
4960c83ad8040b5535f72fff68e49242.ppt
- Количество слайдов: 41
Payor Audits: Preparation, Response and Opportunities July 29, 2010 David E. Jose, Esq. One Indiana Square, Suite 2800 Indianapolis, IN 46204 (317) 238 -6211 djose@kdlegal. com
Audits: Here, There and Everywhere § External audits increasingly common § Use of audits as mechanism to recoup “overpayments”, but other purposes and consequences § Financial, regulatory and criminal penalties associated with billing “errors”
Audits: Here, There and Everywhere § Recognize threats and opportunities posed by external audits § Compliance program needs to include a credible internal audit system § Internal audit system addresses external audit, quality of care and performance improvement purposes
Topics for Presentation § § Appreciating the Context for Audit Activity RAC Audits as a Representative Sample Preparing for and Responding to an Audit Learning from the Audit
Constituencies § § § § Government Payers Commercial Payers Enforcement Authorities Civil Lawsuits Other Treating Providers Staff Patients Competitors
Sources for Concern § Disgruntled Employees § Disgruntled Patients • Senior Medicare Patrol § Increase Awareness of Whistleblowing Opportunities § News Reports
OIG Testimony § ROI of $17 for $1 of Medicare and Medicaid Oversight § FY 2008 • • 455 Criminal Actions 337 Civil Actions 3, 129 Excluded Individuals and Entities 1, 750 New Fraud Investigations Opened
OIG FY 2010 Report § § $3. 1 Billion for first half of FY 2010 $667 Million in Audit Receivables $2. 5 Billion in Investigation Receivables 293 Criminal and 164 Civil Actions
Government Enforcement Activities § Amounts Recovered • “Fraud” • Reducing Expenditures § High Profile Practices and Activity § Trolling for Excluded Individuals § Increased Funding Under Reform
OIG 5 -Principle Strategy § Scrutinize enrollment § Establish payment methodologies responsive to marketplace § Assist providers in adopting practices promoting compliance, including quality and safety standards § Vigilantly monitor fraud, waste and abuse § Respond swiftly and impose punishment to deter
Examples from OIG § Medicaid vulnerabilities relating to schoolbased services § 2010 Work Plan focus on provider-based status § Implications • Site-based services • Physician partnering relationships • Procedures vs. outcomes billing debate
RAC Audits Expanding § Health care reform extends RAC program to state Medicaid programs § Recent support in other areas of government contracting announced by President Obama
RAC Audits – What Can Be Learned § Automated vs. Complex Review § Priority of Targeted Providers (Volume and Value) § Targeted Claims • • Medical Necessity Coding Incorrect Payments Duplicate Claims § Contingency Fee Payments for Independent Audit Contractors
Issues for Claims Review Process § “Certainty Standard” vs. “Good Cause Reason” § Request for medical records and timely response § Licensed health care professional involvement § Notice of full or partial overpayment § Recoupment options and time frames
RAC Appeals Process § Rebuttal to auditor vs. direct appeal § Redetermination Appeal • Avoiding recoupment pending appeal § Reconsideration – Qualified Independent Contractors § Administrative Law Judge • First judicial-type review • Review can go beyond “the record” § Medicare Appeals Council Review § Federal District Court Review
RAC Management Program § Enhancements to Compliance Program § Focus on Target Areas (e. g. , one-day stays) § Timely Response to Records Requests § File Rebuttals and Appeals § Tracking System § Corrective Actions § Opportunities for Improvement
Preparation for Audits § Review Policies • Clinical documentation • Financial billing and collecting • Responding to audit inquiries § Identify Risk Areas § Train Employees § Protocols for Pre- and Post-Audit
Issues for Billing Audits § Retrospective or Prospective § Sample Type and Size • Random • Payer specific • Procedure specific § Issue or Criteria to be Applied § Risk Areas • • Coding Documentation Modifiers Medical Necessity
Top Medicare Billing Errors § § § § § Duplicate Non-Covered Service Medical Necessity Bundled Services Beneficiary Eligibility Incorrect Carrier Medicare Secondary Payer Provider Eligibility Place of Service
OIG Risk Areas § Documentation • Timely • Accurate and legible • Complete (e. g. , reason for encounter, history, examination findings, diagnostic test results, etc. ) • Comparison of denial rates with peer practices
OIG Risk Areas § Reasonable and Necessary Services • Documenting diagnosis and treatment • Seeking denial for secondary payer
OIG Risk Areas § Coding and Billing • Services not rendered • Supplies or services not reasonable and necessary • Duplicate billing • Non-covered services • Unbundling • Clustering • Upcoding
OIG Risk Areas § Improper Inducements and Relationships • Financial arrangements with potential referral sources • Joint ventures • Consulting contracts or medical directorships • Office and equipment leases • Gifts and gratuities
“Medical Necessity” § “… unless otherwise required by statute or regulation, means that a Health Service is compensable, as determined by [Insurer] for the treatment of an injury, sickness, or other health condition and is : (1) appropriate and consistent with the diagnosis or symptoms, and consistent with accepted medical standards; (2) not chiefly custodial in nature; (3) not investigational, experimental or unproven; (4) not excessive in scope, duration or intensity…; and (5) not provided only as a convenience to the Covered Individual or professional provider or health care facility. ”
Background Preparations § Web Site of Commercial Payers • Provider education • Binding (? ) pronouncements § Web Site of Government Payers and Agencies • OIG web site for Corporate Integrity Agreements § Web Sites of Audit Contractors • Targeted issues
Audit Coordinator § Advising personnel of pending audit § Ensuring authorization for disclosure of records § Gathering records § Overseeing auditor’s on-site activity § Organizing exit interview § Follow-up communications with auditors for clarifications or additional documents
American Association of Medical Audit Specialists § Billing Audit Guidelines § Use as Standards • Internal audit • External auditor relationship § Purpose for Health Records
Purpose for Health Record § “Health records exist primarily to ensure continuity of care for a patient; therefore, the use of a patient’s health record for an audit must be secondary to its use in patient care. ” - American Assoc. of Medical Audit Specialists
Preparing to Respond § Tracking System and Specific Payer/Authority § Time Frames, Issues Raised, and Documentation Needed § Medical Necessity or Coding Assistance § Internal or External Assistance (including peer and association support) § Statistical Issues § Costs, Benefits, Distractions, and Consequences
Repayment or Recoupment § § Regular Repayments Provider Self-Disclosure Protocol Audit Appeal Settlement ** New obligation to repay within 60 days of “knowledge”
Audits with Potential Criminal Exposure § § Confidentiality Compliance with Subpoenas Legal Ethics Joint Defense Arrangements
Preparing to Appeal § § § Time Frames for Each Stage Venue and Issues Importance of the Record Repayment vs. Delay Designated Staff Assistance Getting the “F-Word” Off the Table
Medicare Audit Defenses: What Can Be Learned? § “I’m right, you’re wrong, and here’s why. ” § “Treating Physician Rule” • Best position to opine on medical necessity for patient § Waiver of Liability” • Clarity of contract and provider communications § Provider Without Fault”
AMA Report on Claims Processing Accuracy § Claims processing inaccuracies cost $15. 5 Billion § Potential for errors in commercial audits § Most accurate: Coventry @ 88. 41% § Least accurate: Anthem @ 73. 98%
Creative Arguments § § § Context for the Services Supporting Documentation Technical vs. Fundamental Defect Late Entries and Affidavits Engaging Legal Counsel for Settlement
Operational Benefits from the Audit § Policies and Procedures on Outside Investigations • More than payer audits § Enhanced Corporate Compliance Program • Improvements to internal self-audits • Connecting audits, compliance and quality § Improved Payer Communications § Getting Off the “Radar Screen” § Limiting Repayments
OIG Corporate Integrity Agreement § Employee Training • Covering a variety of topics § Engagement of Independent Review Organization § Claims Review Process § Repayment of Overpayments’ § Reporting of “Reportable Events”
Mandatory Compliance Programs § Health care reform legislation authorizes mandated compliance programs § Mandated core elements § Potential rigorous self-auditing and selfreporting features § Potential penalties for not having a credible program
Compliance and Audit Functions § Importance of independence from operations § Clear lines of reporting and authority § Management responsible for compliance and controls § Collaborative support for investigations § Ensure follow-up on recommendations
Audits, Risks and Quality § § § Regulatory Compliance Medical Performance Medical Records Patient Safety Supervision
Questions David E. Jose, Esq. Krieg De. Vault LLP One Indiana Square, Suite 2800 Indianapolis, IN 46204 djose@kdlegal. com Office: (317) 238 -6211 Cell: (317) 695 -1084 Fax: (317) 636 -1507