derry, nolan & associates, llc - physician practice compliance program presented by barbara...

Derry, Nolan & Associates, LLC

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Physician Practice Compliance Program

Presented by

Barbara Derry, BSN, CMPE

Melania “Lani” Antonio, CPC



Overview

• Common Compliance Risk Areas

• Compliance Program Development

Barbara Derry



Common Risk Areas • None or irregular risk assessment• Physician employment/partnership agreements• Governing board, physicians & staff lack

awareness• Physicians not holding each other accountable

for coding & documentation accuracy• Disregarding employees’ concerns• Compliance policies, procedures & documents

not updated –



Common Risk Areas • Physician business agreements – anti-kickback

statutes• Coding & claims submission & reconciliation

inaccuracies lead to claim denials & decreased revenue– demographic & insurance not correct– coding & documentation don’t link – Medical necessity rules not followed



A collaborative cooperative voluntary compliance program, led by physician leadership, promotes early detection, prevention & correction to minimize risks of healthcare fraud and abuse.



Foundation for an Effective Compliance & Ethics Program (OIG’s 7 Elements)

1. Standard Policies & Procedures2. Oversight & Documentation Responsibility3. Education & Training4. Lines of Communication5. Audit & Monitoring6. Enforcement & Discipline7. Response & Prevention



Getting Started↓ Physician’s agree on commitment to the

compliance program “culture” OIG’s 7 elements↓ Assign physician board oversight responsibility↓ Physician board designates compliance officer

for program oversight↓ Assign a compliance committee (C.C.) selected

from major departments↓ Conduct a risk assessment internal vs. external



Self - Risk Assessment• Each organization will have different risk areas• Sets a compass for the organization to follow• Identifies:

policies, procedures and forms education & training audit & monitoring resources



Compliance Committee Recommends Annual Goals

1. Develop a compliance program with physician leadership driving the process that promotes effectiveness & follows new sentencing guidelines:



New Federal Sentencing Guidelines• Encourages organizations to partner with

Federal government in crime control• Provides strong incentives for organizations to

self-police, self-report & cooperative in investigations of its own wrong doing

• Requires board and senior leadership to be knowledgeable about the content and operation of the program to prevent and detect violations – eliminate knowing & doing gap



Compliance Committee Goals

2. Develop an effective communication system for communicating, reporting, correcting possible compliance violations

BoardKnowledgeable & Accountable

Compliance OfficerOversight

Documentation MaintenanceMonitoring & Auditing

Reporting

Compliance Committee

Development & Implementation

Physicians & Staff

Confidential Alert or Hot LineAvailable 24 hrs

Allows for AnonymityTimely feedbackDocument Action



Development Effectiveness• A practical/simple approach to policies,

procedures and forms – communication tools• Resource tools:

OIG 2000 physician practice guidelinesOIG work plans Federal Sentencing GuidelinesMedicare Part B NewsCCI edits,



Development Effectiveness• Provide education & training to board, providers and

staff to promote early detection, prevention & correction

• Substantiate & document awareness• Accurate outpatient billing – NO DENIALS• Audit activities focus on risk areas• Audit results & recommendations to board & senior

management• Follow through with corrective/disciplinary action



Choose Subcommittees who become the working arm of the Compliance Committee

Typical Representation:• Education & Training • Claims Submission & Reimbursement• Audit & Monitoring• Others, as identified



Major Duties of Subcommittees• Research, develop, write, present & amend policies and

procedures for compliance committee• Document progress of outstanding issues• Investigate risk areas via quality improvement efforts• Responsible for education & training (staff & physician)• Responsible for auditing processes to determine

effectiveness• Make recommendations for enhancement• Measure effectiveness



Education & Training Subcommittee

Define organizational structure, governance & organizational chart

• Define “Core” policies most relevant to your organization – focused on “operationalizing” the compliance program

• Based on risk assessment results



Policies May Include

1. Standard of Conduct

2. Confidentiality (Includes HIPAA)

3. Internal & External Communications

4. Conflict of Interest

5. Documentation Retention



Policies May Include Cont’d

6. Self-Reporting of violations of laws/regulations – legal review

7. Physician contracting, Employment Agreements – legal review

8. Organizational contracting (vendors & payers) – legal review

9. Human Resources – awareness & consequences of non-compliance

10.Solicitation: Vendors/Gifts & Gratuities



Policies May Include Cont’d

11. Marketing

12. Coding & Claims Submission

13. Claims Reimbursement & Reconciliation

14. Education and Training

15. Audit & Monitoring

16. Other policies as identified



Example of Core Policy: Education & Training• Board, physicians, manager & staff review pertinent

policies & procedures • Sign appropriate policy acknowledgement forms• Take appropriate tests: providers, billing, non-billing staff• Determine physician & employee knowledge level by

achieving 95% accuracy rates• Additional training and testing for those with less than

95% score • Document training and scores• Provide annual education



Provider EducationAccurate coding & documentation drives

reimbursement & prevents violationsCommon Problems

– under & over coding– default coding– lack of diagnosis specificity– lack of knowledge of Medicare’s national medical

review policies– inappropriate use of modifiers & unbundling services

deemed not medically necessary



Optimal Physician Education & Training• Establish a physician leader to drive education

process• Conduct annual chart audit for each physician to

establish baseline of knowledge • Structure education based on those results• Avoid too generalized coding sessions



Optimal Physician Education & Training• Be specialty-specific• Standardize fee-tickets & documentation

templates• Re-audit in 2-3 months to determine

effectiveness of training• No improvement--document & report

corrective/disciplinary action – 100% chart review, expense charged to provider or department



Example of Partial Fee-Ticket for Ophthalmology with Diagnoses Linked to NCDs & LMRPs



Example of a Standard Documentation Template



Audit & Monitoring SubcommitteeFostering an atmosphere of continuous process

improvement• Follow CMS’s quality integrity program’s 4 elements

– risk assessment and problem identification– solution planning– solution implementation and– monitoring the success of the process

• Audit the highest risk areas• Profile physicians to identify outliers• Investigate all concerns, report findings, make

recommendations (e.g., education)



Claims Submission & Reimbursement Subcommittee

Claims Submission Sub-Policies

OIG’s Work Plan– accurate codes: CPT, HCPCS, ICD-9– use of modifiers: 25, 26, 51 & 59– care plan oversight– incident to




– medical necessity and ABN (GA modifier)– duplicate claims– disputed claims– unbundling– physician services at SNFs




Claims Reimbursement Sub-Policies

OIG’s Work Plan– deductibles, co-payments & coinsurance– Bad debt & small balance write-offs– discounting of services– refunds




– charity care/financial aid application– Professional discounts/designated services– Third party billing payments– Denials, bundled and appealed charges



To Summarize

Physician Practices that implement a culture that promotes and embraces compliance are more likely to have effective compliance programs & are better able to prevent, detect & correct problems


Physician Practice Compliance Program Auditing & Monitoring

Melania “Lani” Antonio, CPC

Group Health Cooperative

Manager, Billing Guidelines Development


Physician Practice Auditing & Monitoring

• Follow CMS’s quality integrity program’s 4 elements

– risk assessment and problem identification– solution planning– solution implementation and– monitoring the success of the process

• Audit the highest risk areas• Profile physicians to identify outliers• Investigate all concerns, report findings, make

recommendations (e.g., education)


Risk Assessment and Problem Identification

– Review Office of Inspector General (OIG) work plan and investigate current practice.

– Review coding activities throughout the organization and identify risk areas.

– Investigate all concerns and identify risk.


Risk Assessment and Problem Identification Cont’d

• OIG 2005 Work Plan– Medicare Physicians and Other Health

Professionals• Billing Service Companies

– “We will identify and review the relationships among billing companies and the physicians and other Medicare providers who use their services. We will also identify the various types of arrangements physicians and other Medicare providers have with billing services and determine the impact of these arrangements on the physicians’ billings.”



• OIG 2005 Work Plan– Medicare Physicians and Other Health Professionals

• Medicare Payments to VA Physicians– “We will assess the validity of Medicare reimbursement for

services billed by physicians who receive remuneration from the Department of Veterans Affairs (VA) for the time the physicians reported as being on duty at a VA hospital. Physicians employed by VA may not bill Medicare for services rendered at other hospitals during the times they were on duty at a VA hospital. Our preliminary work has identified a number of VA physicians who received Medicare reimbursements totaling approximately $105 million for services rendered between January 1, 2001 and June 30, 2003. Using time reporting and payroll documentation from the VA, we will identify the services rendered while the physicians were reported as on duty at the VA hospitals and remunerated for such duty.”




• Care Plan Oversight– “We will evaluate the efficacy of controls over Medicare

payments for care plan oversight claims submitted by physicians. Under the Medicare home health and hospice benefits, care plan oversight is physician supervision of beneficiaries who need complex or multidisciplinary care requiring ongoing physician involvement. Reimbursement for care plan oversight increased from $15 million in 2000 to $41 million in 2001. We will assess whether these services were provided in accordance with Medicare regulations.”




• Ordering Physicians Excluded from Medicare– “This review will quantify the extent of services, if any, ordered

by physicians excluded from Federal health care programs and the amount paid by Medicare Part B. Under Federal regulation, physicians who are excluded from Federal health care programs generally are precluded from ordering or performing services for Medicare beneficiaries. During a current review, we identified a significant number of services that had been ordered by excluded physicians.”




• Physician Services at Skilled Nursing Facilities– “We will examine Medicare Part A and Part B claims with

overlapping services for skilled nursing facility patients and determine whether duplicate payments were made to either the physicians or the nursing homes for the same patient services. Physicians may bill Medicare only for the professional component of a service on behalf of skilled nursing facility patients. The technical component of physicians’ services is covered under the patient’s Medicare Part B stay in the skilled nursing facilities and should not be billed separately by the nursing home. Under an exception to this rule, nursing homes may receive Part B payments for both the professional and technical components of physicians’ services if both parties have an agreement under which only the nursing home may bill and receive these Part B payments.”




Professionals• Physician Pathology Services

– “Our review will focus on pathology services performed in physicians’ offices. Pathology services include the examination of cells or tissue samples by a physician who prepares a report of his findings. Medicare pays over $1 billion annually to physicians for pathology services. We will identify and review the relationships between physicians who furnish pathology services in their offices and outside pathology companies.”




• Cardiography and Echocardiography Services– “We will review Medicare payments for cardiography and

echocardiography services to determine whether physicians billed appropriately for the professional and the technical components of the services. Like many physician services, cardiography and echocardiography include both technical and professional components. When a physician performs the interpretation separately, the modifier 26 should be used to bill Medicare for professional services.”




• Physical and Occupational Therapy Services– “We will review Medicare claims for therapy services provided

by physical and occupational therapists to determine whether the services were reasonable and medically necessary, adequately documented, and certified by physician certification statements. Physical and occupational therapies are medically prescribed treatments concerned with improving or restoring functions, preventing further disability, and relieving symptoms.”




• Part B Mental Health Services– “We will determine whether Medicare Part B mental health

services provided in physicians’ offices were medically necessary and billed in accordance with Medicare requirements. Payments for mental health services provided in the physician’s office setting accounted for approximately 55 percent of the $1.3 billion in Medicare payments for Part B mental health services in 2002. In a prior report, we found that Medicare allowed $185 million for inappropriate mental health services in the outpatient setting. We will also determine the financial impact of claims that do not meet Medicare requirements. ”




Professionals• Wound Care Services

– “We will determine whether claims for wound care services were medically necessary and billed in accordance with Medicare requirements. Medicare-allowed amounts for certain wound care services billed by physicians increased from approximately $98 million in 1998 to $147 million in 2002. We will also examine the adequacy of controls to prevent inappropriate payments for wound care services.”




• Coding of Evaluation and Management Services

– “We will examine patterns of physician coding of evaluation and management services and determine whether these services were coded accurately. In 2003, Medicare allowed over $29 billion for evaluation and management services. In prior work, we found that a significant portion of certain categories of these services is billed with incorrect codes resulting in large overpayments. We will also assess the adequacy of controls to identify physicians with aberrant coding patterns.”




• Use of Modifier -25– “We will determine whether providers used modifier –25

appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is a significant, separately identifiable service from such procedure or service. A provider reports such a circumstance by using modifier –25. In 2001, Medicare allowed over $23 billion for evaluation and management services. Of that amount, approximately $1.7 billion was for evaluation and management services billed with modifier –25. We will determine whether these claims were billed and reimbursed appropriately.”




• Use of Modifiers With National Correct Coding Initiative Edits

– “We will determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative edits. The initiative, one of CMS’s tools for detecting and correcting improper billing, is designed to provide Medicare Part B carriers with code pair edits for use in reviewing claims. A provider may include a modifier to allow payment for both services within the code pair under certain circumstances. In 2001, Medicare paid $565 million to providers who included the modifier with code pairs within the National Correct Coding Initiative. We will determine whether modifiers were used appropriately.”




• “Long Distance” Physician Claims– “We will review Medicare claims for face-to-face physician

encounters where the practice setting and the beneficiary’s location were separated by a significant distance. While all beneficiaries may seek professional services for specialized consultation during leisure travel, those with ongoing illnesses requiring skilled care would be unlikely to travel long distances from home. We will examine these claims to confirm that services were provided and accurately reported. If warranted, we will recommend enhancements to existing program integrity controls.”




• Provider-Based Entities– “We will determine the extent to which health care entities that

have been designated as “provider based” are in compliance with requirements for receiving this designation. In prior work, we found that hospital ownership of physician practices is widespread and that fiscal intermediaries are frequently unaware whether these hospitals are being treated as provider based or freestanding. Medicare and its beneficiaries may be paying excessive amounts for services inappropriately billed as provider based. We will also determine the impact on Medicare reimbursements of entities billing as provider based instead of freestanding.”



DOCUMENTATIONHandwritten or

dictated

Charges are manually entered

Charges are

interfaced

BILLINGSYSTEM

CHARGE

MASTER

INS COMPANYClaims

Processing

$$$

Charge Slip

Charge Slip

DOCUMENTATIONElectronic Medical

Record (EMR)

Provider assigns codes on the charge slip

Typically Non-provider staff maintains code set up in the Charge Master.

Provider assigns codesin EMR

Claim Reject

In some cases, Non-provider staff reviewscoding and makes

appropriate changes priorto manual entry.

Typically Non-provider staff reviewscoding and makes appropriate

changes prior to claim submission

Codes are referenced on the charge slip.

Codes are set up in EMR.

Non-provider staff may change coding in order for claim to be reprocess.

CODING

ACTIVITIES

Coders should review coding set ups for accuracy.

Coders should review & update codes.

Develop policies & procedures on appropriate

coding changes

Coders should review coding set ups for accuracy.


coding changes


coding changes



• Investigate all concerns– Example:

• A pattern of increased denials.• During an exit interview, a staff member

provided concerns on a potential compliance issue.


Integrity Cycle Report

Report #: 1 Date Initiated: __/__/__ Initiated By: {Staff Name}

Source: Compliance Line Employee interview or report

Audit result X Reimbursement or denial pattern

Other (specify):

Problem Identification (research conducted):

A pattern of increased Medicare denial on XXXX services.

Solution Planning and Implementation: Solution planning needs to encompass two areas: 1) resolution of the billing issue for XXX services; and 2) provide education and training

Action Responsible

Person

Date Completed

Comments

{Date} Review documentation Coder

{Date} Provider coding training Coder

{Date} Corrected claims Billing Staff

{Date} Compliance Subcommittee recommend a 2nd audit

Coder

Monitoring Plan:Coder will continue to audit XXXX services prior to claim submission until 80%-100% accuracy is achieved.Claims will not be re-submitted until coding and documentation match.



Auditing Effectiveness

Based on 4 Key Elements– Standardization– Communication– Quality– Tracking


Physician Practice Auditing & Monitoring• Standardization

– Develop an auditing manual for coders/auditors to use as a reference. Manual may include the following:

• Standard policy– Follow policy for provider E&M coding and documentation– Select number of charts (10) reviewed for each provider– Determine acceptable accuracy percentage– Determine number of failed chart audit sessions (3) prior to

disciplinary action of 100% chart review– Provide report to Compliance leadership team with

recommendations.• Guidelines

– Audit E&M by following 1995 OR 1997 guideline.– Should we follow only Medicare guidelines? How about

providers that do not see Medicare patients?• Auditing process



• Communication– Auditor/Coder to Auditor/Coder– Non-provider staff members (i.e. billing staff,

patient account, etc.) to Auditor/Coder– Auditor/Coder to Provider staff members (i.e.

physicians)



• Communication– Auditor/Coder to Auditor/Coder

• Eliminate opportunities for misinterpretations on processes and/or guidelines.

• Communicate new processes and/or guidelines.• Communicate opportunities for improvement.



• Communication– Non-provider staff members (i.e. billing staff,

patient account, etc.) to Auditor/Coder• Eliminate opportunities for misinterpretations in

coding/billing (i.e. usage of modifiers).• Provide feedback on coding/billing (i.e. claim

reject) that may need to be further reviewed and/or investigated (i.e. non-covered diagnosis).

• Provide feedback on coding/billing (i.e. claim reject) that may require provider education (i.e. usage of modifiers).



• Communication– Auditor/Coder to Provider staff members (i.e.

physicians)• Provide coding education in a group setting and/or one-on-

one upon completion of an audit.– Potential problem: Physician may not agree with auditor/coder.

» May request a second review by another auditor/coder.

» If provider still disagrees it is bumped up to the physician compliance leader to resolve and document action taken OR may have a policy that it is sent out according to the auditors recommendations.

• Provide follow-up coding education.• Provide open communication where the provider request

assistance in coding as needed basis.



• Quality– Audit the auditor/coder

• Identify coding errors– Provide additional training– Develop policy on how to address job performance

– Audit revenue cycle• Identify inaccurate coding changes• Improve operational processes• Provide additional training to new process• Re-audit to determine if changes were effective



• Tracking– Track all audits in a centralized location

• Excel• Access Database

– Report back to compliance officer the results and recommendations for improvement.


Key To Success Is

TEAMWORK

derry, nolan & associates, llc - physician practice compliance program presented by barbara...

Documents

compliance policies

compliance officer

nolan associates

program oversight

physician leadership

cpc slide

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