Healthcare Operations Training – Plano, TX – November 12-13, 2013

Mark your calendar, this healthcare training will revolutionize your operations management processes and improve your collections and accountability. We have limited seating available for this intense training on managing the healthcare office environment more efficiently during the trying times of reimbursement cuts, commercial contracts being closed to new providers, audits and investigations from every corner. We know these two days will be intense, but you will leave with viable information and forms to put in place on Thursday upon your return. All speakers have many years experience in the DME and Physician market from operations to audits and investigations.  Lunch is included both days.

Topics to be covered:  Start-ups, ICD-10 preparedness, Accountable Care Organizations (ACO), audits and how to prepare, retail selling, contracting, monitoring billing/revenue reports weekly, monthly, yearly, getting the most out of your EMR or billing software system, employee accountability, and more.

November 12 – Is designed to be applicable to any healthcare provider, physicians, dentist, DME, or Home Health. All providers can benefit from the training to have a more efficient office.

November 13 – Is designed specifically to address billing and collection problems in the DME industry.  We have a program on commercial insurance contracting, system reports, new start up DME process and more.  The building does have wi-fi, bring your computers for interactive sessions.

Read the full program here at this  Healthcare Operations Training Dallas TX Nov 12 13 2013

We are still working out a discount with the hotel and transportation company, so please register below as soon as possible and return the attached Healthcare Training Dallas TX Registration Nov 12 13 2013 packet completed by 10/30/13. In order to get the best discount possible, we need head count. We have worked out some discounts for coding books and such for those that register, with additional information coming in.

Register below for Training Nov 12- 13 2013 to pay by credit card all other payments may be made by mailing the Registration Packet to our office. If your are only registering 1 attendee, please register at the link below. If you have more than 1, please contact us so discount is calculated appropriately.

Health care Training November 2013

Sponsors include:

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OIG Work Plan 2013 – Medical Equipment and Supplies

If you are not aware, every year the OIG ( Office of Inspector General) produces a report on what they plan to audit and review for the upcoming year. The new report does not take past items of interest off the table.

Here are some highlights for medical equipment suppliers:
1. They will review Accreditation Organization and their process for approving providers.
2. Service code modifier KX indicates the patient meets the medical criteria and upon request their is information that supports the medical need of the patient. In audits, they have found that providers have little to no documentation to support medical need. Make sure you read the medical records you obtain from physicians ordering services to ensure they include documentation that supports services you have provided.
3. In audits of lower limb prostheses, they have found in 267 providers audited no history of the patient having a lower limb amputation. I would recommend if you are providing prostheses, you obtain where the amputation was done. Medicare may not have documentation because it was not paid for by Medicare or change of physicians.
4. It appears they will be looking at reimbursement for several items and comparing it to other payor sources to see if they can reduce their reimbursement or frequency for items such as erect aids, back orthoses, parenteral nutrition, and CPAP (frequency).
5. Diabetic supplies will be reviewed for: a) see if medical records corroborate the IDDM as compared to NIDDM (making sure IDDM isn’t submitted just to bill for more supplies), b) multiple supplies, c) make sure supplies are not auto shipped, d) patients requests refill, e) the quantity of supplies left is documented at the time of request for refill, f) compares supplies provided to the competitive bid areas, g) see if “non-mail” order supplies were actually mailed, if they are in competitive bid areas, and h) IF supplies are mailed but KL not applies to indicate so the provider receives a higher rate of reimbursement.

If you have not started your compliance program audit and risk assessment protocol, these are some key areas to look at to reduce your business risk. Ask physicians to provide copies of medical records at the time of the order.

Remember, to look at the OIG Work Plan from 2012.  I outlined hightlights last year that you really need to review if you did not and continue to include those moving forward.

You may find the the OIG Work Plan details at https://oig.hhs.gov/reports-and-publications/workplan/index.asp and see Medicare Part I for Parts A & B.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller is Certified in Healthcare Compliance.  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.

Accountable Care Expo – Dallas – Medical Auditing Solutions LLC August 1 2012

As many of you know the Patient Protection Accountable Care Act has a mandate requiring the implementation of cost containment managed care of patients, or Accountable Care Organization (ACO).  Many have been sitting on the sidelines waiting for the US Supreme Court Ruling on, and since they upheld ObamaCare….this is moving forward.  So, join Dallas area providers as they collaborate on HOW IN THE HECK to implement programs locally and make it work.  Providers and patients need to take a valid interest in being proactive versus treating the present situation.  You can view the agenda and register for the Dallas Accountable Care Expo to be held August 1, 2012 all day attendance is free except for the luncheon.  If you are not in the Dallas area, there are ACO Expos planned for Chicago and Las Vegas with others in the works.

Angela Miller, President of Medical Auditing Solutions LLC will be speaking on the Compliance Program Requirement.  All participants in an ACO must have a compliance program in place to participate so before March 2013.  Ms. Miller has over 18 years experience in corporate compliance programs, healthcare billing, collections, and coding audits.

Edward Vishnevetsky, Healthcare attorney with Munsch Hardt will be the luncheon Keynote Speaker on “Obstacles with ACO.”  Have you ever been able to listen to an attorney for the cost of lunch?  Well, mark this on your calendar and register now.  Mr. Vishnevetsky will also be speaking on the implications of the US Supreme Court Decision to uphold ObamaCare.

Bring your questions, concerns, and ideas on August 1, 2012.  It will be a day of speakers and exhibitor booths.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller is Certified in Healthcare Compliance.  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.

Webinar on What is a Compliance Program 101!

Medical Auditing Solutions is providing a webinar in conjunction with The Cornerstone Insurance Group (Cornerstone) to discuss the Basic Compliance Program Requirements.  We will learn what a compliance program is, what laws require it, the elements of a compliance program, and how the program can be beneficial to the healthcare provide.

Any and all healthcare providers (medical and dental practices as well as ancillary providers such as DME, Home Health, Hospice, etc.) taking Medicare and Medicaid should attend.

No CEU credit is formally given, but you will be welcome to send the handout received post attendance to your accrediting agency and ask for credit.  Some will provide and the worse they can do is say no.

The Cornerstone Insurance Group (Cornerstone) in no way endorses the accuracy of the information being provided.  In registering for this program, you will release and hold Cornerstone harmless of any and all actions you take as a result of this call.  This call is basic information and is simply an avenue for you to educate yourself on compliance program requirements.  This call in no way provides legal advice or provider specific advice without adequate documentation to review.  This is informational purposes only.

Cornerstone providers Total HR management & products including benefits management, Total Insurance products, Wellness Management Services.  Read more about the services Cornerstone offers you may find services that could benefit your organization.  They are primarily in Missouri and surrounding states but do cover additional states.

Program Title:  Compliance Program Basics and Elements

Date:                     July 24, 2012

Time:                    11:30 am-12:30 am CST

Cost:                      Complimentary

Register:              https://cc.readytalk.com/r/yhypbz3hj2p

About more about the speaker and Medical Auditing Solutions LLC:

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller is Certified in Healthcare Compliance.  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.

AAOE – Developing Effective Elements of a Compliance Program Webinar

Angela Miller, CHC and President of Medical Auditing Solutions LCC will be discussing the reason you must have a compliance program, the deadline, and the elements of an effective compliance program.  We will discuss how to make these elements effective.  After the Supreme Court Ruling on Thursday, we know PPACA is here to stay so let’s get started with the compliance program development and it can improve your overall business.

This program was offered at the national AAOE meeting in New Orleans in May 2012; however, due to a funeral I had to cut the program short.  It has take a little bit of time to get this setup, but we are ready to make this available by webinar and will still have 1 hr AAPC credit.  Also keep in mind, you can ask other credentialing organizations if they will consider CEUs for the certification you have.  You will need proof of registration & attendence, this printed out with the learning objectives, and possibly the course material (which may be the materials since they will not be posted on AAOE’s website).  They can only say No.  If you registered for the New Orleans conference, please mention that as there will be no charge to my understanding.  For those of you interested that are not AAOE members or did not attend the Annual Conference, you may still purchase the attendance below.

Please contact AAOE direct about registration at Register Now

This program will be about 1.5 hours in length.

Mark your calendars for the AAOE’s upcoming Webinars:

• July 10, 11:00am–noon Central time: The Technical Side of the ICD-10 Conversion – The Untold Story sponsored by AAOE and Coker Group  
  

• July 19, 11:00am-12:30pm Central time: Developing Effective Elements of a Compliance Program sponsored by AAOE
  

• August 1, 11:00am–noon Central time: Improving Efficiency in the Office Setting sponsored by AAOE and TransPortal

 Save the date for the 44th Annual Conference in San Diego, CA: April 28-30, 2013

About the speaker:

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.

Is Your Credit Card Terminal PCI HIPAA Compliant?

World Pay is a company that I have come across that has some really good educational information for clients and perspective clients on Payment Care Industry or PCI Compliance.  HIPAA extends to protect the financial information of clients.  It is important that you have policies regarding your PCI practices or accepting and processing credit card payments.  If your credit card processing company helping you?  Is your credit card terminal PCI Compliant, feel free to check the lists for WPVeriFone EOL Products and WPHypercom T7Plus End of Life that have reached”End of Life” or are no longer compliant.

A company can be out of PCI compliance in two ways 1) the terminal they use does not meet criteria and 2) through processes of gathering, transmitting and storing data.

Let me tell you what impressed me about World Pay.  They have a terminal that is end to end encrypted to protect financial data.  This company has a tremendous about of education materials on this topic. There fee of $14.99/month of PCI compliance includes 24/7 customer service, guidance to get your policies and procedures in place, a third party vendor to provide PCI Accreditation and Certification for that process only, and $30K of indemnity coverage when using their standard terminal or $100K indemnity coverage if your are using their end to end encrypted terminal, they help with negotiations with visa, master card, etc., if their is a breach.  Additional medical audit and HIPAA breach defense coverage may be obtained through Jim Patterson at Agape Insurance

It is important that you ensure your credit card processing machine and process is HIPAA compliant.  Educate yourself and make an informed decision.  I have included links to PCI websites for further explanation of PCI Compliance.

What will you need to have a free PCI Compliance review provided?

1.  Your Credit Card Statement; Does your statement say “non-validation of PCI” with a fee?

2.  Name/Model# of the Terminal(s) being used

3.  Do you have policies and procedures for use, storage and transmission?

4.  Mention this blog from Medical Auditing Solutions

How do you get this complimentary PCI Compliance Review?

Have the information above available and Contact Martin Anderson with World Pay at *martin.anderson@worldpay.us*

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.

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.

Training for Compliance & HIPAA Privacy and Security

Medical Auditing Solutions LLC launched the Compliance University in September 2011 and is please to announce that for 6 of the programs we have received Continuing Education Credits by Texas Occupational Therapist Association (TOTA) (15 hours) , Texas Board of Professional Counselors (6 hours minimum) , and BOC USA (9.5 hours).

What are you waiting for?  You have to train staff annually on compliance program requirements, fraud and abuse, billing,privacy and security. You have to be able to prove this training was given.  Does your staff have time to develop, track and update?  Did you know the OIG is auditing for these policies, training, sanction checks, and more in 2013 for providers that $5M in annual collections from Medicaid programs?  Did you know that OCR is auditing all types and sizes of healthcare providers from HIPAA privacy and security in 2012 and years to come?  Did you know the state inspector generals and health and human services will be auditing for these policies as well?  We can help you will all aspects of your compliance and HIPAA programs.

These requirements apply to all healthcare providers, DME, home health, physicians, and dental providers.  The size of your business does not matter for HIPAA.  As of  February 2013 for Compliance applies to all as well.

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.

ZPIC Audits What We’ve Learned from 2011 and other Audit Risks Webinar

Edward Vishnevetsky, healthcare attorney with Munsch Hardt has asked Angela Miller to join him as a guest speaker during his presentation next Thursday, February 9, noon-1pm CST.  Audits are inevitable at this point, so better be prepared and proactive for the audits that are coming.  Join us as we discuss ZPIC audits and other audits you can expect in 2012, such as HIPAA, OCR, Medicaid RAC, Commercial audit expansion. Also learn how best to prepare and prevent  adverse outcomes.

You are Invited to Join our Complimentary Medicare ZPIC Audit Webinar

Featuring Topics on:

	Changes to Medicare ZPIC and RAC Audits
	The Office of the Inspector General’s (OIG) take on Audits in 2012 based on the 2012 OIG Work Plan
	Which HCPCS codes may be most vulnerable and subject to scrutiny
	How DME suppliers can work with physicians, hospitals and manufacturers to assist in responding to audits
	Tips on how to effectively respond to audits (based on lessons learned in 2011)
	Other Audit Risk and Prevention

Presentation Given By:

Edward Vishnevetsky

Attorney at Munsch Hardt Kopf & Harr, P.C.

Featuring Guest Speaker:

Angela Miller

President of Medical Auditing Solutions LLC

Date: Thursday, February 9th, 2012

Time: 12:00-1:00 PM CST

Cost: Complimentary

To reserve your Webinar seat, please click here.

After registering you will receive a confirmation email containing information about joining the Webinar.

If you have any questions, please contact Ashley Thomas.

Edward Vishnevetsky has successful defends over 40 physicians, DME providers and HHAs against ZPIC, CERT, MAC and RAC Audits; achieved 100% success rate in removing providers from pre-payment audit.  Successfully defended over 100 providers through all stages of Medicare appeals, including the Administrative Law Judge (ALJ) level.  Read more at Munsch-Vishnevetsky

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.

OIG Work Plan 2012

I participated in a call on Thursday January 19, 2012, on the OIG Work Plan for 2012.  Please reference the link for the full OIG Work Plan spelled out by provider type.  Many items on the Work Plan never change but there were a few points I felt important to draw your attention to for risk management purposes.  Here are a few notes I made because I think the audit risk is high since the result can be subjective:

1.  Outpatient Observation Billing

2.  Critical Access Hospitals:

A.  Distance to nearest, non-critical access hospital

B.  Herceptin and other Chemo Drug quantity

3.  Hospice because 82% of patients do not meet criteria to be admitted to hospice.

4.  Incident to Services by non-qualified personnel.  Even Blue Cross and Blue Shield is recouping and extrapolating on commercial claims for mid-level practitioner billing.  Make sure modifier is used when appropriate and the mid-level meets the licensing requirements to provide the services billed.

5.  Off Label Prescriptions.  Physicians ordering a drug that is approved for Diagnosis A but the drug is used for diagnosis B.

6.  Home Health-but not specific because they are going to review 2010 billing before they decide.

7.  Dialysis and ESRD Drug costs.  What is the drug cost to the provider versus the reimbursement.

8.  Contracts providers have with other providers/facilities.  Make sure you have a health care attorney to review the contract before executing because the health care attorneys are familiar with the Stark and Anti-Kickback provisions which typically the corporate business attorney does not have to consider.

9.  Checking employees, vendors, and providers against Sanction Databases MONTHLY.  You may find the federal links on my website.  The states have their own links.

10.  NY Medicaid reduced the annual revenues to $500K in Medicaid/Medicaid HMO/Managed Care Organizations (MCO) funds for compliance program requirement.

11.  Compliance Program Requirement under Federal Deficit Reduction Act that required all healthcare providers to have a compliance program in place by 2007 if their annual collected revenue of State reimbursement was $5M or more.  This would include Medicaid and respective Medicaid HMO or MCO.

12.  As of 2013 a healthcare compliance program is required for all providers billing Federal or State plans no matter what the annual billing revenue may be.  This would include dental practices because they bill Medicaid!

13.  Overpayments must be disclosed and refunded within 60 days of identification that it is an overpayment.  Failure to refund this money can result in “False Claims” charges and penalties.  Ensure you have someone that is accountable for working your credit balance reports monthly.  Keep documentation of these reviews and refunds issued as a result in a manner that can easily be explained and found.

The OIG Work Plan can be used to determine risk analysis, structure audit plans, and determine growth opportunities.

Do you have a Healthcare Compliance Program?

Do you review the OIG Work Plan Annually?

What else do you review to determine your audit plan?

We can help you analyze the status of your healthcare compliance program and ensure you have focused on the correct risks for your business model.  We are the compliance expert with a vast history and a cost effective way to ensure your compliance program is operating and managing your risk.

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.