Section 4Section 4

National Provider NumberNational Provider NumberClaims & Claims RegulationsClaims & Claims Regulations

Scott Simmons, BSRT

99:30 to 10:00 Section 4Modified for 04-11-1457

031114

The most important thing that Physicians do is care for

their patients.The second The second

most most important important thing they thing they must do, is must do, is understand understand how to how to properly bill properly bill for, these for, these services.services.

INITIAL EVAUATION (E/M) INITIAL EVAUATION (E/M)

CLINICAL TREATMENT PLANNINGCLINICAL TREATMENT PLANNING

ESTABLISHMENT OF TREATMENT PARAMETERSESTABLISHMENT OF TREATMENT PARAMETERS

TREATMENT DELIVERY AND MANAGEMENTTREATMENT DELIVERY AND MANAGEMENT

END OF TREATMENT REPORTEND OF TREATMENT REPORT

FOLLOW-UP (E/M)FOLLOW-UP (E/M)

3

The entire course of radiation therapy fits The entire course of radiation therapy fits between the initial evaluation and the end of between the initial evaluation and the end of treatment summary. Anything that is done for treatment summary. Anything that is done for

the patient during this period of time isthe patient during this period of time is considered part of a single course of radiation considered part of a single course of radiation

therapy therapy

A new physician entering a practice needs to have a valid national provider number to begin billing Medicare patients.

These services may not be These services may not be billed electronically to billed electronically to Medicare or any government Medicare or any government payment program until the payment program until the physician has a valid NPIphysician has a valid NPI

7

NO PROVIDER NO PROVIDER NUMBER ?NUMBER ?

NEVER, EVER, UNDER ANY NEVER, EVER, UNDER ANY CIRCUMSTANCE, EVER LOAN CIRCUMSTANCE, EVER LOAN YOUR PROVIDER NUMBERS YOUR PROVIDER NUMBERS TO ANOTHER PHYSICIAN TO ANOTHER PHYSICIAN FOR BILLING SERVICESFOR BILLING SERVICES

7

The Healthcare Portability The Healthcare Portability Act of 1998 (HIPAA) states Act of 1998 (HIPAA) states that any new billing contract that any new billing contract must be submitted as part must be submitted as part of the application for a new of the application for a new provider number, and the provider number, and the contract must pass the test contract must pass the test for possible conflict of for possible conflict of interest.interest.

HIPAAHIPAA

Covered by pages 10-14

11/57

UNDER THE NEW PRIVACY LAW YOU ARE NOT ALLOWED

TO TELL ME ANY OF YOUR SYMPTOMS

NIB

HIPAA: WHAT TO DO NOWHIPAA: WHAT TO DO NOW

Make sure you Make sure you have In-depth have In-depth Employee Employee TrainingTraining

14/57

NOT THE HIPAA WAY TO FILE DATA

NIB

Be Careful what Data you Be Careful what Data you ReleaseRelease

NIB

Computer memory devices

Hard Drives, floppy discs, CD discs, zip Hard Drives, floppy discs, CD discs, zip discs, and any other form of electronic discs, and any other form of electronic storage media are subject to data retrievalstorage media are subject to data retrieval

If you no longer need the data, If you no longer need the data, DESTROY DESTROY the mediathe media

Don’t rely on just “erasing” the Don’t rely on just “erasing” the data, there is no reliable method data, there is no reliable method of doing this short of total re-of doing this short of total re-formatting formatting

13

NIBDrill a hole and run a screw through it!!

This hard drive will never work again, data recovery is not Totally impossible, but extremely difficult.

NIB

You are responsible for the You are responsible for the security of any information security of any information that you accumulate about that you accumulate about an individual, no matter an individual, no matter where or how it is stored or where or how it is stored or retainedretained

Confirm the Security ofConfirm the Security ofall of Your Computer Systemsall of Your Computer Systems

13

Protect of electronic health information maintained by a

certified EHR.

14

•This is not a simple as you would think•Meaningful use is more stringent than HIPAA•Use the HHS guidelines available on HHS website•Keep firewalls up at all times•Keep anti virus software updated at all times•Download OS software updates as they are posted•Be aware of all locations where PHI is stored, this is where it can be stolen from!

A computer terminal in an unsecure area being remodeled.

It is still turned on and active, a target for breach of PHI

NIB

Or the very worst example a of lapse of security

A live terminal, unattended, still logged in, and totally vulnerable to invasion of patient privacy

NIB

Data Data encryptionencryption

• It is recommended that any computer device that is portable, such as a laptop or flash drive, be fully encrypted to prevent unauthorized use of data stored on the device.

• This is crucial if any PHI is stored on the device.

• A separate record of the encryption is your only proof of security if the device is compromised.

• We must always be aware of where PHI is stored because this is a location from whence it can be stolen

Physician’s stolen laptop Physician’s stolen laptop Containing PHI leads to a $1.5 Containing PHI leads to a $1.5 million settlementmillion settlement Stolen laptops account for one out of

five incidents of compromised data. An unencrypted laptop was stolen. No evidence ever surfaced that any

patient records were compromised. The HHS investigated and assessed a

penalty of $1.5 million to settle “potential“ HIPAA violations.

“This is now the “standard” violation fee!!!

NIB

Who is Who is responsible????responsible????

You are, even if no data was compromised.

A lost device such as a laptop or even a flash drive places you at great liability.

The HIPAA fine starts at $1,500,000. No refund of this fine even if the device

is recovered.

NIB

Who is Who is responsibleresponsible

14

Unfortunately, you are always responsible.

In the event of any unlawful use of PHI, even if the event occurs through no fault of your own, such as computer hacking, stolen records, or stolen computer.

You are also liable if one of your staff improperly accesses patient records.

If you are in Doubt If you are in Doubt about any of the HIPAA about any of the HIPAA regulations, Seek the regulations, Seek the Advice of Competent and Advice of Competent and Knowledgeable Legal Knowledgeable Legal CounselCounsel

13

Medicare considers “up-front discounting” to be a reduction in the fee-for-service

•sympathy for patients•professional courtesy •“we accept assignment”•Even your family members

Pitfalls When YouDiscount Your Fees

Page 14

•HIPAA makes discounting much more HIPAA makes discounting much more hazardoushazardous

•The federal government considers the The federal government considers the discounted fee as being your new feediscounted fee as being your new fee

•Down coding a procedure, on Down coding a procedure, on purpose, or accidentally, is purpose, or accidentally, is

considered discounting, and is considered discounting, and is ILLEGAL ILLEGAL

Discounting is Discounting is IllegalIllegal

15

•The only legitimate discounting of fees is through contractual relationships with HMO’s, PPO’s, VAMC, or other managed care plans.

•If some of these dip below the Medicare allowables, this is allowed under the current law.

15

15

24/57

Documentation to Avoid the Medicare Fraud &

Abuse Laws

15

Healthcare fraud and abuse, (HCFAC) program

The HCFAC program recovers $7.90 for every $1 invested in expenses. It is a very profitable program and will continue.

Recovered $4.1 billion in FY 2011. Recovered $4.2 billion in FY 2012. Total recovery since inception of the

program is $23 billion.

First understand the audit process

CERT, Comprehensive Error Rate Testing Program (local Medicare)

Randomly selected claims.Randomly selected claims. Claims reviewed for compliance.Claims reviewed for compliance. Providers have 30 days to Providers have 30 days to

respond.respond. You may appeal findingsYou may appeal findings

15

RECOVERY AUDIT CONTRACTOR, RAC

Started in 2003 Not intended to replace other audit processes. Performed by private contractors, paid based on

recovery of Medicare overpayments, (and a few underpayments).

The RAC reviews claims post payment. They can look back 3 years from date of claim

payment Initially only hospital claims,

now regularly targeting physicians.

15

The audit The audit processprocess

RAC Recovery Audit Contractor RAC Recovery Audit Contractor (Private)(Private)

Now a financially successful Now a financially successful permanent program.permanent program.

Claims reviewed by “mining”.Claims reviewed by “mining”. 45 days to respond.45 days to respond. You are considered guilty, so you You are considered guilty, so you

must prove your innocencemust prove your innocence.. Auditors are paid on contingency.Auditors are paid on contingency.

15

RAC SELECTION AUDITING

Must target claims through data analysis;

Your initial communication is usually a demand letter requesting medical records, or a refund for overpayment.

15

RAC REVIEW PROCESS

Automated, no record needed, almost certain an overpayment exists based on data review.

Complex, medical record required, high probability of uncovered service.

These must be paid when you are These must be paid when you are notifiednotified, you can appeal within 120 days of notification

15

30/57

RAC PROOFING YOUR PRACTICE You can never be truly RAC proof Correct the type of any previous audit

findings so you don’t keep repeating the same errors.

Conduct internal auditing of your practice to assure compliance with current Medicare rules.

Establish coding protocols that follow the exact current rules of Medicare

15

The audit process

OIG, Office of the Inspector General.OIG, Office of the Inspector General. The government is looking for you.The government is looking for you. They know what they are looking for.They know what they are looking for. They know where it is.They know where it is. They know what you have done.They know what you have done. They know where you live and work.They know where you live and work.

16

• Fraud and abuse is estimated to cost the U. S. Healthcare System about 10% of the dollars spent each year for health related services.

• As a physician, you are responsible for the billing generated by the personnel working for you. Their errors could lead to your conviction!

• You are supposed to completely understand the present laws relating to billing for your services.

• You are totally responsible for the submission of the claim.

The Physician is Responsible

17

•Congressional investigations Congressional investigations found that during, and after found that during, and after the Civil War profiteers the Civil War profiteers engaged in massive fraud in engaged in massive fraud in connection with the connection with the procurement of food, supplies, procurement of food, supplies, and war materials, and and war materials, and reconstruction of the railroads reconstruction of the railroads of the south, post war.of the south, post war.

The False Claims Act17

As a measure of control, on March 2, 1863, Congress passed

the False Claims Act.

NIB

•Brought by private individual known as a relator•Must have original source Must have original source documentation.documentation.•Whistle-blower protection Whistle-blower protection provisions apply.provisions apply.•Allows for monetary award for Allows for monetary award for relator. (Percentage of the relator. (Percentage of the recovery).recovery).

False Claims ActQui Tam Provisions

This person IS MORE LIKELY TO BE AN EX EMPLOYEE OR PARTNER THAN A PATIENT

17

35/57

How to Stay on the Right Side of the Law

Have a compliance plan and actually use it

Make sure your billing staff are billing Make sure your billing staff are billing correctlycorrectly

Don’t bill for what you don’t doDon’t bill for what you don’t do

Properly document the services you Properly document the services you provideprovide

Don’t create false recordsDon’t create false records

Don’t accept kickbacksDon’t accept kickbacks

17

• Healthcare Fraud (Criminal) - Healthcare Fraud (Criminal) - Knowingly and willfully trying to Knowingly and willfully trying to defraud Medicare or private health defraud Medicare or private health plans by false representation.plans by false representation.

• False Statements (Criminal) Made To False Statements (Criminal) Made To Medicare Or Private Healthcare Plans - Medicare Or Private Healthcare Plans - This is knowingly falsifying facts or This is knowingly falsifying facts or statements on claim forms.statements on claim forms.

• Submission of a False Claim - (Civil) - Submission of a False Claim - (Civil) - This covers up-coding, and claims for This covers up-coding, and claims for medically unnecessary procedures and medically unnecessary procedures and services.services.

Healthcare Related Crimes 18

Civil Enforcement Efforts

•The vast majority of improper The vast majority of improper Medicare claims are handled by Medicare claims are handled by carriers and fiscal intermediaries carriers and fiscal intermediaries as overpayments.as overpayments.

Mere negligence and Mere negligence and mistakes are handled in this mistakes are handled in this fashion.fashion.

18

Remember, the Remember, the physician, is ultimately physician, is ultimately responsible regardless responsible regardless of who is performing of who is performing

the billing.the billing.

18

1) Your charge capture must be 1) Your charge capture must be 100% accurate100% accurate..2) Your billing must reflect 2) Your billing must reflect exactly what was exactly what was performedperformed..3) The 3) The procedure countprocedure count on the bill must agree with on the bill must agree with the number of procedures documented in the record.the number of procedures documented in the record.4) 4) Dates of serviceDates of service on billing must correspond exactly on billing must correspond exactly to dates of services found in your records.to dates of services found in your records.5) 5) Complexity levelsComplexity levels follow the generally accepted follow the generally accepted CPT guidelines.CPT guidelines.6) The 6) The number of proceduresnumber of procedures being performed and being performed and billed is not in excess of the norm.billed is not in excess of the norm.7) Every billed item has 7) Every billed item has corresponding documentationcorresponding documentation in the chart, backed up by physician orders for in the chart, backed up by physician orders for performance, and physician signatures indicating performance, and physician signatures indicating acceptance of the procedure.acceptance of the procedure.8) 8) Electronic signaturesElectronic signatures areare requiredrequired, with electronic , with electronic charting, an original signature must be on file.charting, an original signature must be on file.

18

If you follow these simple guidelines, If you follow these simple guidelines, your chances of surviving a Medicare your chances of surviving a Medicare audit or a RAC audit are significantly audit or a RAC audit are significantly improved.improved.

The keys are documentation of The keys are documentation of medical necessity, and medical necessity, and documentation that the procedure documentation that the procedure was physician ordered, properly was physician ordered, properly performed and accurately performed and accurately captured for billingcaptured for billing

18

WHAT TO DO WHEN YOUR WHAT TO DO WHEN YOUR MEDICARE CLAIM IS MEDICARE CLAIM IS

DENIEDDENIED

Covered by pages 20-29

44/57

Why is the claim being denied?

Are you submitting claims that are Are you submitting claims that are being denied each time for the same being denied each time for the same reason?reason?

What did you do wrong?What did you do wrong? Are you continuing to do it wrong?Are you continuing to do it wrong? Can you correct the problem?Can you correct the problem? If you don’t know, GET HELP!!!If you don’t know, GET HELP!!!

THE FEDS MAY THINK YOU ARE THE FEDS MAY THINK YOU ARE DOING THIS ON PURPOSEDOING THIS ON PURPOSE

NIB

The submission of a claim The submission of a claim undergoes an automated undergoes an automated review to determine if the review to determine if the service claimed is a covered service claimed is a covered service and if the charge for the service and if the charge for the service is in line with the service is in line with the limiting charge.limiting charge.

Medicare Claims Processing

20

•The Medicare carrier may The Medicare carrier may conduct an analysis of conduct an analysis of selected, processed claims and selected, processed claims and the supporting documentation.the supporting documentation.

•If problems are found, the If problems are found, the carrier may undertake carrier may undertake educational corrective actions educational corrective actions or send a warning letter.or send a warning letter.

20

What to include in your request for an independent

auditAny additional evidence should be submitted with Any additional evidence should be submitted with

the request for reconsideration. All evidence the request for reconsideration. All evidence must be presented must be presented before the before the reconsideration is issuedreconsideration is issued. If all evidence is . If all evidence is not submitted prior to the issuance of the not submitted prior to the issuance of the reconsideration decision, you will not be able to reconsideration decision, you will not be able to submit any new evidence to the administrative submit any new evidence to the administrative law judge unless you can demonstrate good law judge unless you can demonstrate good cause for cause for withholding evidence from the withholding evidence from the qualified independent contractorqualified independent contractor..

23

•It is very important when filing a request for a first review that It is very important when filing a request for a first review that additional key documentation, which was not included on the original additional key documentation, which was not included on the original claim, should be included.claim, should be included.• This information may be vital to helping the reviewer to understand This information may be vital to helping the reviewer to understand any special circumstances which contributed to the particular course any special circumstances which contributed to the particular course of treatment and the services performed by the radiation oncologist.of treatment and the services performed by the radiation oncologist.• For example, copies of the pages of the patients medical record with For example, copies of the pages of the patients medical record with the physician's the physician's signed approvalsigned approval, and copies of any other reports or , and copies of any other reports or tests used in developing and administering a course of treatment may tests used in developing and administering a course of treatment may strengthen the case with the initial case reviewer.strengthen the case with the initial case reviewer.• You must know what is being questioned, and supply all of your You must know what is being questioned, and supply all of your pertinent documentation. pertinent documentation. • Without this backup material, such as the isodose plans if IMRT or Without this backup material, such as the isodose plans if IMRT or other Dosimetry is in question, you have a very high probability of other Dosimetry is in question, you have a very high probability of loosing the appeal.loosing the appeal.

•This will be your best opportunity to make your This will be your best opportunity to make your case valid.case valid.

23

51/57

Five Levels of appeal Medicare (CMS®) Appeals Process Medicare (CMS®) Appeals Process Available to resolve concerns about Available to resolve concerns about

payment and coverage decisionspayment and coverage decisions

The appeals process consists of The appeals process consists of five levels. Each level must be five levels. Each level must be completed for each claim at issue completed for each claim at issue prior to proceeding to the next prior to proceeding to the next level of appeallevel of appeal.

23

Medicare (CMS) Appeals Medicare (CMS) Appeals Process Consists of; these Process Consists of; these 5 levels5 levels

RedeterminationRedetermination ReconsiderationReconsideration Administrative Law JudgeAdministrative Law Judge Departmental Appeals BoardDepartmental Appeals Board Judicial ReviewJudicial Review

23

Audit/appeals

In 2012 Medicare processed over 1 billion claims. Only 3.7 million of rejected claims were appealed,

this is less than 4% of all denied Medicare claims were actually appealed.

80% of these were part B physician. 20% of these were part A hospital. 25% of part A appeals were decided favorably for

the hospital. 50% of part B appeals were decided favorably for

the physician.

Audit and Audit and appealsappeals

Why were these not appealed. The primary reason is that inside review revealed

that the denial was appropriate. Missing documentation prevented the appeal

process from going forward. The billing person was too busy with current

cases to tackle the time-consuming job of appeals.

The lack of appeal results in a significant loss of income to the practice.

Audit and Audit and appealsappeals

Why should you always appeal a case that is denied?

Because better than 50% of part B appeals were decided in the favor of the physician.

The appeal process takes time but it is also a learning experience.

Find out why the claim was denied and don't repeat the mistake.

HOW FAR DO YOU WANT TO GO IN THE APPEAL PROCESS?

This depends upon the amount of money involved, and how firmly you believe that you are right.

The process is there for you to use, if you want to go all the way, or cut your losses and stop

27

•The information presented herein is The information presented herein is intended to provide a general review intended to provide a general review of the Medicare appeal process and of the Medicare appeal process and should not be interpreted as a should not be interpreted as a detailed description or a detailed description or a representation of every component of representation of every component of that process.that process.• The information presented in this The information presented in this section is not meant to serve as a section is not meant to serve as a substitute for legal advice. substitute for legal advice. • A radiation oncologist should consult A radiation oncologist should consult with his or her legal counsel in with his or her legal counsel in seeking guidance on review of a seeking guidance on review of a denied Medicare claim.denied Medicare claim.

27

General Billing, Documentation

Hints Document, Document, Document, when in doubt

document. Bill for only what’s documented at the correct level, and

date. Everything done in Radiation Oncology has to have a

Physician’s Order, a Physician’s Oversight and a Physician’s documented approval and report.

No order is understood or Standing. Being electronic does not mean new documentation rules. Billing is vastly different in Global, Technical and

Professional Environments. Never ever put the actual CPT code on the

documentation. Every CPT code billed should have its own support

documentation; DO NOT bundle. The selected date of service and the date of occurrence

on the billing have to match.

28-29

END 4

PRINCIPLES OF BILLING, CODING AND

COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2014

End 4

End section 4 4

End Section 4

There will be 4 morning sessions

covering sections 1,2, 3, 4, and 5

Dr Bogardus

Dr Bogardus

Susan Vannoni

Dr Bogardus/ Susan Vannoni

Scott Simmons

THIS SCHEDULE

MAY BE MODIFIED

PRINCIPLES OF BILLING, CODING AND

COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2012

End 4

Next session is Next session is Section #5 at 10:45Section #5 at 10:45

I sent this email regarding an appeal, what is the errorNIB

the government can deem it a  HIPAA violation to send a patient's name and social through email. 

your message contained a social security number/Medicare number and patient's name in your email. to the government, under HIPAA, those are PHI.

This was the reply I received (She never did answer my question)

NIB

BE CAREFUL WITH PHIBE CAREFUL WITH PHI16/57

AssignmentAssignment

THE BASIC RULES OF MEDICARE PAYMENT ARE WELL COVERED IN THE USERS GUIDE AND WILL NOT BE REPEATED HERE

EOB – Explanation of BenefitsEOB – Explanation of Benefits

Limiting ChargeLimiting Charge

Co-PaymentCo-Payment

Pages 4-6

USE ONLY THE NPINational Provider

Identifier

DO NOT USE ANY OTHER NUMBERDO NOT USE ANY OTHER NUMBER

Failure to comply will reject your Failure to comply will reject your claim.claim.

SHARE THE NEW NPI WITH ALL SHARE THE NEW NPI WITH ALL BUSINESS PARTNERSBUSINESS PARTNERS

7

A CT scanner being moved, still has power on and is subject to discovery of images and other PHI

Computers in storage in an area accessible with little security, subject to being stolen

NIB

NATIONAL PROVIDER NUMBER

Only one NPI is required.Only one NPI is required. This number now works for This number now works for almost all health plans.almost all health plans.

This number is required for This number is required for electronic transmittalelectronic transmittal

CHECK WITH YOUR CHECK WITH YOUR CARRIERCARRIER

7

$5,700,000.00 NIB

NIB

NIB

Remember; Insurance companies are Remember; Insurance companies are designed to collect premiums,designed to collect premiums, NOT NOT TO PAY BENEFITSTO PAY BENEFITS

NIB