Mistakes are inevitable, but it is what we do next that defines our character…

- Kameron Gifford, CPC

On February 11, 2013 Departments of Justice and Health and Human Services announced record-breaking recoveries of 4.2 billion in CY 2012. http://www.hhs.gov/news/press/2013pres/02/20130211a.html

This “joint effort to combat healthcare fraud” does not appear to be going away anytime soon.  In fact, I believe the only way that we can stop the governments intrusion into healthcare is to create accountability within the industry. How long do you think audits would continue if they revealed compliant operating and billing practices? Without recoveries the funding would stop.

There are seven things that will destroy us: Wealth without work; Pleasure without conscience; Knowledge without character; Religion without sacrifice; Politics without principle; Science without humanity; Business without ethics.
- Mahatma Gandhi

If you practice medicine, run a hospital, or manage a practice, you are intimately aware that even the best people can make mistakes. Have you ever spent days looking for a missing chart or come across a critical lab that had been “misplaced”? Or maybe you received a list of medical records to be audit by an insurance company and 1 of the dictations has “disappeared” or better yet, the patient never came in that day. Was this a malicious act by your front office staff or biller? Probably not, but it is what you do at that exact moment of discovery that will determine the potential of a negative outcome.

In my experiences it a combination of blunt honesty and a sincere desire to “make it right” that yields the greatest possible outcomes. We are human and mistakes are inevitable.

With increasing oversight and increasing expectations of due diligence, all eyes will be on the healthcare industry. What can we do if we have received a letter relating to an investigation or audit? What if we have recently settled a claim of “upcoding or over-billing”?

Take actions to improve. Remember, everything happens for a reason. We often suffer through misfortune before we can reach the high points in life. View this as an opportunity to show the world your inner strength and resilience. Create a stronger corporate culture, invest in education, and continue to strive every day to do something more than you did yesterday.

If you have not yet been the target of an audit, prepare now, because you will be one day. Audit yourselves just as the OIG, Medicare or Medicaid or a commercial payor might. Our best offense is a great defense. Create transparent processes, encourage conversations between your entire team, and get a second opinion. A fresh perspective may be your most valuable resource. 

Retrospective Chart Reviews now Medicare Fraud?

Kameron Gifford, CPC – 6/8/2013

The U.S. government has shown again this week that they are serious about finding and prosecuting Medicare fraud.  Health plans who participate with the Medicare Advantage program continue to be a primary target for both OIG and CMS auditors, and this pressure is sure to increase with new incentives for Whistleblowers in 2014. The focus on due diligence and oversight has never been greater than it is today. The Department of Justice has been relentless in their pursuit of “accountability” and every summary judgment re-emphasizes the responsibility of compliance among all “down-stream entities”.

In this climate of regulatory reform, healthcare companies must strengthen their internal auditing and compliance programs to comply with current interpretations of these new laws. The “old way” of doing things isn’t just bad business anymore, now it can mean civil and/or criminal penalties. The expectation is that of knowledge and ignorance is no longer a defense.

New Risks in Retrospective Chart Reviews

Historically, Medicare Advantage programs have performed retrospective chart reviews to submit missing diagnoses to Medicare. Health plans routinely contract with coding companies to review the medical records of their members for diagnoses that are properly documented. These properly documented codes are then submitted to CMS as corrections. But what about the original claims submitted by the physician? Are these diagnoses codes being verified for compliance?  If not, this might be considered fraud.   

In a recent settlement agreement between SCAN and the US government, SCAN agreed to pay more than $300 million to settle allegations of “upcoding” among other things. This case represents the first time that this “standard practice” of retrospective chart reviews had ever been challenged in a court of law. The practice of engaging in chart reviews for the sole purpose of adding codes violates the federal rules of the Medicare Advantage program. By not providing the coding contractors with original claims data, the initiative will never result in less diagnoses or a reduction in revenue. 

Consider this article in the LA Times written 8/24/2012:

"The alleged manipulation of those patient risk scores was a key part of the federal whistle-blower suit against SCAN. Separately, SCAN agreed to pay $320 million to resolve allegations that it was overpaid by the state's Medi-Cal program, which serves the poor and disabled. SCAN denied wrongdoing in that settlement as well."
"Federal prosecutors didn't allege any fraud by SCAN. But Susan Hershman, an assistant U.S. attorney in Los Angeles, said investigators concurred that SCAN didn't share certain information with Medicare that would have reduced payments."
 (http://articles.latimes.com/2012/aug/24/business/la-fi-medicare-loss-risks-20120825)

Implications for MRA Programs

• Retrospective Audits Must Be Dual Purpose –
• Verification of previously submitted codes in addition to catching “missing” codes.
• Use a Third Party for MRA Education –
•  Transparency is your most valuable resource.
• Invest in the Resources that you have –
• Educate everyone, knowledge is power.

Empirical Risk Management can help you identify risks in your MRA process, make recommendations and provide quality education for your entire organization.

Initiating Change from the Initial Point of Contact www.ermconsultinginc.com

Administration officials plan to announce the new fraud numbers Thursday as they push for more help from seniors in fighting fraud.

Kelly Kennedy, USA TODAY6:47 p.m. EDT June 5, 201

WASHINGTON — The government has revoked the ability of 14,663 providers and suppliers to bill Medicare over the past two years — almost two and a half times the number that had been revoked in the previous two years, new Department of Health and Human Services statistics to be released Thursday show.

In some states, the number of revocations has quadrupled.

"We have always been doing some of this," said Peter Budetti, Center for Medicare Services deputy administrator for program integrity. "But there has been a special focus under the Affordable Care Act."

Administration officials plan to announce the new fraud numbers Thursday as they push for more help from seniors in fighting fraud. One proposed rule would allow people who report fraud to earn up to $9.9 million in reward money in a new fraud-prevention program. Before today, beneficiaries could receive up to $10,000 for tips leading to recovery of fraud money.

A key part of the anti-fraud effort, Budetti said, includes a new, easier-to-read summary statement that allows recipients to see exactly who has billed Medicare with their identification numbers. That's a "landmark change," he said.

"Our best weapon in fighting fraud is our 50 million Medicare beneficiaries," he said. Upping the incentive amount from a possible $10,000 per case to a possible $9.9 million would "attract the kind of attention" the government needs to spotlight the program, Budetti said.

During the past four years, the government has recovered $14.9 billion in Medicare fraud money, due in large part to the 2010 health care law, also known as the Affordable Care Act. The law allowed the government to analyze data to spot indications of fraud and stop paying providers. Budetti explained that all providers had to go through a reapplication process to participate in Medicare.

Those who didn't meet a requirement, had felony convictions, had incorrect addresses or who weren't properly licensed are no longer allowed to bill Medicare. Officials focused on providers in areas that have historically high levels of fraud, such as durable medical equipment, home health care and ambulance services. In the two years before the system was in place, just 6,307 providers and suppliers had their Medicare billing privileges revoked, according to CMS.

However, the program faced pressure from Congress in October when members learned the system had not yet integrated Medicare's payment program.

"The key question is, when will Medicare officials finally have a fully operational and effective anti-fraud system so we can turn off the spigot of fraudulent Medicare payments?" said then-senator Scott Brown, R-Mass. He added that the system was "months late."

At the time, officials said it would be integrated by January. CMS reported in January that the system was saving $3 for every $1 spent in the first year.

The system is now working, Budetti said, although he wants to see it work harder. Last year, seniors called Medicare's fraud hotline to report billing from doctors they had never seen. Using that information, Budetti said they learned of one provider that had sparked calls from 200 to 300 Medicare recipients. In other cases, seniors reported the fraudulent use of their Medicare numbers. Officials then used the system to track providers with a history of using Medicare beneficiary numbers fraudulently.

Budetti said officials are still looking for a good way to reissue beneficiary numbers to the 284,000 people who, according to a report by HHS' inspector general, have had breached or stolen numbers. The numbers tie in to several government systems, such as Social Security, so it's difficult to change them.

In the meantime, the new statements should help, Budetti said. Last year, between 40,000 and 50,000 phone calls to the Medicare hotline were key to fraud investigations, he said.

Last week, HHS Secretary Kathleen Sebelius credited fraud reduction as part of the reason Medicare solvency had been extended by two years in the annual trustees report.

http://www.usatoday.com/story/news/politics/2013/06/05/medicare-revoking-providers-billing-fraud/2393561/