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.

Advertisements

Senate Finance Committee Seeks Feedback on Fighting Fraud & Abuse as They Look at ZPICs


Reposted from email blast received May 2, 2012.
FOR IMMEDIATE RELEASE
May 2, 2012
CONTACT:  Julia Lawless/Antonia Ferrier (Hatch)              (202) 224-4515
                            Communications Office (Baucus)                          (202) 224-4515 

HATCH, BAUCUS LEAD FINANCE COMMITTEE MEMBERS IN BIPARTISAN EFFORT TO COMBAT WASTE, FRAUD, & ABUSE IN
MEDICARE & MEDICAID PROGRAMS
In an open letter to members of the health care community Senators write, “Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.”


WASHINGTON – Today, six members of the Senate Finance Committee, led by Ranking Member Orrin Hatch (R-Utah) and Chairman Max Baucus (D-Mont.), announced a bipartisan effort to begin soliciting ideas from interested stakeholders in the health care community regarding effective solutions to improve federal efforts to combat waste, fraud, and abuse in the Medicare and Medicaid programs. Joining Hatch and Baucus in the effort are:  Senators Tom Coburn (R-Okla.), Ron Wyden (D-Ore.), Chuck Grassley (R-Iowa), and Tom Carper (D-Del.).

In an open letter to members of the health care community, the Senators wrote, “We believe federal efforts would be strengthened by input from members across the health care community – providers, payers, health plans, contractors, non-profit entities, consumers, data analytics entities, governmental partners, and patients. Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.”

This week, the lawmakers invited interested stakeholders to submit white papers offering recommendations and innovative solutions to improve program integrity efforts, strengthen payment reforms, and enhance fraud and abuse enforcement efforts. Submissions are due by June 29, 2012. A summary document highlighting key proposals will be compiled and released later this year.

The Senate Finance Committee has jurisdiction over the Medicare and Medicaid programs.

To view a signed copy of the letter click HERE.

Below is the full text of the letter:

May 2, 2012

To Members of the Health Care Community:

According to the Government Accountability Office (GAO), few programs are as much at risk for fraud, waste and abuse as the Medicare and Medicaid programs.  Estimates of the amount of fraud and misspending in these programs vary widely, from $20 billion to as much as $100 billion. Just this week, testimony before the Senate Finance Committee underscored the seriousness of this problem, as witnesses testified that while much has been accomplished in the fight against fraud and abuse, much more needs to be done.  As Senators and members of the Finance Committee, we have a duty to ensure that taxpayer funds are being spent wisely.

Combating fraud in Medicare and Medicaid has long been a challenge for the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services Inspector General (HHS OIG) and the Department of Justice (DOJ).  To date, numerous efforts have been made to reduce fraud, yielding a mixed record of successes and failures.  We believe federal efforts would be strengthened by input from members across the health care community – providers, payers, health plans, contractors, non-profit entities, consumers, data analytics entities, governmental partners, and patients. Drawing on the collective wisdom and accumulated insights of thousands of professionals and individual experiences could offer a fresh perspective and potentially identify solutions that may have been overlooked or underutilized.

Today we are announcing an effort to solicit ideas from all interested stakeholders in the health care community, regarding solutions and suggestions for how to better prevent and combat the multi-billion dollar problem of waste, fraud and abuse in the Medicare and Medicaid programs.  We invite you to submit white papers offering your best ideas, built on years of experience and insight.  We want to know what areas you see for improvement in current program integrity efforts, as well as additional solutions that we should consider. Working together, we hope to identify innovative solutions that will provide taxpayers with a better return on the investments being made to combat the overpayments in these federal health care programs.

Below are the general categories in which we seek input, though some recommendations may include multiple categories:

&#61623      Program Integrity Reforms to Protect Beneficiaries and Prevent Fraud and Abuse

&#61623      Payment Integrity Reforms to Ensure Accuracy, Efficiency and Value

&#61623      Fraud and Abuse Enforcement Reforms to Ensure Tougher Penalties Against Those Who Commit Fraud

 

Entities interested in submitting white papers should email a PDF or Microsoft Word document to ProgramIntegrityWhitePapers@finance.senate.gov by June 29, 2012.  Submissions should include summary information about the entity or individual submitting a white paper, as well as phone and email contact information. White papers should be as succinct and concrete as possible.  When possible, please include cost-benefit or potential savings information.  Our staff will review submissions and compile a summary document highlighting key proposals later this year.

We appreciate your submission of thoughtful and constructive solutions, as we work to conduct targeted oversight to improve federal efforts to reduce fraud and abuse in Medicare and Medicaid. Together, we believe we can improve program integrity and be better stewards of taxpayer dollars.

Sincerely,

BAUCUS
HATCH
COBURN
WYDEN
GRASSLEY
CARPER

###

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.

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.

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.