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.

Speaking Engagements 2011


March 1, 2011
California Association of Medical Providers & Suppliers

Angela Miller speaking for Zirmed Financial Workout Webinar Series

April 20, 2011

VGM’s Heartland Conference

June 8 – 9, 2011

Texas Osteopathic Medical Association

June 17, 2011  10am-noon

Medtrade Fall 2011

October 26 & 27

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KY Medical Equipment Suppliers Associate (KYMESA)

November 9, 2011 – Compliance Program Implementation

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PaychexsIrving Texas office contact Christina Rossini to register.

December 6, 2011 – Compliance Program Requirements

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Medtrade Spring 2012

April 10-12, 2012

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American Association of Osteopathic Executives

May 20-22, 2012

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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.

Happy Holidays!


Warm Holiday Wishes to You

Happy Holidays!  May you be blessed with the riches of life.  As we wind down the year, the holidays are a time to spend with friends and family sharing joy, laughter, and love.  The holidays are also a time of reflection and gratitude.  I want to thank each of you for making this a successful happy year, it has been a true gift in my life.  So many of you are friends, business advisers, business partners, clients, and maybe all of these, but you are truly appreciated.  Some of you make me reflect more often than I might like but I’ll keep you anyway..LOL.  I wish each of you a happy and safe holiday that is a road to a successful new year for you, your family and business.   I look forward to you being a part of my life in 2011 too.

Remember to pray for our soldiers and their families during the holidays, and if you see them during travels thank them.

How to Connect with Medical Auditing Solutions LLC?


You can find a complete scope of services under my blog.  In short, I work with most types of health care providers to setup compliance programs and training and anything that impacts cash flow.

You can follow us through our blog by scrolling to bottom of this blog, click follow then enter your email address.

You may follow Angela Miller and Medical Auditing Solutions if you a a profile on any of the following:

Website: http://www.medicalauditingsolutions.com
Blog: http://www.angelamillermas.wordpress.com or via website
Linkedin: http://www.linkedin.com/in/medicalauditingsolutions
Twitter: http://twitter.com/AngelaMillerMAS
Facebook: http://www.facebook.com/home.php#!/MedicalAuditingSolutions

Those who have recently attended a speaking engagement, I am connecting you through my blog. If you want to connect on the other sites feel free. I do not send out many email blast and utilize my blog the most.

HITECH Compliance & Implementation Tips Happy Hour


Starts: Wednesday October 27, 2010, 05:30PM CDT
Ends: Wednesday October 27, 2010, 07:00PM CDT
Event Type: Conference
Location: BlackFinn
4440 Beltline Rd
Addison, TX  US
Intended for: Physicians, Office Managers, Information Technology Managers, Privacy Officers, Health Care Attorneys, Owners, Upper Management, Senior Level Management
Industry: hospital, physician, dental, pharmacy, DME, home health care
RSVP: kpearson@marjencapital.com or angela@medicalauditingsolutions.com
Organization: Marjen Technology Group & Medical Auditing Solutions LLC

This event is exclusively for health care providers and health care attorneys due to the content of the program. Please RSVP as seating is limited to 35.

HIPAA HITECH Happy Hour Drink Coupons & Appetizers Provided

We will provide a short presentation on new HITECH HIPAA highlights 6:00pm-6:30pm allowing time for Q&A

Topics:  Meaningful Use, What is Encrypted, and Tips to encryption without breaking the bank

Speakers:   Karen Pearson & Raj Croager Marjen Technology Group

Angela Miller Medical Auditing Solutions LLC

There will be prizes worth showing up for such as a new WatchGuard firewall that protects PHI before it leaves and Consulting Certificates.

MARJEN Technology Group is a privately held technology services company located in Arlington, Texas, bringing over two decades of experience to Dallas/Fort Worth area businesses.  Our mission is to bring enterprise class technology and services, at affordable prices, to small and medium size businesses.

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.

Your Duck is Dead


I seem to share bad and/or scary crazy news so thought I would share a laugh today. This is a cute joke that is clean and will make you laugh and you can share with patients.

Your Duck is Dead

A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet pulled out his stethoscope and listened to the bird’s chest.

After a moment or two, the vet shook his head and sadly said, “I’m sorry, your duck, Cuddles, has passed away.”

The distressed woman wailed, “Are you sure?”

“Yes, I am sure. Your duck is dead,” replied the vet..

“How can you be so sure?” she protested. “I mean you haven’t done any testing on him or anything. He might just be in a coma or something.”

The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black Labrador Retriever. As the duck’s owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the duck from top to bottom. He then looked up at the vet with sad eyes and shook his head.

The vet patted the dog on the head and took it out of the room. A few minutes later he returned with a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back on its haunches, shook its head, meowed softly and strolled out of
the room.

The vet looked at the woman and said, “I’m sorry, but as I said, this is most definitely, 100% certifiably, a dead duck.”

The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman..

The duck’s owner, still in shock, took the bill. “$150!” she cried, “$150 just to tell me my duck is dead!”

The vet shrugged, “I’m sorry. If you had just taken my word for it, the bill would have been $20, but with the Lab Report and the Cat Scan, it’s now $150.”

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.

RAC and ZPIC Audits: How to have a Successful Payer Audit?


In the last twelve months, there has been more money than ever before put into fighting fraud and abuse.  Contractors are requesting more charts than ever before to review for fraud and abuse.  How do you have a successful payer audit?  The simple answer is provide the documents requested, but there is more to it.

First, Make a checklist for each chart.  Pull each chart and copy all records requested.  The request period may not include the delivery or start date and copies of initial qualifying test results and/or chart notes, include them if it is pertinent to the determination of ongoing medical necessity for example rentals of equipment.  If you did not obtain the test results or physician chart notes at the time of the start of care, request them now because the physician is not penalized if he does not respond.  Physician failure to respond to a request is an error and results in “overpayment/error” paid by the provider.  It is in your best interest to gather and submit each patient record in an organized manner.  This needs to be top priority because you have limited time frame to produce and failure to respond timely results in overpayment calculations!

Have you seen or heard the “error rates” being published?  The way it sounds, ever provider will have an audit with an error rate, it is just a matter of time.  A error rate published March 1, 2010, by Noridian was over 102 files with 86% error rate.  This is a small sample to create a crisis over.

I would recommend you have an independent third party, whether consultant or your health care attorney,  review the records before you send them off.  You can typically be granted one extension.  Do not wait until the last minute to start this process.  If you have a large number, have someone review a sample then expand based on the determined error rate.

If more than 20-30 charts are requested, I would notify outside counsel.  I am receiving new clients weekly with 200, 300, 400 or more charts being requested.  To produce duplicate copies of these records and obtain physician records in 14-21 days may be difficult and still run your business.

If you haven’t received an audit to this point, be prepared for when it happens.  Any overpayment determination in a payer audit requires payment arrangements prior to the appeal process being completed.  Be proactive, have an audit of your business to be prepared for when that day comes.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, 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 has extensive experience with Medicare and Payer audits.  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.