OIGPhysicians and Suppliers: ComplianceWith Assignment Rules Reviewing for Inappropriately billed in excess of amounts allowed by Medicare and to assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.
OIGPhysicians and Other Suppliers: HighCumulative Part B Payments Reviewing for a high cumulative payment defined as an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse.
OIGPhysician-Owned Distributors of SpinalImplants Reviewing to what extent to which physician-owned distributors (POD) provide spinal implants purchased by hospitals and analyzing Medicare claims data to determine whether PODs that have been identified in review are associated with high use of spinal implants. Congress has expressed concern that PODs could create conflicts of interest and safety concerns for patients.
OIGPhysicians: Place-of-Service Errors Reviewing physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed.
OIGPhysicians: Incident-To Services Medicare Part B pays for certain services billed by physicians that are performed by non-physicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. We also found that unqualified non-physicians performed 21 percent of the services that physicians did not perform personally.
OIGPhysicians: Impact of Opting Out of Medicare Reviewing the extent to which physicians are opting out of Medicare and determining whether physicians who have opted out, are permitted to enter into private contracts with Medicare beneficiaries. As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.
OIGChiropractors: Part B Payments for Services Reviewing Medicare Part B payments for chiropractic services to determine whether such payments were in accordance with Medicare requirements. Medicare chiropractors’ services include only treatment by means of manual manipulation of the spine. Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable.
OIGEvaluation and Management Services: Use of ModifiersDuring the Global Surgery Period Reviewing the appropriateness of the use of certain claims modifier codes during the global surgery period to determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period.
Steps to a Compliance PlanThe OIG has established a list ofSeven key elements whenestablishing your Complianceplan.
Step One…Have a written policyand procedure manual
Step Two…Designate a ComplianceProfessional to overseethe plan
Step Three…Conduct an effective trainingprogram
Step Four…Provide an effectivecommunication program
Step Five…Develop an internalmonitoring program
Step Six…Enforce your standards witha corrective action plan
Keys to Success Foster a Culture of Compliance Besure that policies are updated and user friendly Make training a part of the job
Keys to success Stay current Be visible and approachable Take appropriate corrective action Conduct regular audits
Address Areas of Concern Coding Contracts Quality of Care
False Claims ActThis act addresses any entity whosubmits or causes to be submitted a claimfor services that are: Not rendered Miscoded Already covered under another claim Not supported in the medical record Violates Stark Law
Penalties If a claim is submitted by an individual who "knows or should know“ (termed deliberate ignorance) that they are filing a false claim, civil sanctions may be imposed.
Penalties Civil sanctions may be as much as $11,000 per claim ($50,000 for an anti-kickback violation) plus an assessment of up to three times the amount improperly claimed. Each claim for payment could cause a separate penalty.
Qui Tam Suits Whistle blower suits pay 30% of the recovered amount. Who are known whistleblowers: Patients Patients family members Competitors Past and Present Employees Ex-Business Partners
Code of ConductEach compliance plan should begin with acode of conduct. All employees, physicians, and any member of practice oversight should be educated. As a record of education you should have a signed copy of acknowledgement on file.
Training Annual training should be conducted on all areas of compliance and a record of attendance should be kept and readily available.
Ongoing Training Keep up with changes and communicate with all staff New Employees need intense training and all employees need refreshers Make sure all training complies with state and federal regulations.
Ongoing Training Be sure that all employees know the compliance plan, as well as, who should be notified when an issue arrives. If you are the compliance professional: Be approachable and always have a no retaliation policy.
Follow-up on Reports Conduct investigation Document the areas of concern and how the issue was resolved Self report, when necessary
Policies to Keep in MindPatient Discounts Routine Waiver of Co-pays/Deductibles Attempt to collect policy Bad debt write-offs Discounts and processional courtesies
Policies continued…Coordination of Benefits Medicare/Medicaid Medicare as a Secondary Payer Liability or No-Fault Insurance
Policies…Business Relationship Stark Law Private Contracting Physician Coverage Arrangements
Policies…Documentation Guidelines 1995 and 1997 Proper Documentation for Consultations Global and Bundled Services Care Plan Oversight Screening Services
Audit Program Establish a realistic audit schedule Decide if all audits will be done in-house, if you will seek outside help, or will use a combination of both Decide if you need additional auditing or training based on what you discover Self report on your findings Implement corrective action to promote compliance
Audit Program Random sample vs targeted Sample all types of service provided Review the encounter form (charge ticket) and EOB in addition to the medical record. This will help you locate missed charges or inappropriate payments. Take the opportunity to begin proactive education approach to ICD-10