health care litigation – coding and documentation audits
DESCRIPTION
Health Care Litigation – Coding and Documentation Audits. Amper, Politziner & Mattia LLP Coders Day September 2009. Coding and Documentation Audit. Index Overview of Coder’s role in HC litigation Case Study #1 Case Study #2 Case Study #3 Conclusion. Coding and Documentation Audit. - PowerPoint PPT PresentationTRANSCRIPT
Amper, Politziner & Mattia LLPCoders Day
September 2009
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Coding and Documentation AuditIndex
Overview of Coder’s role in HC litigationCase Study #1Case Study #2Case Study #3Conclusion
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Coding and Documentation AuditCoder’s role in HC litigation
Coding specialistGather evidence for HC attorneyExpert witness in Court
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Coding and Documentation AuditCase Study #1Situation
Medicare sends an audit letter to the practiceNo indication of the reason for nonpaymentPayment for all Medicare services stoppedPractice retains HC legal counselLegal counsel retains Amper
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Coding and Documentation AuditCase Study #1Results of Amper Review
All office visits billed at levels 4 or 5Numerous lab tests per patient per visitNumerous procedures at every visitNumerous high risk diagnosis at every visitMedicare nurse reviewers requested additional
documentation to complete their review
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Coding and Documentation AuditCase Study #1Results of Amper Review
Additional documentation supplied to MedicareMedical Director states he has a medical
necessity concern even though documentation is complete
Audit is disruptive to the practice’s cash flowImportance of a Compliance ProgramBilling Company role for documentation
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Coding and Documentation AuditCase Study #1Results of Amper Review
Managing partner to discuss clinical approach with Medicare’s Medical Director
Healthcare attorney involvement for all discussions with Medicare
Numerous coding and documentation corrections noted to the practice by Amper
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Coding and Documentation AuditCase Study #1Outcome of Efforts
Negotiated settlement with MedicareNo Fraud indictments issuedPractice no longer services Medicare patients
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Coding and Documentation AuditCase Study #2Situation
Private payor audit regarding consultationsPayor requested an overpayment request in
excess of $500,000 from the practicePayor threatened fraud indictmentPractice retained HC legal counselLegal counsel retained Amper
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Coding and Documentation AuditCase Study #2Results of Amper Review
Consults billed for all visits including new and established visits
Frequent and repetitive administration of testing procedures
High number of procedures performed on family members
Diagnosis did not support level of office visit or medical necessity
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Coding and Documentation AuditCase Study #2Results of Amper Review
Practice invested in an electronic medical records system – HC attorney suggested to use this investment as a defense against the payor Inadequate documentation for any visit Missing patient chart information Missing documentation of procedures
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Coding and Documentation AuditCase Study #2Outcome of Efforts
Overpayment request by payor reduced by 40%
Physician no longer serviced patients from payor
Fraud charges not brought against physicianPhysician sold practice
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Coding and Documentation AuditCase Study #3Situation
Physician sued by an imaging management company for overpayment of professional services
Portrayed as a contract dispute between management company and the physician
Physician retains HC legal counselLegal counsel retains Amper
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Coding and Documentation AuditCase Study #3Results of Amper Review
Management company billed global charges under the physician’s provider number
One owner of management company debarred from Medicare, but company continued to bill
Billings under the physician’s name after he retires
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Coding and Documentation AuditCase Study #3Results of Amper Review
The same series of ultrasounds and/or echocardiograms were performed on all patients
Numerous billings for family membersIncorrect reporting of diagnosis or procedures
to maximize paymentsBillings also submitted incorrectly to all private
payors
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Coding and Documentation AuditCase Study #3Outcome of Efforts
HC attorney turned over Amper findings to U.S. Attorney’s office
Criminal charges brought against owners of imaging management company
Physician was not required to return any overpayments requested by the management company
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Coding and Documentation AuditConclusion
Fraud and abuse is prevalent in healthcareCoder plays a key role in the proper billing of
servicesCoder assists legal counsel defend providers in
requests for overpaymentsEssential for all healthcare organizations to
have Compliance Programs
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Coding and Documentation AuditContact Information
Michael J. McLafferty CPA, MBA, FACMPE, CHFP
Partner, Healthcare Services GroupAmper, Politziner & Mattia [email protected] – 732-287-1000 Extension 1284Cell - 732-598-8858
“The material contained in this presentation is for general information and should not be
acted upon without prior professional consultation.”