The Auditors Are Coming! Are You Prepared for an OIG/BIU Audit? - PowerPoint PPT Presentation

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The Auditors Are Coming! Are You Prepared for an OIG/BIU Audit?

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Title: The Auditors Are Coming! Are You Prepared for an OIG/BIU Audit?


1
The Auditors Are Coming! Are You Prepared for an
OIG/BIU Audit?
  • By
  • Jane Wilkinson-Bunch

2
2009 OIG Work Plan
  • At the Beginning of each fiscal year, the OIG
    identifies vulnerabilities in DHHS programs and
    activities, and works to improve their efficiency
    and effectiveness
  • It is a year-round project that continually
    changes with new information, new issues and
    shifts in the priorities in the Congress,
    President and Secretary

3
WHAT IS CORPORATE COMPLIANCE?
  • For a DME supplier, compliance means being aware
    of all of the laws, policies and regulations
    affecting DME operations and ensuring the company
    follows all of them.
  • The HHS OIG has established requirements for
    compliance programs throughout the healthcare
    industry.

4
WHAT IS CORPORATE COMPLIANCE?
  • The compliance requirements are based on past
    lessons learned in the OIGs ongoing efforts to
    reduce fraud, waste and abuse in healthcare.

5
WHAT IS CORPORATE COMPLIANCE?
  • To assist the industry, the OIG has published
    Compliance Program Guidance for virtually every
    type of healthcare entity.
  • An effective compliance program takes time and
    commitment it is worth the effort to do it and
    to do it right!

6
WHY IMPLEMENT A CORPORATE COMPLIANCE PLAN?
  • The Quality Standards for DME Suppliers published
    on August 14, 2006 require suppliers to
  • implement business practices to prevent and
    control fraud, waste, and abuse by
  • Using procedures that articulate standards of
    conduct to ensure the organizations compliance
    with applicable laws and regulations and
  • Designating one or more individuals in
    leadership positions to address compliance
    issues.

7
Employee Education and Testing
  • Sample Test Questions
  • What does the KX modifier represent?
  • Explain what capped rental means
  • Identify three capped rental modifiers?
  • How are items in the capped rental category
    billed?
  • Who completes Section A of a CMN?
  • Name one item that you would bill with a span
    date.
  • When is an ABN used? Explain.
  • Educational Tools
  • DMERC Supplier Manual
  • Supplier Bulletins
  • EOBs
  • Medicare Seminars
  • Online Training programs(such as VGM University)
  • Trade publications
  • State/National Associations
  • Company In-services
  • Employee evaluation process

8
MEDICARE FRAUD
  • 70 BILLION IN IMPROPER MCARE BILLING EVERY YEAR
  • 700 MILLION OF THIS COMES FROM DME
  • GAO REPORTS A LOT OF THIS IS DUE TO A POOR
    PROCESS IN ALLOWING FRAUDULENT PROVIDERS IN THIS
    INDUSTRY!
  • REPORT SUSPECTED FRAUD WITH THE OIG AT
    800-447-8477!

9
2009 Areas Focused on forHome Medical Equipment
  • DME Payments for Beneficiaries Receiving Home
    Health Services
  • Therapeutic Shoes
  • KX and KS Modifiers
  • Medical Necessity of DME
  • Medicare Pricing of Equipment and Supplies

10
Beneficiaries Receiving Home Health Services
  • A review of medical records for DME items and
    supplies for beneficiaries receiving HHA
    services, to determine if the items and supplies
    were reasonable and necessary for the
    beneficiaries condition

11
Therapeutic Footwear
  • Determination will be made whether therapeutic
    footwear was reasonable and necessary for the
    beneficiaries whom it was provided.
  • Previous OIG report indicates that a significant
    percentage of beneficiaries did not have adequate
    documentation to support the medical necessity of
    the footwear

12
Therapeutic Shoes and Inserts for Diabetic
Patients
  • Physician Order (coverage good for 1 calendar
    year) Must be signed by Dr. treating patient for
    diabetes
  • Must also be treated for diabetes
  • ICD-9 CM Codes 250.00-250.93 AND
  • Patient must meet medical policy guidelines
  • KX Modifier, RT right, LT left
  • Pair is reported as two units
  • Prescribing physician writes order for shoe,
    modifications, and/or inserts (may be a
    pedorthist, M.D.,D.O., podiatrist or orthotist)

13
Therapeutic Shoes and Inserts for Diabetic
Patients
  • Be sure you have documentation that the personnel
    fitting your shoes and inserts have appropriate
    training and you document how the patient was
    fitted
  • Check state licensure requirements for O P

14
Some States Require Licensure for Therapeutic
Shoes
  • These are some of the following states that
    require state Licensure to provide diabetic
    shoes
  • Alabama, Arkansas, Florida, Illinois,
    Mississippi, New Jersey, Ohio, Oklahoma,
    Tennessee, Texas, Rhode Island and Washington
  • There are more requiring licensure constantly, so
    check your state requirements regularly!!

15
KX and KS Modifiers
  • When a claim is filed with the KX or KS modifier,
    the provider, upon request, must provide
    documentation to support the claim for payment
  • OIG has found that many suppliers had little or
    no documentation to support the claims,
    therefore many of these claims should not have
    been paid

16
Most Items Requiring KX Modifier
  • Diabetic Shoes and Inserts
  • Urological Supplies
  • Group I, II and III Support Surfaces (including
    wheelchair cushions)
  • Diabetes Monitor Supplies (insulin dependent)
  • Dialysis Supplies (Epoetin Alpha-Epo)
  • Refractive Lenses
  • Bedside Commodes
  • Cervical Traction Equipment (E0849)
  • Conductive Garment (E0731)
  • Ankle Gauntlets
  • Orthopedic Footwear
  • Continuous Positive Airway Pressure Devices
    (CPAP) Supplies
  • Respiratory Assist Devices Supplies
  • All Walkers Accessories
  • Negative Pressure Wound Therapy Pump
  • High Frequency Chest Wall Oscillation Devices
  • Hospital beds Accessories
  • All Wheelchairs Accessories
  • Trapeze Bars

17
Medical Necessity of DME
  • Determine the appropriateness of Medicare
    payments for items such as Power Wheelchairs,
    Wound Care equipment and supplies and orthotics
  • Assessment will include documentation to support
    claim, documentation to support medical necessity
    and whether the beneficiary actually received the
    item

18
Medicare Pricing of Equipment and Supplies
  • Comparison of Medicare payment rates for certain
    medical equipment and supplies with rates of
    other Federal and State Programs as well as
    wholesale and retail prices
  • Review will cover such items as Wheelchairs,
    Parental Nutrition, Wound Care equipment and
    supplies, and Oxygen equipment and supplies

19
CERT Audits
  • CERT program calculates error rate for
  • Carriers
  • DMERC (Durable Medical Equipment Regional
    Carries)
  • FI (Fiscal Intermediaries)

20
History of CERT
  • DHHS and OIG produced Medicare FFS error rates
    from 1996 through 2002
  • Initial sampling method only estimated the
    national FFS paid claim error rate (the
    percentage of dollars that Carriers/DMERCs/FIs/QIO
    s erroneously allowed to be paid)
  • CMS decided to establish additional measurements
    for the performance of the Carriers/DMERCs/FIs/QIO
    s, and to analyze the the cause of errors

21
New Measurements
  • Provider compliance error rates (measure how well
    providers prepared claims for submission)
  • Paid claims error rates (measure how
    accurately Carriers/DMERCs/FIs made coverage,
    coding, and other claims payment decisions)
  • CMS began publishing their findings in 2003

22
Usage of CERT
  • The program uses random samples and therefore is
    not used to measure fraud. Reviewers are often
    unable to see provider billing patterns that
    indicate potential fraud when making payment
    determinations
  • CERT can, however, detect fraudulent behavior
    when the CERT documentation contractor is unable
    to locate a provider or supplier when requesting
    medical record documentation (a lack of response
    would cause a no documentation error)

23
Reporting Periods
  • November 2006 report would contain claims
    submitted in the 12 month period ending March
    31, 2006
  • May 2007 report would contain claims submitted in
    the 12 month period ending September 30, 2006
  • November 2007 will contain claims submitted in
    the 9 month period ending march 31, 2007

24
IPIA
  • Improper Payments Information Act
  • Requires use of Gross figures when reporting
    improper payment amounts and rates
  • A gross improper payment amount is calculated by
    adding underpayments to overpayments

25
CERT Methodology
  • Randomly selected sample of approximately 120,000
    claims
  • Request medical records from providers who
    submitted the claims
  • Review the claims, and medical records, for
    compliance with Medicare coverage, coding, and
    billing rules

26
Initial CERT Letter Example
27
First Example Page
  • Introduction and short description of CERT
    program

28
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29
Second Example Page
  • Describes what you need to do to comply with CERT
    program
  • Has a due date. Ensure you have information back
    to CERT by the due date without exception

30
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31
Third Example Page
  • Instructions to follow to get the information
    back to the CERT contractor
  • States that if items requested are not sent in by
    the required date they will assume the services
    on the claim were not rendered

32
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33
Fourth Example Page
  • Provides you with beneficiary information, CCN
    number, HCPC, DOS

34
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35
Fifth Example Page
  • Gives a list of documentation requested. List is
    very extensive.
  • Spells out how to correctly copy and send the
    information. Ensure all copies are legible

36
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37
CERT Attestation Letter
  • Used when files have been partially or completely
    destroyed

38
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39
CERT Tech Stop
  • Used when you provided documentation but CERT is
    requesting additional information
  • Must be responded to by the date indicated

40
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41
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42
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43
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44
CERT Physician Letter
45
(No Transcript)
46
Will You Be Audited?IS JANE BUNCH SOUTHERN? ?
  • Targeted Audits
  • Bill more than one million per year
  • Limited product mix
  • Beneficiary /other complaints
  • Frequent claims for abused items
  • Recurring errors on claims
  • Abnormal charge pattern
  • Dramatic changes in fees
  • Repeated billing for overutilization
  • Routine Audits

47
TARGETED TYPES
  • Program Integrity
  • Reviews documentation and record content
  • Utilization Review
  • Verifies need and frequency
  • ECS
  • Authenticity/signature on file
  • Phone/Fax
  • Mail (Love Letter from CMS)
  • On-site
  • RAC Audits
  • CERT Audits
  • Are you prepared to survive?

48
Your Internal Audit Should Include
  • Review of Documentation Requiring Beneficiary
    Signature
  • Assignment of Benefits
  • Supplier Standards
  • Release of Information
  • Rental/Purchase Option
  • Delivery Ticket/Pickup Slip
  • HIPAA Notice of Uses/Privacy Practices
  • ABN (Advanced Beneficiary Notice)
  • Review of Medical Necessity Documentation
  • Physician Orders
  • WOPDs
  • CMNs

49
Patients Medical Records
  • The CMN is not enough if audited
  • Attempt to obtain the following
  • Physicians Office Records
  • Labs and X-Rays related to diagnosis
  • Hospital Records
  • Nursing Home records
  • Home Health Agency Records
  • Records from other Healthcare Professionals
  • The medical records should contain objective
    data to support the physician statement,
    diagnosis or condition.

50
Auditing The Delivery Ticket
  • Patients Full Name Address
  • Quantity of equipment and/or supplies delivered
  • Detailed description of the item being delivered
  • Brand name of equipment or supplies
  • Serial and/or lot numbers
  • Patients/Designee signature and date

51
Delivery Ticket Requirements
  • Signature date must be the date that the item was
    received by the beneficiary or designee
  • Designee is
  • Any person who can sign and accept the delivery
    of durable medical equipment on behalf of the
    beneficiary. Relationship must be noted on
    delivery slip
  • 7 days to call...
  • 5 days to bill...
  • 48 hours following discharge after hospital /
    discharge ...

52
Auditing the AOB Form
  • Assignment of Benefits
  • Equipment / supply itemized
  • New signed form required for each new product
    class
  • Must be itemized with each supply or piece of
    equipment the patient is authorizing you to bill.
  • Patient unable to sign Requirements must be met

53
Auditing the ABN
  • Advanced Beneficiary Notice
  • Specific situation/reason noted
  • Must be obtained before delivery
  • Correct use of modifiers
  • GZ beneficiary did NOT sign ABN
  • Upgrade with NO ABN
  • GL free upgrade provided
  • GK item physician actually ordered
  • Item must be billed correctly
  • GA upgrade provided and supplier has obtained a
    signed ABN from beneficiary before item was
    delivered
  • Patient signature and date
  • Correct form used?

54
ABN cont
  • Routine" or Blanket" ABNs to Medicare
    beneficiaries are not permitted
  • An ABN should not be given to a Medicare
    beneficiary unless the supplier has a genuine
    reason to expect that Medicare will deny payment
    for some or all of the services.
  • Assigned and non-assigned claims
  • ABNs are only good for ONE YEAR!

55
NEW ABN FORM
  • (A) Notifier(s)
  • (B) Patient Name (C) Identification Number
  • ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
  • NOTE If Medicare doesnt pay for
    (D)_____________ below, you may have to pay.
  • Medicare does not pay for everything, even some
    care that you or your health care provider have
  • good reason to think you need. We expect Medicare
    may not pay for the (D)_____________ below.
  • (D)
  • (E) Reason Medicare May Not Pay (F) Estimated
  • Cost
  • W HAT YOU NEED TO DO NOW
  • Read this notice, so you can make an informed
    decision about your care.
  • Ask us any questions that you may have after
    you finish reading.
  • Choose an option below about whether to receive
    the (D)_____________listed above.

56
NEW ABN FORM CONTD
  • Note If you choose Option 1 or 2, we may help
    you to use any other
  • insurance that you might have, but Medicare
    cannot require us to do this.
  • (G) OPTIONS Check only one box. We cannot choose
    a box for you.
  • ? OPTION 1. I want the (D)__________ listed
    above. You may ask to be paid now, but I
  • also want Medicare billed for an official
    decision on payment, which is sent to me on a
    Medicare
  • Summary Notice (MSN). I understand that if
    Medicare doesnt pay, I am responsible for
  • payment, but I can appeal to Medicare by
    following the directions on the MSN. If Medicare
  • does pay, you will refund any payments I made to
    you, less co-pays or deductibles.
  • ? OPTION 2. I want the (D)__________ listed
    above, but do not bill Medicare. You may
  • ask to be paid now as I am responsible for
    payment. I cannot appeal if Medicare is not
    billed.
  • ? OPTION 3. I dont want the (D)__________listed
    above. I understand with this choice
  • I am not responsible for payment, and I cannot
    appeal to see if Medicare would pay.
  • (H) Additional Information
  • This notice gives our opinion, not an official
    Medicare decision. If you have other questions
  • o n this notice or Medicare billing, call
    1-800-MEDICARE (1-800-633-4227/TTY
    1-877-486-2048).
  • Signing below means that you have received and
    understand this notice. You also receive a copy.
  • (I) Signature
  • (J) Date
  • According to the Paperwork Reduction Act of 1995,
    no persons are required to respond to a
    collection of information unless it displays a
    valid OMB control

57
Auditing Financial Hardship
  • Acceptable Form Utilized
  • Completed and signed
  • Patient meets hardship guidelines
  • Hardship Approval
  • Policy and Procedure developed
  • Poverty Guidelines
  • New one every Feb/March

58
2009 HHS Poverty Guidelines
59
SADMERC CHANGES
  • EFFECTIVE AUGUST 18, 2008
  • NORIDIAN ADMINISTRATIVE SERVICES, LLC WILL ASSUME
    THE DUTIES OF THE SADMERC FROM PALMETTO GBA
  • 830 AM UNTIL 400 PM PDAC CONTACT CTR HOURS
    877-735-1326
  • WWW.DMEPDAC.COM

60
Summary
  • Audit now to be prepared later
  • Compliance plan adopted?
  • HIPAA Implementation
  • Test employees regularly

61
Jane Wilkinson-BunchPresident/CEOJanes
Healthcare Consulting, Inc.(770) 366-0644
cell(770) 517-9109 faxBillhme_at_aol.comAn
advocate for the Independent HME provider
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