Implementing an Effective Compliance Plan in Response to a

Medicare Audit

Presented byCandice Fenildo, CPC, CPMA, CPB, CENTC, CPC-I

Date: May 25, 2016

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Agenda• State of the Industry

• Why audits?

• Why a compliance program/plan?

• Determining what the Plan will encompass

• Where to start

• Identifying your risk areas

• Identifying who should be involved

• When & how to do chart audits

• How to respond to help ensure the best outcome

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State of the Industry

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Why Audits?The efforts to identify and eliminate healthcare waste, fraud and abuse are on the rise.

Source: Healthcare analytics, Thomson Reuters

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Why Audits?

• Health care costs continue to soar

• Investigations continue to find improper payments• In 2014, the Government estimated a 12.7%

improper payment rate, equaling $45.8 billion.

• To combat these findings, the US Government has employed a taskforce of agencies to investigate and combat fraud and abuse

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Who are these agencies?

Federal program enforcers include:

• Office of Inspector General (OIG)

• Department of Justice (DOJ)

• Federal Bureau of Investigations (FBI)

• Medicare Administrative Contractors (MAC)

• Quality Improvement Organizations (QIO)

• Program Safeguard contractors (PSC)

• Medicare Zone Program Integrity Contractors (ZPIC)

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Who are these agencies?

Federal program enforcers include:

• Medicaid Fraud Control Units (MFCU)

• State Medicaid Inspector General

• State Attorney General

• Recovery Audit Program (RAC)

• Comprehensive Error Rate Testing (CERT) contractors

• Payment Error Rate Measurement (PERM)

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2012 HCCA SurveyIn 2012, the Health Care Compliance Association (HCCA) launched a survey to assess the volume of audits. The goal was to determine the level of audit activity and the impact it is having on the compliance profession and the institutions they serve.

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Percentage of Respondents Reporting at Least One Audit

Auditing the AuditorsA survey by the Health Care Compliance Association (2012)

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The Compliance Program

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Health Care Fraud is a Serious Problem

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Fraud includes obtaining a benefit through intentional misrepresentation or concealment of material facts

Waste includes incurring unnecessary costs as a result of deficient management, practices, or controls

Abuse includes excessively or improperly using government resources

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Medicaid Audit and Data Mining

• Some results from the NY OMIG:• Women who had babies and then gave birth to another

baby 5 months later

• Children under 10 giving birth

• 50-year-old women who gave birth with no corresponding fertility treatments – “we recovered $500,000 on this alone.”

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FBI Statistics

• Reports Estimate….• Fraudulent health care billing accounts for between 3% and

10% of all health care expenditures.• Most prevalent schemes identified are

• Billing for services not rendered• Upcoding services or items to a more expensive version• Filing duplicate claims• Unbundling• Billing for services in excess of a patient’s actual needs• Medically unnecessary services• Kickbacks

www.fbi.gov/publications/financial/fcs_report2007/financial_crime_2007.htm#health

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“We expect that every health care provider will have an effective compliance program.”Daniel Levinson, Inspector General, Office of the Inspector General, 2009 Compliance Institute, Las Vegas, NV

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Why Should I Comply?

• It’s the right thing to do.

• Enhances correct billing

• Reduces denials

• Increases billing efficiency

• Minimizes the risk of a Government audit

• Minimizes the risk of a substantial overpayment.

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