Texas Dental Providers – Take Aways from HHSC Committee Meeting 3/20/12


I listened to the live Texas Senate Committee meeting regarding the Health and Human Services Commission (HHSC) Charge 4 (dental & orthodontics) yesterday 3/20/12.  Unfortunately, this Senate Committee is concerned about the amount of money paid for orthodontic services and convinced Orthodontic services were provided at an abusive level and they want this money back.  I am providing what I took away from this meeting and we will discuss how to protect yourself.

  1. Senator Jane Nelson is willing to push thru legislation to allow parents in the treatment room.  I didn’t understand this…I suspect she has received a complaint from a parent where the Dental Provider refused to allow the parent in the treatment room.  My opinion is, this is one thing if the room has a door or if the patient is sedated because you do not want to add liability to your business.  Having a second company staff member in the room present will reduce risk as well.  As for HIPAA, what are your privacy and security policies for this situation?  If you do not have policies, they have been required since 2003 and 2009 respectively so very important to get this done.
  2. They want to go after dentist for the unlimited orthodontic visits.  Policy said “unlimited”!  Keep in mind if the Dental Provider was racking up unnecessary visits, it doesn’t matter if it is unlimited visits in policy, the visits were unnecessary therefore a potential fraud and abuse overpayment.  If these were legitimate visits and necessary, you should not pay that money back.  So policy for this is being reduced to 12 visits, they say.
  3. They pay for transportation to the dentist if the patient cannot afford it.  At present the patients are paid upfront or MCD pays the transportation company.  In the future, they will have to provide proof of visit and proof they used the transportation to be reimbursed.
  4. They are looking at bundling orthodontic rates versus per visit rate.
  5. More talk of suspending provider numbers based on allegations of credible fraud.  This is huge and critically important to include exit interviews with staff that is leaving the company.  You also need to have a compliance program with reporting mechanism in place.  If you collect $5M or more in Medicaid funds you were required to have a healthcare compliance program in 2007.  All other Medicaid providers are required to have a compliance program by 2013.
  6. Inspector General has 31 current investigations of Orthodontic practices at this time.
  7. Senator Jane Nelson and the committee want the business to have to be licensed and registered with the dental board similar to a pharmacy with the pharmacy board.  I suspect changes will follow for a proposal of such.  This will bring additional revenue into the Dental Board but it will permit investigations into complaints of ABC Dental versus the need for a dental providers name which is the current requirement.
  8. Expect audits to pick up on Orthodontic services.  They noticed as of 10/1/11 when the requirement to send molds went into place, request dropped and PARs were denied.  If you provided orthodontics to children under 13 or now 12, those are especially at risk for audit.
  9. They put a lot of emphasis on HLD Scores.  Where do you record these and how you measure to get the score?
  10. The TMHP Medicaid contractor responsible for reviewing this information basically rubber stamped requests.  They did not review for “medical necessity;”  it was primarily to make sure the form was completed and the HLD Score was >=26.  The Dental Director was terminated and they have hired a replacement.  They HHS/IG will be auditing the approved PARs (Prior Auth Requests) and recouping money.  The debate is if they will recoup from TMHP or from the provider.  Again, if the services were fraudulent and dishonest it, I fully expect they will go after the provider.  There is always a possibility if TMHP didn’t review and it did not meet the coverage criteria, they will try to recoup from the provider as well.  They expect these audits to be complete in 6-12 months and they have already started.
  11. By using Dental Managed Care Payers, these organizations have experience in other states and they have ideas on how to reduce Fraud & Abuse (F&A).  They think by using someone with experience to review and process these claims will reduce F&A.
  12. On the federal level, in 2010 Office of Audit Services contacted Texas inquiring about Orthodontic billing and providers.  So the federal government has taken notice of Texas and since they provide funding to the medicaid program, Texas has to respond to the concerns.
  13. No recruiting clients in parking lots….…this seems to be an issue.
  14. The HHSC office admitted the policies were such that it didn’t catch issues and the department processing was not staffed properly.
  15. I would expect a tremendous increase in audits and policy changes.
  16. Texas spent as much as 49 other states total from 9/1/08-5/28/11 on Orthodontic services.  An additional 500,000 kids were seen for checkups after the rates increased in 2008 by 50-100% than in previous years.
  17. The committee suggested HHSC do a Cost Benefit Analysis on providing orthodontic care to children and if that prevented excessive spending later if it were not done.

Now, what should you do?  I strongly recommend the following and sometimes it is good to get an outside consultant to review because of objectivity and the familiarity with issues being identified.

  1. Make sure you have HIPAA policies in place that are applicable to your business.
  2. Assess whether you need a healthcare compliance program now (because you were required in 2007) or if not make a plan to get this done.
  3. Items 1 and 2, a vital if you are investigated now even if not required.  Corporate culture is first questions the government asks.
  4. A sample audit of claims.  This is critical because you need to assess your risk as a company.  Assess the documentation versus coverage criteria.
  5. If audited, NEVER just cut a check for the overpayment requested!  Why, you ask?  The payer sees this as admission of guilt and if they haven’t extrapolated already they are more likely to do so.  This is not a good surprise to get in the mail6-12-14 months later!!  I have seen this happen.  Get a consultant and attorney and prepare a defense.  It will be less expensive to do when you get the audit than after the appeal process has started.

We work with several dental practices and the goal is to educate providers so they reduce risk and pass audits.  We also work with Looper, Reed, and McGraw LP, a law firm with attorneys that specializes in dental practices.  We work as a team with our practice and emphasize “proactive”operations.  We will be happy to schedule

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

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Medtrade-Atlanta Want to Shake Your Hand


Medtrade will be here in just a few short weeks.  I would like to meet the health care providers attending.  I am taking appointments now.  This is a tough time for health care providers and I would like to take the opportunity to shake your hand and pat you on the back for all your hard work to make a difference in this industry.

I speak on Thursday, November 18, 8:30am on Got Your KX? Get Cash.  This is a may audit issue.  We will discuss how to safe guard your business.  You can still register to attend now at Medtrade.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

Date of Death Audits for DME & Inpatient Facilities


Beware, this is just one region that has published the date of death audit for DME and inpatient facilities such as rehab, hospital, LTC, SNF facilities.  This audit is done periodically and most suppliers are hit with a few thousand to upwards of $20K in overpayment refund requests.  Be prepared with a reserve of cash based on the size of your business.  At a minimum, I would suggest a set back of $5K even if you are outside of Region A.  Region A tends to publish this type of information earlier than other areas. These audits typically take place about every three years which is why the dollar amounts are so high.

We all know that payment after date of death will never be paid; however accidents will happen.  Ensure your billing staff doesn’t just “resubmit” claims without working the denial, this can cause a fraud audit even if you are not getting paid!  Likewise, if payment does occur it is usually less than 90 days from date of death when family fail to contact suppliers because they think the equipment belongs to the patient.  It could be a pick up ticket was not entered or a facility span date was not stopped at date of death instead of the full episode.  Note these are being audited by the RAC!

Republished:
NHIC, Corp.
DME MAC A ListServe
For Immediate Release
August 12, 2010

CMS Approved Audit Issues Posted for Region A Recovery Audit Contractor

DCS, the Medicare Recovery Audit Contractor (RAC) for Region A, recently posted new CMS approved audit issues for RAC review.

The new CMS approved audit issues are listed below and apply to the states of Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

* Date of Death – DME
* Date of Death – Inpatient

See the CMS approved audit issues at DCS’ RAC website: http://www.DCSRAC.com for more information.

Region A includes the states of Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

PECOS: Uncover the mystery! Extended 1/3/2011


**NEWS FLASH** Found at least one gov’t contract with an extension notice of Jan 3, 2011 posted!

What is PECOS? Basically, this is an online 855 application process which is also linked to NPPES (NPI database).  The official name  is Medicare Provider Enrollment Chain and Ownership System.

Where did the info in PECOS come from? They uploaded (in some fashion) from the fiscal intermediary that processes your 855 paper enroll applications.

Why do I need to bother if they have the information from 855? The information in many circumstances is inaccurate and it can stop your cash flow reimbursement.  My guess is, as with any software or data conversion, exceptions to eliminate terminated data were not built in sufficiently.  So, with that said, it is very possible information is incorrect which can result in revoked provider number. For example I recently worked on a provider’s PECOS records that showed locations that have been closed for several months. If the Medicare contractors visit locations or call a phone number that is no longer valid including an invalid area code, they can suspend or revoke the provider number.

You must register in PECOS.  This means you must obtain a username and password in PECOS to review and validate all your information.  Before you begin view and print (save to complete) the 855 they show. You may need copies of your previously submitted 855’s. If you did not keep a copy, do so for all applications in the future.  You can save the information and go back to finish if need be.   Do not click “begin submission” until you are 100% certain you are finished.  Any changes will require a “submission” then you must print out the certification documents for signature to submit hard copy to the address that prints on confirmations.

Do not let incorrect information or failure to register in PECOS stop your PESOS (Cash Flow).  Register deadline for PECOS by UPDATED**7/6/2010 or 1/1/2011 (depending on what article you read) will stop your Medicare payments also.   ADDED**This is the latest note I found on CMS’ website “July 6: Please read the news release found at the following location http://www.cms.gov/apps/media/press/release.asp?Counter=3774 , the January 2011 deadline was superseded by a statutorily established deadline in the Affordable care act. As soon as a firm enforcement date of the regulations has been determined we will announce it.”

This is not going away.  It will take 1-1.5 hours to gather corporate and provider documents.  It will take about 2 hours per provider record to review documents, data, make corrections, make necessary copies of documents, sign and mail.

I have provided a list of numerous documents that you should have available for this as well as site visits.  I recommend maintaining all the important records in a three ring binder to be handy for site inspectors.

If you need help getting this done, we can help with this project.  We will register you, save all log in data for you, save the existing PECOS record, make necessary updates based on the documents provided, save revised document, print all certification forms to PDF.  All documents will be password protected and returned to you by email for $289.00 per provider number.  We can overnight the certification pages and a CD with all documents back to you for an extra $30.00 for all provider records being returned.  Please contact us so that we may sign a confidentiality contract.

PECOS  CHECKLIST

  • Sale purchase agreement, if applicable
    • Asset acquisitions require a new provider number
    • Also note, Home Health Agencies with a provider number less than 36 months old will require a new provider number also
    • Were the state and local agencies informed of the acquisition?
  • State Licensure such as pharmacy license, DME/HME License, typically health care business line specific, if applicable
  • Local- state licenses such as occupancy or business licenses
  • Copy accredit certificate (DME, HHA,
  • IRS 147C letter
  • NPI letter/email
  • Any Adverse Action
  • Director of Nursing/Administrator license
  • Medical MalPractice Insurance Certificate
  • Liability Insurance Certificate must have correct location address on it for minimum $300K
  • HHA: Documentation to demonstrate capitalization requirements
  • Board of Directors, Owners with 5% or more, Manager (w-2), clinical provider Information:
    • Full Name
    • Social Security Number
    • Date of Birth
    • In some states, like FL &CA, finger print cards are required for the mentioned
  • If owned by another company or venture capital company:
    • Need the company(ies) TID#
    • Corporate Business Address
  • If complex ownership, please provide an organizational chart of ownership even if handwritten.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

“15 Minute Thought” Schedule – Free Informational Programs


“15 MINUTE THOUGHT”

MAS is pioneering an informational program that you can listen to over a cup of coffee while you organize your day or on your drive to work. The name of the program is “15 Minute Thought”.  These calls will be free and informative.  Our focus is to give you a new thought once per month to help improve your business during these tough regulatory times.

Program your Phone and Calendar:

The 2nd* and 3rd Wednesday Every Month                 at 8:30am-8:45am CST

* Indicates specific audience

MAS Conference Call Dial-in#:         218-862-1300

Conference Code:                               622911

MAS Office number:                          972-459-1508

MAS Fax:                                               214-461-0295

Who should call in?

Any health care provider, Health care business owner or manager, Attorneys, Compliance Officer, and Office Managers

Schedule & Topics

July 14, 2010               Bankruptcy Attorneys & other Attorneys:  What you need to know about Medical Receivables*

July 21, 2010               Patient Visits: Changes, Increase Revenue, & Ordered Services

August 11, 2010         Physicians: NP & PA Visits: Can the non-physician provider be billed under the physician?*

August 18, 2010         Payer Audits Giving “RAC’d” a Whole New Meaning: Tips to Manage Audits

September 8, 2010      Conflict of Interest: Pay Attention or Write a Big Check

September 15, 2010    Compliance Officer:  Who? What? …Really?

October 13, 2010        Dental Providers:  Reform & Common Audit Errors*

October 20, 2010        Reserve Chute: Not just for jumping out of planes

There will be guest speakers.  We will release the brief description of the call within the next 24 hours.  There are plans to have Edward Vishnevetsky of Thompson Coe, Darrell Armer of Looper Reed & McGraw, David Reimer of Dental Medical Economics as well as others guest such as Advocate, MD present over the next few months as we roll this program out.  You will hear thoughts from some of the best in the health care industry.  The guest schedules are not finalized and they may participate in programs setup on this schedule.  We may increase the number of calls depending on the attendance.

Follow MAS Blog for Schedule & Updates.  You can “follow” MAS on all social media and new blog links are published.  We only publish useful information and breaking news.

Blog:  http://www.angelamillermas.wordpress.com or via website
Linkedin:  http://www.linkedin.com/in/medicalauditingsolutions
Facebook:  http://www.facebook.com/home.php#!/AngelaMiller.MAS

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

Health Care Reform: Compliance Programs, Reduce Filing Limits, Limited Ownership


The Health Care and Education Reconciliation Act of 2010 signed March 23, 2010, has made significant changes to health care providers and claims filing requirements.  Remember, CMS will have to publish written notification and post implementation deadlines; however, it will make your life easier to start educating staff and changing practice now.

*  Mandatory Effective Compliance Program for ALL health care providers that bill Medicare, Medicaid, and other federally funded program from hospital to mental health and everyone in between.

A compliance program has been required for providers collecting $5 million or more per year in Medicaid funds collectively since 2006.

http://www.cms.gov/smdl/downloads/SMD121306.pdf

New York Office of Inspector General implemented state requirement for effective compliance program 10/1/2009. http://www.omig.state.ny.us/data/content/view/79/1/

An effective compliance program contains 7 elements which includes Compliance Officer, Compliance Committee, Code of Conduct (approx 70 pages), Policies & Procedures (50+ depending on practice), Minimum of 5 hours of training per year on specific relationship and billing topics, Auditing and Monitoring Function, Reporting Options without fear of retaliation, and a few others that are embedded in these items.  It takes at least 12 months to roll out a compliance program and about 18 months to see effectiveness.  As a note, accreditation policies typically do not include most of the elements likewise the audits typically are not coverage criteria based or risk based.

*  Physicians must have a Face to Face with patients prior to ordering DME (durable medical equipment) and HHA (Home Health) Services effective 2/23/10.  This should be taking place now; however, if not, do not wait until CMS publishes an effective date.  This is good business practice and should be implemented immediately.

*  Physicians must be a Medicare provider as of July 1 2010, if they order DME and HHA that will be billed for Medicare reimbursement.

*  Physicians must provider medical record documentation to support referral orders or be subject to a revoked Medicare supplier number for a period not greater than one year **ADDED**

*  Claim submission filing limit has been reduce from 18 months to 12 months.  Until CMS publishes an effective date, you will have 18 months.  Be on the look out.  Announced 5/14/2010

*  Expanded Stark Law regulations will limit physician ownership in hospitals as of 12/31/2010.

*  Must provide patient choice when you have diagnostic equipment in your office such as MRI, PET, CAT.

*  Stark & Anti-kickback violations will also receive penalties until Federal False Claims Act.

*  Overpayments must be refunded to Medicare/Medicaid within 60 days whether you identify the overpayments or the refund is requested.  Failure to do so is likely to result in a revoked provider number and sanction from participating with the Medicare and Medicaid programs.  This was actually part of the Patient Affordable Care Act.  CMS announced 10/15/2010 see also Cynthia Stamer’s Blog.  This announcement also has language on Self Disclosure of Self Referral practices that have taken place.

*  Have heard from several people, that Oxygen will be reduced from 36 months to 13 months.  However, I have searched the full text and amendment and cannot find it. **ADDED**

*  It will require insurance payers to reimburse preventative services at 100% with no co-pay.  Please note, this has not been published with an implementation date so continue to file claims as normal.  Patients cannot expect to receive free preventative services until their payer publishes this change!

*  It appears to me that only companies with 50 or more employees will be required to provide health insurance for all W-2 employees.  I will be interested in seeing how this turns out.   It also appears that in 2018, you will have to use the government health care program or loose tax credits of 25-35% of the premiums.  I wish I had one of this money trees in my back yard!

This covers many of the highlights that impact provider billing, but there are so many more points.  Read over the information so your are prepared.  If you find you need your compliance program reviewed and developed remember to find a consultant that focuses on ALL aspects of compliance not just a compliance program.  They need to understand billing and operations and we are one of the companies that offers an all encompassing solution to health care providers.

You can reference the full text http://www.cbsnews.com/htdocs/pdf/Senate_health_care_bill.pdf and amendments http://www.cbsnews.com/htdocs/pdf/House_reconciliation_package_031810.pdf as well as a blog from Looper, Reed, & McGraw http://www.lrmlaw.com/pdf/ALERT-Healthcare-Reform-Alert.pdf.  Search the document for key words used in bullet points.  I have also included a Timeline link that has many items bullet pointed except the ones that apply to providers and reimbursement for Medicare services http://docs.house.gov/energycommerce/TIMELINE.pdf

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

TAHCS Lone Star Conference


REGISTER NOW!   http://www.box.net/shared/5mqkgyr94e Early Bird Pricing Extended 1 week, so hurry!

ALL DAY ONLY $99 INCLUDES LUNCH & free  Happy Hour

I will be participating at the ALL DAY Conference.  We tried to make this a half day conference but there is so much information and so many changes that we just could not fit it into 4 hours.  This conference will include session presented by Thompson Coe, myself and representatives from CIGNA and VGM.  This conference will discuss the many woes that you are facing as health care providers from Competitive Bidding, ZPIC & RAC Audits, Compliance Issues, Effects of the new Healthcare Bill, Reimbursement and Legal Aspects to protect your business.  There will be many vendors that focus on helping health care providers run their businesses more efficiently and save money.

The 2010 LoneStar HME Conference will be held at the Dallas Crown Plaza Market Center Hotel. This one-day event will bring together top professionals in various fields, including numerous lawyers from Thompson Coe, who will present on topics including, but not limited to, the following:
  • Competitive Bidding; the HITECH Act Edward L. Vishnevetsky (Thompson Coe)
  • Medicare’s Latest Changes – Mark Loney (Cigna Health Service)
  • ZPIC/RAC Audits – John G. Browning (Thompson Coe)
  • Governmental Affairs Update – Mark Higley (VGM)
  • DME Manufacturer/Supplier Lawsuits – Jeff Otto (Thompson Coe)
  • Texas Legislative Update in Health Care – Jay Thompson (Thompson Coe)
  • Effective Lobbying of HR 3790 – Barry Johnson (TAHCS)
  • Choice of Business Entity for DME Suppliers – Bruce Bringardner (Thompson Coe)
  • Proactive Chart Documentation – Angela Miller (Medical Auditing Solutions)

You will leave with a great deal of knowledge and only for $99 which includes lunch.  The Free Happy Hour is sponsored by Thompson Coe.  You will have a chance to network and have your questions answered by the best experts in the industry.  Get a double dose of information while enjoying yourself !  Now where can you spend an hour with 3-4 attorneys networking and asking questions for free?

Don’t miss this extraordinary meeting.  Take advantage of our industry experts in a relaxed atmosphere.  Learn how to survive tough times and do not miss the insider information

Early Bird Pricing Extended 1 Week 4/7/10, so hurry!  If you include the following code you can extend the early bird price of $99. 9-52  code- 042610

HME Lone Star Conference

2010 HME Lone Star Conference.
Crowne Plaza – Dallas Market Center
7050 N. Stemmons Freeway
Dallas, TX 75247

April 26, 2010
8:30 to 4:00 pm
Free parking
Lunch included with registration

REGISTER NOW AT:   http://www.box.net/shared/5mqkgyr94e
Make plans to attend this informative
HME meeting featuring nationally
recognized speakers. Presented By: TAHCS & Thompson Coe