was provided
 A service should be documented when it is provided in
order to maintain an accurate record (timeliness)
 Confidentiality of the medical record should be fully
maintained consistent with the requirements of medical
ethics and law
Effective Compliance Program Elements
U.S. Federal Sentencing Guidelines and relevant
Compliance Program Guidelines include the
following requirements:
– Establishing compliance standards (policies and procedures)
– Assigning senior management oversight responsibility
– Using “due care” when assigning responsibility to an employee
(I.e., screen employees for past offenses)
– Conducting effective training and education
– Establishing reporting and monitoring mechanisms
– Enforcing standards and disciplining violators
– Responding to violations to prevent future offenses
Preventive “Medicine”







Implement a Compliance Plan
Employee Background Checks
Annual question on “Employee Evaluations” inquiring as to:
 Illegal conduct
 Unethical conduct
 Fraudulent conduct
Require signature
Exit interview forms requesting similar information
“Spot Check” on billing/medical record information
Audit 10 records per year per provider (non-statistical sample)
Preventive “Medicine”
•
•
•
•
•
Implement a document retention and destruction
policy
Require signed attendance sheets for all relevant
training (on-site, carrier, teleconference)
Require initials on all Carrier Notices
Require all employees to access the CMS MedLearn site
Only maintain documents as to the steps actually
undertaken – NOT what you THINK the government
“would like to see”
Preventive “Medicine”
 Establish a Coding Compliance Committee
 Meet periodically or annually to




Approve policies and procedures
Review findings and results from audits
Focus on problem areas, and
Determine actions that need to be taken
OIG Compliance Program for Individual
and Small Group Physician Practices
October 5, 2000 Federal Register
http://oig.hhs.gov/authorities/docs/physician.
pdf
Simple Sample Plans:
http://www.healthplan.org/pdf/SampleCompli
ancePlan.pdf
http://www.med-certification.com/practicecompliance-plan-sample-oig
Other Compliance Points
• HIPAA
• OSHA
– Blood Borne Pathogen
– Worker Safety
• Stark
– Compensation Arrangements
– Below Market Rents
• Human Resources (EEOC, Overtime, State
Unemployment Agency)
Compliance
Everyday compliance – you should have this
in place right now:
 PREVENT
 DETECT
 CORRECT
Final Thoughts
•
•
•
•
•
•
Be Proactive, not Reactive
Implement a compliance plan
Put policies, procedures and systems into place
Train, educate and inform all staff
MONITOR ongoing compliance
View HEAT Provider Compliance Training
Webcast Modules
http://www.oig.hhs.gov/newsroom/video/2011/he
at_modules.asp
Final Thoughts
Whether you are an employee or an
employer ALWAYS, ALWAYS consult legal
counsel prior to any communications with
government agents.
Questions & Answers
Reed Tinsley, CPA
www.rtacpa.com
[email protected]