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The Nurse’s Role in Preventing and Detecting Fraud and Abuse

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The Nurse s Role in Preventing and Detecting Fraud and Abuse Joan A. Kavuru, J.D., R.N. Director of Compliance The Brody School of Medicine October 27, 2006 – PowerPoint PPT presentation

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Title: The Nurse’s Role in Preventing and Detecting Fraud and Abuse


1
The Nurses Role in Preventing and Detecting
Fraud and Abuse
  • Joan A. Kavuru, J.D., R.N.
  • Director of Compliance
  • The Brody School of Medicine
  • October 27, 2006

2
Overview
  • The Importance of Nurses to the BSOM Compliance
    Program
  • Particular Areas of Concern that Impact Nursing
  • Reporting Incidents of Potential Non-Compliance
  • Practical Issues in Everyday Practice

3
Importance of Nurses to the BSOM Compliance
Program
  • BSOM Compliance Program is an oversight mechanism
    that provides a framework to prevent, detect, and
    resolve potential incidents of non-compliance
  • Why do we have a compliance program?
  • Industry standard Office of Inspector General
    (OIG) guidance
  • New requirement to receive Medicaid funding under
    the Deficit Reduction Act
  • We want to do the right thing
  • What is considered an effective compliance
    program?
  • Seven key elements as set forth by the OIG
  • Assess, educate, implement, monitor, educate
    (again), and follow-up.

4
Importance of Nurses to the BSOM Compliance
Program
  • Many nurses are on the front lines and identify
    issues every day
  • Possess rich institutional knowledge and history
  • Viewed as honest and trustworthy
  • Patients and co-workers tend to confide in nurses
  • Patient care and safety is 1

5
Particular Areas of Concern that Impact Nursing
  • Background The False Claims Act
  • False Claims Act (FCA) prohibits anyone from
    knowingly submitting a false or fraudulent
    claim for payment
  • Knowingly means (i) actual knowledge (ii) acts
    in deliberate ignorance of the truth or falsity
    of the information or (iii) acts in reckless
    disregard of the truth or falsity of the
    information.
  • No proof of specific intent to defraud is
    required liability is proven by evidence of
    deliberate ignorance or reckless disregard of
    truth of the claim

6
Particular Areas of Concern that Impact Nursing
  • Background The False Claims Act (contd)
  • Damages Triple damages and penalties of 5,500
    to 11,000 per false claim for submission or
    causing submission of false claim.
  • Claim is generally defined as a CMS 1500
  • May result in imposition by the government of a
    corporate integrity agreement

7
Particular Areas of Concern that Impact Nursing
  • Background Qui Tam Actions
  • The FCA allows a private person (a qui tam
    relator) to bring a civil action in the name of
    the United States.
  • Qui tam relators share in any money recovered
    (including settlements).
  • If government joins in action, relator is
    entitled to 15 to 25 of proceeds depending on
    relators contribution to case.
  • If government does not join in action, court may
    award relator not less than 25 and not more than
    30 of proceeds.

8
Particular Areas of Concern that Impact Nursing
  • Poor Quality of Care
  • May be actionable under the False Claims Act to
    knowingly (or with reckless disregard) bill for
    services that are worthless.
  • Medicare only pays for services reasonable and
    necessary to treat a condition poor quality
    services do not meet this definition.
  • False Certification Theory This theory has been
    widely used in the nursing home industry to
    combat poor quality care.
  • Has resulted in large settlements Vencor 219
    Million in 2001
  • Theory is being extended to hospitals
    submission of quality data to CMS may increase
    exposure

9
Particular Areas of Concern that Impact Nursing
  • Billing and Reimbursement
  • Billing for services not performed (or
    underperformed)
  • Ordering/billing for medically unnecessary
    services
  • Use of residents and teaching physician
    supervision
  • In order for attending physicians to bill for
    services performed by the resident, the attending
    must be present during the key portion of the
    exam or procedure (exceptions exist for primary
    care clinics)
  • Doesnt mean that attending has to be physically
    present during every resident visit, but
    attending cannot bill unless present

10
Particular Areas of Concern that Impact Nursing
  • Billing and Reimbursement
  • Incident-to services are those services commonly
    furnished in a physicians office that are
    incident to the professional services of a
    physician.
  • Incident-to services performed by a nurse or
    mid-level provider (e.g., nurse practitioner,
    physician assistant, etc.) can be billed under
    the physicians provider number provided that
  • Physician must personally perform an initial
    service for each new condition, make an initial
    diagnosis, and establish a treatment plan.

11
Particular Areas of Concern that Impact Nursing
  • Billing and Reimbursement (Incident-to
    Requirements contd)
  • Physician must personally perform subsequent
    services at a frequency that reflects his/her
    active participation in and management of the
    course of the treatment for each medical
    condition (i.e., physician must examine patient
    on a regular basis, e.g., every third or fourth
    visit).
  • Services must be performed under a physicians
    direct personal supervision
  • Present in the office suite and immediately
    available to provide assistance and direction
    throughout the time the ancillary staff or NPP is
    performing the incident to services.
  • Billed under attending physicians number

12
Particular Areas of Concern that Impact Nursing
  • Providing Services under the Incident-to
    Billing Rules (contd)
  • Services must be performed by an individual who
    is an employee (or leased employee) or
    independent contractor of BSOM.
  • Incident to services provided by NPPs may be
    billed using the CPT code for established patient
    visit that best describes the E/M service
    furnished.
  • Incident-to services provide by an R.N. can only
    be billed using the lowest level CPT code
  • Important points related to incident-to billing
  • Incident to services can never be applied to a
    new patient (i.e., patients first visit)
  • Cannot be furnished in an inpatient setting

13
Particular Areas of Concern that Impact Nursing
  • Billing and Reimbursement Split or Shared
    Services
  • For evaluation and management (E/M) services,
    nurses are only permitted to perform and document
    the past social family history and the review of
    systems
  • Cannot perform or document further portions of
    the evaluation and management (E/M) service for
    the physician (i.e., history of present illness,
    physical exam, or medical decision making)
  • May act as a scribe but must actually witness
    the physician performing the service and requires
    physician co-signature
  • Do not use the physicians password to document
    in Centricity level 2 HIPAA violation and
    results in disciplinary action.

14
Particular Areas of Concern that Impact Nursing
  • Time and Effort Reporting
  • If you are working on a project that is funded
    with outside grant monies, you are required to
    complete a time and effort report
  • Are not permitted to overcharge grant for time
    spent on grant-funded project
  • Cannot inflate time spent on grant
  • Many recent settlements related to poor time and
    effort practices
  • University of Alabama 3.39 million settlement
    Inflated percentage of work effort researchers
    devoted to projects to more quickly access grant
    money also siphoned off money to cover budget
    shortfalls in other areas and pay people who did
    not work on projects

15
Particular Areas of Concern that Impact Nursing
  • Research
  • Clinical Trials Billing
  • Cannot bill third party payors for items that are
    reimbursed by sponsor
  • Conflict of Interest Issues
  • Full disclosure required consulting
    arrangements, ownership in sponsor just to name
    a few
  • Compromises integrity of study and patient safety

16
Particular Areas of Concern that Impact Nursing
  • Pharmaceutical and Medical Device Company
    Marketing Practices
  • Egregious practices have been targeted by the
    government
  • PhRMA Guidelines set forth standards for
    marketing practices
  • Supply of meals education must be provided
  • Some medical schools have recently adopted a no
    funds policy

17
Particular Areas of Concern that Impact Nursing
  • Pharmaceutical and Medical Device Company
    Marketing Practices
  • Implicates the Federal Antikickback Statute
  • Forbids any knowing and willful conduct involving
    the solicitation, receipt, offer or payment of
    any kind of remuneration in return for referring
    an individual or for recommending or arranging
    the purchase, lease or ordering of an item or
    service that may be paid for under a federal
    health care program.
  • Criminal and civil liability for failure to comply

18
Reporting Incidents of PotentialNon-compliance
  • Encouraged to use supervisors, administrators as
    the first line of reporting of any known
    incidents of noncompliance.
  • BSOM Compliance Hotline
  • Available 24 hours a day, 7 days a week
  • Can be anonymous
  • Toll free 1-866-515-4587
  • No retaliation for good faith reporting of
    incidents of noncompliance.
  • All good faith reports will be fully
    investigated.
  • Confidentiality maintained to the fullest extent
    possible.
  • As nurses you have a professional duty to report
    potential problems

19
Practical Issues in Everyday Practice
  • Questions/Discussion

20
Office of Compliance at BSOM
  • Serves as a resource to all faculty and staff
  • Contact information
  • 744-5200
  • kavuruj_at_ecu.edu
  • Thank you for attending!
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