Corporate ComplianceCorporate ComplianceEducation 2009Education 2009Presented byPresented by

Thom SinnetteThom SinnetteVA-NWIHCS Compliance VA-NWIHCS Compliance

OfficerOfficer

Why Corporate Why Corporate Compliance?Compliance?

To ensure compliance with federal To ensure compliance with federal and state laws and regulationsand state laws and regulations

To promote the prevention, detection To promote the prevention, detection and resolution of conduct that does and resolution of conduct that does not conform to requirements not conform to requirements applicable to ethical business applicable to ethical business practices.practices.

7 Elements of a Program7 Elements of a Program Establish compliance standards and procedures Establish compliance standards and procedures Make high-level personnel responsible for overseeing Make high-level personnel responsible for overseeing

compliance. compliance. Use care to avoid delegating substantial discretionary Use care to avoid delegating substantial discretionary

authority to individuals whom the organization knows, authority to individuals whom the organization knows, or should have known, have a propensity to engage in or should have known, have a propensity to engage in illegal activities. illegal activities.

Effectively communicate standards and procedures to Effectively communicate standards and procedures to all employees and agents. all employees and agents.

Take reasonable steps to achieve compliance with Take reasonable steps to achieve compliance with standards, including using monitoring and auditing standards, including using monitoring and auditing systems and publicizing a system for employees to systems and publicizing a system for employees to use to report violations of code standards, as well as use to report violations of code standards, as well as criminal conduct, without fear of retribution. criminal conduct, without fear of retribution.

Consistently enforce the standards through Consistently enforce the standards through appropriate disciplinary mechanisms. appropriate disciplinary mechanisms.

Take all reasonable steps to respond appropriately and Take all reasonable steps to respond appropriately and prevent further similar offenses, when an offense is prevent further similar offenses, when an offense is detected.detected.

Corporate Compliance Corporate Compliance ProgramsPrograms

Focus on compliance with fraud and abuse laws;

Civil False Claims Act

•provides civil remedy against those who defraud the government (Knowingly submit false claim)

Anti-Kickback statutes

•Prohibits knowing and willful offer/payment of remuneration in cash or in kind to induce referrals

Stark Law

•restrictions on physician self-referrals

DefinitionsDefinitions

Fraud:Fraud: Intentional deception or mis- Intentional deception or mis-representation that an individual or representation that an individual or organization makes such as a false organization makes such as a false statement/claim to the Medicare statement/claim to the Medicare program.program.

AbuseAbuse: Incidents or practices which are : Incidents or practices which are inconsistent with accepted sound inconsistent with accepted sound medical, business or fiscal practices and medical, business or fiscal practices and directly or indirectly create unnecessary directly or indirectly create unnecessary costs to the Medicare programcosts to the Medicare program

Examples of FraudExamples of Fraud Billing for services not renderedBilling for services not rendered (not (not

documented)documented) Soliciting, offering, or receiving aSoliciting, offering, or receiving a kickback kickback, bribe or , bribe or

rebaterebate Using an incorrect or Using an incorrect or inappropriate provider inappropriate provider

numbernumber to be paid to be paid Signing blank recordsSigning blank records or certification forms to or certification forms to

obtain Medicare paymentobtain Medicare payment Offering incentives to Medicare patientsOffering incentives to Medicare patients not not

offered to non-Medicare patients (e.g., offered to non-Medicare patients (e.g., waiver of deductible/coinsurance)waiver of deductible/coinsurance)

Falsifying informationFalsifying information on medical records or billing on medical records or billing statementsstatements

Misrepresenting as medically necessary, non-covered Misrepresenting as medically necessary, non-covered services by using services by using inappropriate procedure or inappropriate procedure or diagnosis codes diagnosis codes

Examples of AbuseExamples of Abuse

Using procedure or revenue codes Using procedure or revenue codes thatthat describe more intensive describe more intensive servicesservices than actually performed than actually performed

Routinely Routinely submitting duplicate submitting duplicate claimsclaims

Billing for services in excessBilling for services in excess of of those needed by patientsthose needed by patients

Billing for services more Billing for services more expensiveexpensive than used than used

What does this mean?What does this mean?

Government will be Government will be aggressiveaggressive

Increased scrutiny Increased scrutiny of claimsof claims Coding and Coding and

documentationdocumentation Critical CareCritical Care ConsultationsConsultations Pre-operative Pre-operative

history and physicalhistory and physical

Physician Documentation is main Physician Documentation is main cause of “Compliance Failures”cause of “Compliance Failures”

4 categories of errors4 categories of errors1) Medical record contains insufficient 1) Medical record contains insufficient

documentation to determine patient’s documentation to determine patient’s condition or diagnosis warranting condition or diagnosis warranting serviceservice

2) Service was performed but 2) Service was performed but documentation did not indicate service documentation did not indicate service was medically necessarywas medically necessary

3) Claims filed for noncovered services 3) Claims filed for noncovered services and miscellaneous coding errorsand miscellaneous coding errors

4) Service was coded at a higher level 4) Service was coded at a higher level than supported by the relevant than supported by the relevant medical recordmedical record

Physician Physician ResponsibilitiesResponsibilities

Order individual testsOrder individual tests (not group or (not group or routine)routine)

Provide specific Provide specific diagnostic diagnostic informationinformation (ICD-9) at the time of the (ICD-9) at the time of the order for each testingorder for each testing

Ensure Ensure sufficient documentationsufficient documentation to to justify procedure/service codejustify procedure/service code

Physician CompliancePhysician Compliance

Medical Record should be complete and Medical Record should be complete and legiblelegible

Each patient encounter should include:Each patient encounter should include: Reason for encounter and relevant historyReason for encounter and relevant history Physical examPhysical exam Diagnostic test resultsDiagnostic test results AssessmentAssessment Clinical impressionClinical impression Plan for carePlan for care Date and legible identity of providerDate and legible identity of provider

Appropriate health risk factors should be identifiedAppropriate health risk factors should be identified Patient’s response to and any changes in Patient’s response to and any changes in

treatment or revision in diagnosis is documentedtreatment or revision in diagnosis is documented

Documentation…Key Documentation…Key points!points!

Every service billed must be documented.Every service billed must be documented. There must There must be clear evidence in the patient’s record that the be clear evidence in the patient’s record that the service, procedure, or supply was actually performed or service, procedure, or supply was actually performed or supplied.supplied.

The medical necessity for choosing the procedure, The medical necessity for choosing the procedure, service or medical supply must be substantiated.service or medical supply must be substantiated.

Every service must be coded correctly.Every service must be coded correctly. Diagnoses must Diagnoses must be coded to the highest level of specificity, and be coded to the highest level of specificity, and procedures codes must be current.procedures codes must be current.

The documentation must clearly indicate who The documentation must clearly indicate who performed the procedure or supplied the equipment.performed the procedure or supplied the equipment.

Although it may be dictated and transcribed, Although it may be dictated and transcribed, legible legible documentation is required.documentation is required. Existing documentation Existing documentation may not be embellishedmay not be embellished (e.g. adding what was omitted (e.g. adding what was omitted in the initial documentation); however, additional in the initial documentation); however, additional documentation that supports a claim may be submitted.documentation that supports a claim may be submitted.

Teaching Physician RulesTeaching Physician Rules(42 CFR (42 CFR §415.172)§415.172)

General rule: General rule: Teaching physician should Teaching physician should bebe present during any service in which present during any service in which he/she involves a residenthe/she involves a resident Teaching physician must be physically Teaching physician must be physically

present during the portion of the service present during the portion of the service that determines the level of E&M service that determines the level of E&M service billedbilled

Teaching physician must personally Teaching physician must personally document his/her presence in services via document his/her presence in services via writing or dictated note (summarize writing or dictated note (summarize resident’s assessment)resident’s assessment)

Teaching Physician RulesTeaching Physician Rules

PsychiatryPsychiatry Teaching physician supervising Teaching physician supervising

resident must be a physicianresident must be a physician Concurrent observation of service Concurrent observation of service

may be met by use of one-way mirror may be met by use of one-way mirror or video equipmentor video equipment

Audio alone does not meet this Audio alone does not meet this exceptionexception

Teaching Physician RulesTeaching Physician Rules Time Based CodesTime Based Codes

For procedure codes specifying time, For procedure codes specifying time, the teaching physician must be the teaching physician must be present for the time which the claim present for the time which the claim is madeis made

Time spent by the resident alone Time spent by the resident alone cannot be added to the time cannot be added to the time spent by the teaching physicianspent by the teaching physician

Individual medical psychotherapy Individual medical psychotherapy (90804-90829) (90804-90829)

Critical Care codes (99291-99292)Critical Care codes (99291-99292) Prolonged services (99354-99359)Prolonged services (99354-99359) Care plan oversightCare plan oversight (99375)(99375) AnesthesiaAnesthesia

Teaching Physician RulesTeaching Physician Rules Interpretation of Diagnostic Radiology and Interpretation of Diagnostic Radiology and

Other Diagnostic testsOther Diagnostic tests If Resident prepares and signs If Resident prepares and signs

interpretation of diagnostic tests, the interpretation of diagnostic tests, the teaching physician must indicate he/she teaching physician must indicate he/she has also personally reviewed the test/image has also personally reviewed the test/image and resident’s interpretation and either and resident’s interpretation and either agrees with it or edits its findingsagrees with it or edits its findings

Countersignature alone is not sufficient Countersignature alone is not sufficient documentationdocumentation