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Big Data: Implications of Data Mining for Employed Physician Compliance Management

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PYA Principal Denise Hall presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” at Becker’s Annual CEO & CIO Strategy Roundtables, November 18-19, 2015.
The presentation explored:

Data being aggregated by the government, as well as new approaches by regulators.
Public relations and litigation risk from the public dissemination of data by the government.
Big data connections to payment through quality metrics and the potential for new theories of False Claims Act (FCA) suits.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.

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Big Data: Implications of Data Mining for Employed Physician Compliance Management

  1. 1. Page 0November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Big Data: Implications of Data Mining for Employed Physician Compliance Management Becker’s 2015 Annual CEO Roundtable November 18-19, 2015
  2. 2. Page 1November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Big Data “Big-data initiatives have the potential to transform healthcare, as they have revolutionized other industries. In addition to reducing costs, they could save millions of lives and improve patient outcomes. Healthcare stakeholders that take the lead in investing in innovative data capabilities and promoting data transparency will not only gain a competitive advantage, but will lead the industry to a new era.” (McKinsey)
  3. 3. Page 2November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Agenda • Public relations and litigation risk from the public dissemination of data being harvested and aggregated by the government (e.g. Physician payment data, Sunshine Act regulations, discharge data) • Internal use of Broad Spectrum Analytics in Employed Physician Compliance Management • Determination of Risk Tolerance and Customizing Analytics that are “Outside the Box” • Benchmarking, Monitoring, and Defining Physician/Focused Risk Area Reviews
  4. 4. Page 3November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Big Data Trends • Trends in the use and public dissemination of healthcare financial, claims, and quality data – Publicly Available & Third-Party Data • Federal Charge Data • State-level Charge Data • Physician and other Supplier Public Use File • Broad Disclosure of Physician Payment Information under Sunshine Act • Public Use Files of Part C and D Reporting Requirements Data • Other Public or For Purchase Data Sources
  5. 5. Page 4November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Federal Charge Data • CMS has released hospital-specific data from 2011 comparing the charges for the 100 most common inpatient services and 30 common outpatient services • Inpatient DRG examples: – Heart Failure & Shock w cc – G.I. Obstruction w cc – Transient Ischemia 4
  6. 6. Page 5November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Federal Charge Data (cont.) • Outpatient examples: – Level III Endoscopy Upper Airway – Level I Nerve Injections – Level 1 Hospital Clinic Visits See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and- Reports/Medicare-Provider-Charge-Data/index.html 5
  7. 7. Page 6November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable • Numerous states also provide state-level charge data • The information and format varies • Examples: – Wisconsin, X Facility, Cesarean Delivery: $12,881 – Tennessee, All Facilities, Rotator Cuff Repair, Average charge without another procedure: $23,483 – Oregon, X Facility, Esophagitis, gastroent & misc. digest disorders w/o MCC, Average Charge: $8,546 State-Level Charge Data 6
  8. 8. Page 7November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician and Other Supplier Public Use File • Physician and Other Supplier Public Use File released for the first time in April 2014 • Contains 100% of final-action physician/supplier Part B non-institutional line items for the Medicare fee-for-service population for CY2012 paid through June 30, 2013 7
  9. 9. Page 8November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician and Other Supplier Public Use File (cont.) • Contains information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals, including: – Utilization – Submitted charges – Payment (allowed amount and Medicare payment) See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and- Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html 8
  10. 10. Page 9November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Broad Disclosure of Physician Payment Info under Sunshine Act • Manufacturers of drugs, devices, biologicals, and medical supplies, and some group purchasing organizations (GPOs), must report payments and other transfers of value to “covered recipients” which are defined as: – Teaching hospitals – Physicians (except physicians who are employees of the applicable manufacturer) • CMS must make information submitted in transparency reports and physician ownership reports publicly available on a searchable website 9
  11. 11. Page 10November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Public Use Files of Part C and D Reporting Requirements Data • Federal regulations require Medicare Advantage (MA) plans and Part D sponsors to report to CMS information on (among other things): – Enrollment and Disenrollment (Part C and Part D) – Grievances (Part C and Part D) – Special Needs Plans Care Management (Part C) – Organization Determinations/Reconsiderations (Part C) – Coverage Determinations and Exceptions (Part D) – Long-Term Care Utilization (Part D) – Medication Therapy Management Programs (Part D) – Redeterminations (Part D) 10
  12. 12. Page 11November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Big Data Trends • Other Government Data Sources – Medicare Fraud Strike Force Team – Data-Driven Quality Initiatives – Other Non-Public Government Data Sources • Government Uses of Data for Compliance and Enforcement – Adventist results
  13. 13. Page 12November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable What Providers and Payers Can Expect • Scenario 1: Increased Media Exposure • Scenario 2: Linking Manufacturer Payments Data to Anti-Kickback Allegations • Scenario 3: Quality of Care FCA Litigation
  14. 14. Page 13November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 1: Increased Media Exposure See http://time.com/#198/bitter-pill-why-medical-bills-are-killing-us/ 13
  15. 15. Page 14November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 2: Linking Manufacturer Payments Data to AK Allegations • Expect qui tam relators to attempt to bolster complaints by “linking” physician payments to “increased” drug or device utilization in order to allege an Anti-Kickback Statute (AKS) violation 14
  16. 16. Page 15November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable FRCP 9(b) & Big Data • Interplay of Rule 9(b) Motions to Dismiss and Big Data Scenario 2: Linking Manufacturer Payments Data to AK Allegations 15
  17. 17. Page 16November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 2: Linking Manufacturer Payments Data to AK Allegations Rule 9(b) Relator’s Counsel “In Their Own Words” “Sunshine data instantly provides qui tam attorneys a host of information that would have been impossible or very difficult to find before the Act. [One relator’s counsel] believes the information would, right off the bat, add credibility to a relator's allegations. Attorneys will be able to corroborate their client's allegations or confirm suspicions of widespread conduct by running a simpl[e] search.” 16
  18. 18. Page 17November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 2: Linking Manufacturer Payments Data to AK Allegations “At the very least, Sunshine data will provide facts to beef up a plaintiff's complaint. Rule 9(b) of the Federal Rules of Civil Procedure requires that for ‘alleging fraud or mistake, a party must state with particularity the circumstances constituting fraud or mistake.’ [One relator’s counsel] notes that the exact dates of transactions and the precise amounts of payments will add that required specificity.” See http://www.policymed.com/2014/02/physician-payment-sunshine-act-will-sunshine-data- help-qui-tam-whistleblowers-and-their-attorneys.html 17
  19. 19. Page 18November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 3: Quality of Care FCA Litigation Linked To Data • Expect qui tam relators and/or government to contend payment structures and reporting measures set forth in various new quality programs materially affect payment and are thereby conditions of payment—and that violations triggers False Claims Act (FCA) liability 18
  20. 20. Page 19November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 3: Quality of Care FCA Litigation Data-Driven Quality Initiatives • Programs resulting from the Patient Protection and Affordable Care Act (PPACA), the American Recovery and Reinvestment Act (ARRA) as well as those initiated by OIG and CMS reflect an increased focus on quality • Health Information Technology for Economic and Clinical Health (HITECH) Act established the Electronic Health Record (EHR) Meaningful Use Program to provide financial incentives to providers to promote the adoption and meaningful use of certified EHR technology to improve patient care (ARRA, Public Law 111-5, Division A, Title XIII and Division B, Title IV) 19
  21. 21. Page 20November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Scenario 3: Quality of Care FCA Litigation Data-Driven Quality Initiatives (cont.) • PPACA establishes numerous quality-related programs, potentially exposing providers to increased liability for quality shortfalls; these include, among others: – Medicare Physician Quality Reporting Improvements: financial incentives and penalties for reporting or failure to report Physician Quality Reporting Initiative (PQRI) measures (PPACA §§ 3002, 3007) – Value-Based Purchasing Program: pays hospitals based upon how well they perform on specific quality measures (Id. § 3007) 20
  22. 22. Page 21November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Potential Review Results PQRS/QUALITY REPORTING DETAILED RESULTS PQRS Results Family Practice Internal Medicine Other Specialties Met 757 247 103 Not Met 545 145 68 PQRS code and/or ICD-9 code not documented 144 56 50 Supporting ICD-9 or additional PQRS code should be reported 99 26 6 A different PQRS code was documented 107 29 7 No documentation received 0 2 4 Corresponding CPT code not supported 195 32 1 Modifier deficiency1 6 0 0 1 Of note, Not Met is counted per transaction or claim line versus the deficiencies listed which include transaction-level and component-level errors. Modifier deficiency is a component-level error; meaning that the error count in some instances may also be captured in one of the other categories.
  23. 23. Page 22November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Real World Examples of Physician Compliance Risk 1. Overuse of -25 modifier 2. Overuse/exclusive use of high level E/M codes 3. Extremely high levels of production 4. Psychiatry time-based codes and use of E/M codes with same 5. High utilization of specialty-related services (Oncology, Cardiac)
  24. 24. Page 23November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable How Can We Mitigate Risk? Think like a reporter, a qui tam relator, a MAC, MIC, ZPIC, RAC, DOJ, and the OIG, etc.
  25. 25. Page 24November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Key Questions • Are you incorporating data sets in your compliance and internal audit activities? • Is data analytics a key part of your monitoring and auditing plan? • Are you assessing data analytics capabilities (or lack thereof) as part of your annual risk assessment? • Are you evaluating where you are amongst your peers? • If you are an outlier, is there a legitimate reason why, or do you need to mitigate an issue through corrective action?
  26. 26. Page 25November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Resources to Identify Most Significant Areas of Potential Risk • OIG Work Plan • OIG Semi-Annual Report to Congress • OIG Special Fraud Alerts • OIG and DOJ Announcements • Corporate Integrity and Deferred Prosecution Agreements • RAC Audits • RADV Audits • Complaints, Investigations, and Audits • . . . Your Gut!
  27. 27. Page 26November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Using Data Effectively • Considerations when designing an effective data analytics function: – Availability of data – Accessibility to the data – Timeliness to gain access to the data – Quality of the data – Expertise of those using the data – Corporate support for the program – Privacy and Privilege considerations
  28. 28. Page 27November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician Compliance Monitoring Making the information come to you…
  29. 29. Page 28November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Making Physician Compliance Manageable AND Meaningful Targeted Physician Probes Effective use of physician analytics allows a physician compliance program to be extremely detailed while remaining efficient and cost-effective. Analytics Suite on All Employed Physicians Focused Physician Reviews
  30. 30. Page 29November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Typical Areas of Focus “REV $”“PHYS ALIGN”“CODING” •Area/Metric •Area/Metric •Area/Metric •Area/Metric •Area/Metric •Area/Metric •Area/Metric •Area/Metric •Area/Metric Develop unique areas of focus, metrics to measure, and thresholds to assess compliance and risk. This is an active, fluid initiative.
  31. 31. Page 30November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Other Customized Analytics: Getting “Outside of the Box” In addition to a number of analytics to evaluate certain “expected” areas of physician utilization (e.g., E/M bell curves), consider other topical ways to assess physicians based upon a customized list of targeted service areas to determine if “outlier” patterns exist. Some example focus areas include: CODING PHYS ALIGN REV $ • Critical Care Service Utilization • 25-Modified E/M Services • Preventive Medicine Services (e.g., ratio of G-code to 9-code use) • Extended Discharge Day Management Services • Incident-to/Split Shared Services • Time Studies/Work RVU Analysis • EP Study Utilization • Long-term Drug Use ICD-9 Code Utilization
  32. 32. Page 31November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician Analytics Suite Examples
  33. 33. Page 32November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable E/M Distribution (“Bell Curve”) Analysis CODING PHYS ALIGN REV $
  34. 34. Page 33November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Benchmark Specialty Procedural Service Mix Analysis CODING PHYS ALIGN REV $ Physician Rank Percent CPT/HCPCS Codes Appended CPT/HCPCS Brief Description Neurosurgery Benchmark Rank Neurosurgery Benchmark Rank Percent of Total Benchmark Units CPT/HCPCS Brief Description Physician Rank 1 23% 99232 Subsequent hospital care 8 1 14% 99213 Office/outpatient visit est 63 2 15% 99222 Initial hospital care 16 2 7% 99214 Office/outpatient visit est 55 3 14% 99231 Subsequent hospital care 7 3 6% 99212 Office/outpatient visit est - 4 7% 99223 Initial hospital care 13 4 5% 99204 Office/outpatient visit new - 5 5% 63047 Removal of spinal lamina 28 5 5% 99203 Office/outpatient visit new - 6 3% 99233 Subsequent hospital care 21 6 4% J2323 Natalizumab injection - 7 2% 63048 Remove spinal lamina add-on 12 7 3% 99231 Subsequent hospital care 3 8 2% 22851 Apply spine prosth device 14 8 3% 99232 Subsequent hospital care 1 9 2% 22551 Neck spine fuse&remov bel c2 37 9 3% J0585 Injection,onabotulinumtoxinA - 10 2% 99221 Initial hospital care 24 10 2% G8447 Pt vis doc use EHR cer ATCB - 11 2% 61781 Scan proc cranial intra - 11 2% 99205 Office/outpatient visit new - 12 1% 22614 Spine fusion extra segment 17 12 2% 63048 Remove spinal lamina add-on 7 13 1% 22552 Addl neck spine fusion 46 13 2% 99223 Initial hospital care 4 14 1% 61312 Open skull for drainage - 14 2% 22851 Apply spine prosth device 8 15 1% 22845 Insert spine fixation device 33 15 2% 99215 Office/outpatient visit est - Specialty Benchmark Comparison PHYSICIAN Specialty Benchmark Comparison NEUROSURGERY
  35. 35. Page 34November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Targeted Physician Probes Special Data Analytics for High Risk Concerns
  36. 36. Page 35November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable New vs. Established Patient E/M Services CODING REV $ Physician Ratio Est Patient E/M to New Patient E/M PHYSICIAN Ratio Est Patient E/M to New Patient E/M BENCHMARK Percent Variance Dashboard >=50% >=35% >=20% Physician A 1.3 3.6 177% Physician E 0.9 2.4 176% Physician I 1.7 3.6 112% Physician C 1.2 2.4 100% Physician B 3.2 4.0 25%
  37. 37. Page 36November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Focused Benchmark Analysis: Modifier Use Physician Modifier Use > 30% Above Benchmark Modifier Use > 25% Above Benchmark Modifier Use > 20% Above Benchmark Physician A 25, 80 59 Physician B 51 22 Physician C 51 51 Physician D 80 59 51 Physician E 25 22 Physician F 22 25 Physician G 25 Physician H 59 25 80 Physician I 80 59 25 Significant separately identifiable E/M service 59 Distinct procedural service 80 Surgical assistant 22 Increased procedural service CODING PHYS ALIGN REV $
  38. 38. Page 37November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician Productivity Analysis: Addressing Work Relative Value CODING PHYS ALIGN REV $ Physician Specialty Work RVUs Weighted Average Work RVU per Unit 90th Percentile Work RVUs per MGMA Work RVUs as a % of 90th Percentile Dashboard >200% >150% >100% Physician A Geriatrics 20,658 1.43 6,194 334% Physician B Hospitalist 21,666 1.03 6,901 314% Physician C Endocrinology 16,232 0.94 6,801 239% Physician D Geriatrics 14,163 1.58 6,194 229% Physician E General Surgery 18,179 2.63 10,730 169% Physician F Gynecology/Oncology 16,233 1.24 10,775 151% Physician G OB/GYN 16,022 1.88 10,432 154% Physician H Gastroenterology 15,609 1.75 12,604 124% Physician I Hospitalist 9,244 1.80 6,901 134% Physician J Family Medicine 7,790 0.35 7,082 110% Physician K Plastic/Reconstructive Surgery 6,551 1.87 11,411 57% Physician L Psychiatry 3,819 1.34 6,189 62%
  39. 39. Page 38November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Physician Productivity Analysis: Work RVUs CODING PHYS ALIGN REV $
  40. 40. Page 39November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Place Of Service Impact Analysis The Office of Inspector General reports the following in its HHS OIG Work Plan for Fiscal Year 2014: “Federal regulations provide for different levels of payments to physicians depending on where services are performed (42 CFR §414.32). Medicare pays a physician a higher amount when a service is performed in a non- facility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department…” CODING REV $ Physician SORTED BY CLIENT Billed in Non-Facility ($$) Setting Benchmark Billed in Facility ($) Setting CLIENT | Benchmark Place of Service Match Dashboard Reimbursement Higher Based upon CLIENT Compared to Benchmark Place of Service Physician D 70% 30% Physician A 61% 39% Physician G 1% 76% Physician C 0% 100% Physician O 0% 77% Physician K 0% 51%
  41. 41. Page 40November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Non-Physician Practitioner (“NPP”) Collaboration “Probe” Analysis Define physicians who may collaborate with NPPs to perform incident-to, split/shared E/M visit and post-operative follow-up services. CODING PHYS ALIGN REV $ Physician SORTED BY Percent Billing Provider = MD and Rendering Provider = MLP Dashboard >=50% >=35% >=20% Physician B 55% Physician A 47% Physician C 35% Physician D 33% Physician G 20% Physician K 15% Physician O 0%
  42. 42. Page 41November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Benchmark Physician Time Study Analysis Physicians with “higher than expected” FTE-equivalent levels often collaborate with NPPs, nursing, and other ancillary staff to engage in the workflow/practice patterns necessary to support high utilization levels. CODING PHYS ALIGN REV $ Physician Total Professional Service Time (in Hours) FTE-Equivalent (Based upon 2,000 Annual Hours) Dashboard >=3.0 >=2.5 >=2.0 <2 Physician B 9,702 4.85 Physician A 9,616 4.81 Physician C 6,803 3.40 Physician D 4,995 2.50 Physician G 4,306 2.15 Physician K 4,211 2.11 Physician N 2,683 1.34 Physician O 2,386 1.19 Best calculated using the current Medicare Physician Time Study and 2,000 total annual hours per full-time equivalent.
  43. 43. Page 42November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable PHYS ALIGN Gross and Net Revenue “Pulse Check” Analysis Use data to gain a high-level understanding of any potential areas of revenue “vulnerability.” REV $
  44. 44. Page 43November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Outcome: “At a Glance” Reporting CODING PHYS ALIGN REV $ Specialty Physician Total Work RVU Benchmark Comparison Total Work RVUs by Service Type Weighted Average Work RVU per Unit by Service Type Productivity Stability Probe E/M Services Total Days Worked by Day of the Week Average Daily Billed Service Hours by Day of the Week Benchmark Physician Time Study Analytics Physician A Physician B Physician C Physician D Physician E Physician F Physician G Physician H Physician I Physician J Physician K Physician L Physician M Physician N Physician O Physician P Physician Q Physician R Electrophysiology Interventional Cardiology
  45. 45. Page 44November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Next Steps: Focused Physician Reviews No more annual 10 chart provider review compliance plan commitments!!! Grading or Compliance Rate Considerations Feedback During Review Process Trending Corrective Action Plans
  46. 46. Page 45November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Coding and Documentation Review Guidelines • CPT • ICD-9-CM • ICD-10-CM • HCPCS • 1995/1997 Documentation Guidelines for E/M Services • Medicare/Medicaid/Other Gov’t • State and Federal Documentation • Explanation of Benefits • CMS 1500 • Medical Record VS.
  47. 47. Page 46November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Coding and Documentation Review • Chief Complaint • History of Present Illness • History Level • Review of Systems • Examination • Past, Family, and/or Social History • Medical Decision Making Level • Modifier Usage • CPT Selection • Modifier Usage • ICD-9 Selection • Signature Compliance • Time-Based Code Support • NPP/Midlevel Provider Compliance • NCCI/Bundling Compliance • Other Agreed-Upon Regulatory or Facility-Specific Areas of Interest • ICD-10 Documentation Readiness E/M Compliance Elements General Compliance Elements
  48. 48. Page 47November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% All Internal Medicine Physician A Physician B Physician C Physician D Physician E Physician F Physician G Physician H Physician I Physician J Physician K Physician L Physician M Physician N Physician O Physician P Physician Q Physician R Physician S Physician T Physician U Compliance Missing Provider Signature Not Documented Missed Opportunity to Bill Bundled Insufficient Documentation to Bill Overcoded Undercoded Inaccurate CPT/HCPCS Assigned Potential Review Results INTERNAL MEDICINE SNAPSHOT – PHYSICIAN CODING DEFICIENCY FINDINGS (In Compliance Rate Order)
  49. 49. Page 48November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Potential Review Results Family Practice Internal Medicine Other Specialties Provider Compliance Dashboard <60% 61-89% 90-100% Provider Compliance Dashboard <60% 61-89% 90-100% Provider Compliance Dashboard <60% 61-89% 90-100% Physician A 90% Physician A 83% Physician A 85% Physician B 89% Physician B 80% Physician B 75% Physician C 88% Physician C 79% Physician C 71% Physician D 86% Physician D 75% Physician D 68% Physician E 76% Physician E 75% Physician E 66% Physician F 75% Physician F 75% Physician F 65% Physician G 75% Physician G 75% Physician G 63% Physician H 74% Physician H 72% Physician H 60% Physician I 74% Physician I 68% Physician I 60% Physician J 73% Physician J 67% Physician J 58% Physician K 71% Physician K 65% Physician K 53% Physician L 71% Physician L 62% Physician L 52% Physician M 69% Physician M 61% Physician M 50% Physician N 69% Physician N 53% Physician N 50% Physician O 68% Physician O 45% Physician O 40% Physician P 65% Physician P 43% Physician P 36% Physician Q 65% Physician Q 40% Physician Q 30% Physician R 65% Physician R 40% Physician R 27% Physician S 64% Physician S 37% Physician S 24% Physician T 63% Physician T 36% Physician T 18% Physician U 62% Physician U 20% Physician U 7% Physician V 61% Physician V 5% Physician W 59% Physician X 59% Physician Y 58% Physician Z 58% Physician AA 58% Physician AB 57% Physician AC 57% Physician AD 57% Physician AE 55% Physician AF 54% Physician AG 54% Physician AH 53% Physician AI 52% Physician AJ 52% Physician AK 48% Physician AL 47% Physician AM 45% Physician AN 43% Physician AO 40% Physician AP 38% Physician AQ 37% Physician AR 35% Physician AS 34% Physician AT 33% Physician AU 31% Physician AV 24% COMPLIANCE RATES PER PROVIDER
  50. 50. Page 49November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Potential Review Results TOTAL AND SPECIALTY GROUPING ERROR COUNTS
  51. 51. Page 50November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Potential Review Results E/M CODING DETAILED RESULTS Met 267 55% Met 127 61% Met 70 39% Not Met 217 45% Not Met 81 39% Not Met 111 61% Undercoded 95 20% Inaccurate CPT/HCPCS Assigned 2 1% Inaccurate CPT/HCPCS Assigned 9 5% Insufficient Documentation to Bill 74 15% Insufficient Documentation to Bill 13 6% Insufficient Documentation to Bill 9 5% Overcoded 35 7% Missing Provider Signature 1 0.5% Missing Provider Signature 6 3% Not Documented 6 1% Not Documented 17 8% Not Documented 28 15% Bundled 4 1% Overcoded 39 19% Overcoded 52 29% Inaccurate CPT/HCPCS Assigned 2 0.4% Undercoded 9 4% Undercoded 7 4% Missing Provider Signature 1 0.2% Family Practice E/M Coding Detailed Results Internal Medicine E/M Coding Detailed Results Other Specialties E/M Coding Detailed Results
  52. 52. Page 51November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Potential Review Results PROCEDURAL CODING DETAILED RESULTS
  53. 53. Page 52November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Identifying Overpayments
  54. 54. Page 53November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Medicare Parts A & B: Identifying Overpayments Medicare Parts A & B • 60‐Day Overpayment Proposed Rule – 10-year look‐back period – Duty to take affirmative investigative action related to potential overpayments 53
  55. 55. Page 54November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Medicare Parts C & D: Identifying Overpayments Medicare Parts C & D • 60-Day Overpayment Final Rule – Six-year look-back period – “[I]f an MA organization or Part D sponsor has received information that an overpayment may exist, the organization must exercise reasonable diligence to determine the accuracy of this information, that is, to determine if there is an identified overpayment ... ‘‘day one’’ of the 60-day period is the day after the date on which organization has determined that it has identified the existence of an overpayment.” 54
  56. 56. Page 55November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Questions
  57. 57. Page 56November 18-19, 2015 Prepared for Becker’s 2015 Annual CEO Strategy Roundtable Thank You! Denise Hall, RN, BSN Principal, Healthcare Consulting Pershing Yoakley & Associates, P.C. (404) 266-9876 dhall@pyapc.com

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