Frequently Asked Questions About Compliance

1
Frequently Asked Questions About Compliance

• Presented by Penny Osmon
• Coding Reimbursement Educator
• Wisconsin Medical Society
• penny.osmon_at_wismed.org

2
History of Compliance

• Coding and compliance continue to be hot
  topics within the health care industry.
• On September 25, 2000 the OIG issued its final
  Compliance Program Guidance for Individual and
  Small Group Physician Practices to assist
  physicians in developing compliance programs for
  their practices.
• A direct result of HIPAA

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What is a Compliance Program?

• Management commitment to play by the rules
• Not just words, on-going management and
  organizational efforts to prevent fraud, waste
  and abuse
• Each compliance program is custom to the
  organization

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What Does an Effective Compliance Program Need?

• The compliance program guidance contains seven
  components which will provide a foundation in
  which a practice can create a voluntary
  compliance program.
• This guidance provides a step-by-step approach to
  follow while developing and implementing a
  compliance plan.
• The key due diligence, culture and ethics

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What Does an Effective Compliance Program Need?
(contd)

• A compliance program is a centralized process to
  promote honest, ethical behavior in the
  day-to-day operations of an organization, which
  will allow the organization to identify, correct,
  and prevent illegal conduct.
• Good compliance is good business.
• It is a system of
• FIND IT FIX IT PREVENT IT

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The Seven Components

• Conducting internal monitoring and auditing
• Implementing compliance and practice standards
• Designating a compliance officer or contact
• Conducting appropriate training and education
• Responding appropriately to detected offenses and
  developing corrective action
• Developing open lines of communication and
• Enforcing disciplinary standards through
  well-publicized guidelines.

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The Seven Components

• The OIG has acknowledged that full implementation
  of all 7 may not be feasible.
• They suggest that the steps be implemented
  gradually and recommend Step 1 be auditing and
  monitoring.
• Utilizing the OIGs yearly work plan is a good
  basis for identifying areas to focus an audit on.

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Getting Started

• The first step to designing a compliance program
  is to perform a needs assessment.
• This assessment is to identify areas which may be
  at significant risk.
• These may include
• Medicare and Medicaid billing requirements
• Anti-Kickback and Stark self-referral laws
• State laws which regulate physician practices
• Coding and documentation rules

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Getting Started (contd)

• Most physician compliance programs focus on
  billing, coding and documentation.
• Perform a risk assessment to determine areas of
  highest risk.
• Identify existing policies and procedures and
  review for accuracy.
• Develop an action plan.

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Why Perform a Risk Assessment?

• Risk areas need to be addressed based on each
  practices specific needs.
• Risk areas may differ substantially between a
  primary care practice and a general surgical
  practice.
• OIG states that risk areas be tailored to the
  specific physician practice.

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Coding Billing Areas of Risk

• Billing for services or items not rendered
• Medical Necessity
• Double billing
• Billing for non-covered services
• Misuse of provider identification numbers
• Upcoding
• Incorrect modifier usage
• ABNs
• Incident-to

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Chart Audit

• First step in identifying potential risks
• Recommend 10-15 chart notes per physician be
  reviewed
• Analyze coding patterns
• Review the charge ticket

13
What is the Standard for Developing the Standards?

• Written policies and procedures addressing proper
  coding should reflect the current requirements
  described in the applicable statutes,
  regulations, federal, state and private payers
  requirements.
• The standards should be clear and communicated to
  all employees.

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Development of Standards

• Review existing policies and procedures
• Develop a plan based on specific practice needs
• Draft polices and procedures and obtain
  appropriate approvals
• Educate staff

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Any health care entity which does not have a
compliance program is institutionally
nutsKaren MorrisetteDeputy Chief of the
Criminal DivisionDivision Fraud Section of the
U.S. Department of Justice
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Fact or Fiction?

• There are many myths regarding what you can and
  cannot do about compliance issues, fees and
  charges.
• There is some fact in the myths however, there
  is much distortion from these being interpreted
  by many people.
• Lets explore some of these

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You Cant Ask a Colleague at Another Physician
Office What They Charge for a Service

• In some cases you can ask a colleague their
  charge.
• If you are not competitors with the other
  practice, no antitrust issues arise.
• Same specialty in the same community may pose a
  riskier situation and may violate Section 1 of
  the Sherman Antitrust Act.
• http//www.justice.gov/atr/public/guidelines/1791.
  htmCONTNUM_49

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You Cant Charge Self Pay Patients Less Than Your
Standard Fee

• You may charge your self-pay patients less than
  your standard fee.
• You may even apply no charge to an uninsured or
  self-pay patient.
• The OIG states that it does not use your
  discounted or free care in the calculation of
  your usual charge.
• http//edocket.access.gpo.gov/2007/pdf/E7-11663.pd
  f

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What about Medicaid?

• Wisconsin administrative code, DHS Chapter 1
  defines usual and customary charge as the
  providers charge for providing the same service
  to persons not entitled to MA benefits (DHS
  101.03 (181)
• DHS 106 states that the provider has a
  responsibility to retain as evidence, a copy of
  the usual and customary charges to recipients and
  to persons or payers who are not recipients (DHS
  106.02 (9)(c)

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For most services, providers are required to
indicate their usual and customary charge when
submitting claims. The usual and customary charge
is the providers charge for providing the same
service to persons not entitled to the programs
benefits. For providers using a sliding fee
scale, the usual and customary charge is the
median of the individual providers charge for
the service when provided to non-program
patients. For providers who have not established
usual and customary charges, the charge should be
reasonably related to the providers cost for
providing the service.
Source Forward Health On-line Handbook, 2009
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You Dont Need a Compliance Plan If You Are a
Small Practice

• Small practices are not immune to the rules and
  regulations pertaining to compliance.
• For every entity, whether its a one-physician
  practice or one thousand, the rules and
  regulations apply to all providers who bill
  Medicare/Medicaid and third-party payers.

22
You Cant Charge a Medicare Patient for a No
Show Appointment

• In 2007, CMS issued a transmittal stating that
  you can bill a Medicare patient for a missed
  appointment.
• Transmittal 1279
• CMS also stated in their policy that in order to
  charge a Medicare patient for a missed
  appointment, you also have to charge non-Medicare
  patients for them.
• Cant bill Medicare

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I Can Waive Co-pays and Deductibles

• You are able to reduce the cost of care for
  Medicare patients in the form of waivers if the
  patient is experiencing financial hardship.
• The Health Insurance Portability Accountability
  Act (HIPAA) have listed requirements that must be
  met in order to waive co-pays and deductibles. 42
  USC 1320a-7a(i)(6)(A).
• Dont offer the waiver as part of any
  advertisement or solicitation and
• Dont routinely waive co-pays and deductibles and
• You must either
• Waive the co-pay and/or deductible amounts after
  determining in good faith that the individual is
  in financial need or
• Waive the copy and/or deductible after making
  reasonable collection efforts that fail to obtain
  payment

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I Can Waive Co-pays and Deductibles (contd)

• With the exception of hardship, you may not waive
  co-pays and deductibles for which patients are
  required to pay under indemnity, HMO or PPO plan
• Determining financial need
• Are they eligible for Medicaid?
• Use customary methods

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I Have to Bill Medicare MyLowest Fee

• Providers are not required to give Medicare their
  lowest fee.
• The law states that you cannot bill Medicare for
  items or services substantially in excess of
  your usual charges.
• But, whats the point?
• You will rarely get more than the allowed amount

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You Have to Charge All Payersthe Same

• You can have multiple fee schedules.
• Verify through contract review for most favored
  nation clause.
• Maintaining multiple fee schedules may be more
  work than its worth.
• There is no federal or state documentation to
  support either way.

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What About Documentation?
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What is Documentation?

• Medical record documentation is required to
  record facts, findings and observations about a
  patients health.
• This includes past and present illnesses,
  examinations, tests, treatments and outcomes.
• The medical record documents in chronological
  order the care of the patient.
• It is unique to each patient.

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General Principles of Medical Documentation

• The medical record should be complete and
  legible.
• The documentation for each encounter should
  include
• The reason for the encounter and relevant
  history physical exam findings and test results
• Assessment, clinical impression or diagnosis
• Plan of care and
• Date and legible identity of the observer

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May I Bill for Services Not Yet Documented?

• Documentation of the service you provided a
  patient must be documented when you submit a
  charge.
• The CPT and ICD9 codes reported on the claim form
  should be supported by the documentation in the
  medical record.
• If its not documented its not done.

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Supervision of Non-Physician Practitioner
Documentation

• There is no federal statute or benefit under
  Medicare that requires a physician to co-sign a
  mid-levels progress note, APNP or PA.
• CMS leaves this up to individual states, each
  state has its own rule.
• Check with carriers also, they may have different
  requirements.
• Wisconsin does not require a co-signature by the
  supervising physician.

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Fraud vs. Abuse

• Fraud making false statements or
  representations of material facts in order to
  obtain some benefit or payment for which no
  entitlement would otherwise exist.
• Abuse practices that, either directly or
  indirectly, result in unnecessary costs to the
  Medicare program or other payer.

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False Claims Act

• Prohibits knowingly filing a false or fraudulent
  claim for payment to the government, knowingly
  using a false record or statement to obtain
  payment on a false claim or conspiring to defraud
  the government by getting a false claim paid.

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False Claims Act

• 31 U.S.C. 3729
• Makes providers liable for both damages and
  penalties
• Civil and Criminal Fines
• Criminal (Up to 25,000 and/or up to 5 years
  imprisonment)
• Civil (5,500 -11,000 per claim)
• Plus an additional up to three times the damages
  sustained by the government
• Most providers are also sanctioned from the
  program

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Additional References

• Social Security Act
• Medicare Claims Processing Manual
• Section 42 of the CFR
• Documentation Guidelines for Evaluation and
  Management Services (1995/1997)
• Federal Register
• 6/18/2007
• 9/15/2003
• 10/5/2000

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Questions/Comments/DiscussionThank
You!penny.osmon_at_wismed.org608-442-3781