Posts Tagged OIG
Complementary rules may extend electronic health record (EHR) safe harbor for an additional three years to encourage adoption. The proposed rules, one from the Centers for Medicare & Medicaid Service (CMS) and another from the Office of Inspector General (OIG) extend the 2006 rules relaxing federal Stark and anti-kickback laws from December 2013 to December 2016.
The 2006 rules waived the laws to encourage hospitals to provide financial and technical assistance to office-based physicians to adopt EHRs without fear of accusation of financial conflicts of interest in referrals. Based on an executive order by President George H. Bush, the waivers were accompanied by the establishment of the Office of the National Coordination for Health Information Technology (ONC) at the U.S. Department of Health & Human Services (HHS).
The rule set to expire at the end of this year requires EHR systems to be interoperable and certified by a certification body recognized by HHS with the previous 12 months to qualify for the waivers.
The proposed rule says that the EHR must be certified by a certification body authorized by the ONC within the previous 24 months instead. The rules also propose limiting waivers to cover hospitals, group practices, prescription drug plan sponsors, and Medicare Advantage plans, reflecting concerns that the previous rules – which included “any donor” under Medicare or Medicaid – was too broad.
April 19th, 2013
By Robert A. Pelaia, Esq., CPC, CPCO
It’s foolish to ignore the signs that set off Office of Inspector (OIG) radar. Look around your work environment. If an OIG investigator walked into your office right now, what would he or she see (or not see) that shows compliance is not taken seriously in your practice?
Here are 10 telltale signs, in no particular order, to show investigators that they should take a second look at your compliance activities:
1. Patient Records are in Plain Sight: This is a big Health Insurance Portability and Accountability Act (HIPAA), red flag. It shows that you have no regards for confidentiality of patient information.
2. You Have No Compliance Contact: Your office should designate someone to be in charge of compliance activities. Whether you have an individual or group of individuals responsible for compliance, it’s important to have a “go-to” person for compliance issues.
3. Coding Books Are Outdated: Coders must keep on top of all the newest coding changes and if coders are using outdated coding books or software, that’s a compliance risk. It’s good to keep old coding books around as a historical reference; however, never code from outdated books.
4. Free Limousine Transportation Offered to Medicaid Patients: Section 1128A(a)(5) of the Social Security Act, enacted as part of HIPAA, imposes significant civil money penalties on providers who offer free gifts or services to Medicare or Medicaid beneficiaries that can influence the beneficiary to order items or services from the provider.
5. Coder “Cheat Sheets” Are Posted: It’s alright for coders to have code lists to help work more efficiently; however, an OIG investigator might have a significant problem if the “cheat sheet” only reflects high level codes. For example, if you are listing new patient evaluation and management (E/M) codes on your “cheat sheet,” make sure you list all five levels of new patient E/M codes, not just ones that pay the most money.
6. Memos Posted Instructing Coders to Change Diagnosis Codes: It’s okay to have a list of “covered” diagnoses, but it is not appropriate for the coder to change the diagnosis to one not supported in the medical record. Posted memos telling coders to use particular codes only when submitted with certain “covered” diagnoses and to change to another code if the “wrong” diagnosis is submitted is a red flag to OIG investigators.
7. Coders Get Bonuses when Revenue Increases: The government will closely scrutinize a bonus structure paid to a coder based on increases in revenue because the arrangement might be an incentive for an unscrupulous coder to “up-code.” Coding is complex enough without muddying the water with bonus structures tied to revenue. The less risky route is to base the incentive on productivity, timeliness, or accuracy, rather than revenue.
8. Dusty Compliance Manual: A compliance manual should not sit on the bookshelf, as it should be a useful and comprehensive reference tool used often and updated periodically.
9. Employee Complaints with No Follow-up: An organization that receives complaints or uncovers evidence of improper billing must demonstrate it responded appropriately to the situation, including taking necessary steps to prevent further similar offenses. If the organization’s management personnel fail to investigate employee complaints promptly, this questions the effectiveness of the program.
10. Not Employing “Certified” Coders: You can tell a lot about a health care employer by the company it keeps—it is true that you get what you pay for. Employers who hire certified coders are employers who maintain higher standards, value integrity, and understand that compliance activities are a requirement.
Disclaimer: Information published in this article is the personal views of the author and is not intended to be, nor should it be considered, legal advice. Readers should consult with an attorney to discuss specific situations in further detail.
April 16th, 2013
Intermountain Health Care Inc., the largest health system in Utah, agreed to pay the United States $25.5 million to settle Stark Statute and False Claims Act violation claims. The allegations are for ”engaging in improper financial relationships with referring physicians,” according to a U.S. Department of Justice (DOJ) Press Release on April 3.
The alleged relationships involved 209 physicians in violation of Stark Statute and included employment agreements where:
- Physicians received bonuses that improperly took into account the value of some of their patient referrals; and
- Office leases and compensation arrangements between Intermountain and referring physicians that violated other requirements of the Stark Statute.
Intermountain Discloses Itself
When Intermountain discovered their wrong doing, it disclosed the issues to the government. The OIG’s special agent in charge of Utah, Gerald Roy said, “I applaud Intermountain for recognizing their liability and coming forward to self-disclose these violations.”
Intermountain is known for a reputation of quality and efficiency of care. In fact, Intermountain’s reputation received accolades from President Barack Obama in a 2009 speech, according to ModernHealthcare.com‘s article, ”Intermountain to pay $25.5 million to settle Stark case.” Obama said in the speech, “We have to ask why places like … Intermountain Health in Salt Lake City … can offer high-quality care at costs well below average, but other places in America can’t. We need to identify the best practices across the country, learn from the success, and replicate that success elsewhere.”
A physical therapy (PT) operation in Tennessee has agreed to pay the federal government for medically unnecessary services.
Therapists have struggled with payment policies over the last three decades as legislative efforts have employed methods that “supposedly” aim to bring the cost of services down by paying for the quality, rather than quantity, of care. Lynn S. Berry, PT, CPC, said “Therapists must juggle clinical concerns with documentation burdens to meet the challenge” of reimbursement.
While most therapists are meeting these challenges, a few have bent under the pressure of lowered payments. For example, Grace Healthcare, LLC and its affiliate Grace Ancillary Services, LLC (Grace) in Chattanooga, Tenn. On March 8, the Department of Justice (DOJ) and Office of Inspector General (OIG) announced that Grace’s therapy providers agreed to pay $2.7 million, plus interest, to resolve allegations of false billing for medically unnecessary therapy services.
According to the DOJ press release:
“The settlement resolves claims that in ten nursing home facilities in which Grace provided physical, occupational, and speech therapy for periods ranging from 2007 through June of 2011, Grace pressured therapists to increase the amount of therapy provided to patients in order to meet targets for Medicare revenue that were set without regard to patients’ individual therapy needs and could only be achieved by billing for a large amount of therapy per patient.”
Don’t let this happen to you. While waiting for more positive changes in the reimbursement system, there are things therapists can do to improve the current situation.
Properly Document when Using New G Codes and Severity Modifiers
To ensure you are compliant when rendering PT services, Berry’s recommendation is to “provide an audit trail by documenting in the medical record the G codes and severity modifiers, their rationale for use, and the pertinent tests provided. After the primary impairment goal is reached, a secondary impairment may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer.” The G codes and severity modifiers for PT, occupational therapy, and speech-language pathology are noted in the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule.
Will Payment Challenges Get Better for PTs?
There is positive action taking place on the horizon. According to Berry:
“For PT, the American Physical Therapy Association (APTA) is already working on a new payment system. Their draft of an Alternative Payment System (APS), or the Physical Therapy Classification and Payment System (PTCPS), was released to members for comment March 15, 2012. The CPT® Editorial Panel in Memphis, Tenn., Oct. 2-3, 2012, fully supported their efforts. A workgroup will be started that is open to all advisors to rewrite the Physical Medicine and Rehabilitation Section of CPT®. This is a two-part, per session payment system: One set of codes for evaluations, and another set of per-session codes for treatments. Each combines consideration of the complexity of the visit and the severity or complexity of the patient’s condition. APTA expects this system to begin Jan. 1, 2015.”
When that system goes into effect, “therapists can then move forward to provide efficient, effective care for their patients and meet the challenge of high quality care at reasonable cost,” said Berry.
For more information on capturing proper reimbursement for therapy services, read the articles “Therapy Services: The Uphill Climb to Better Codes and Reimbursement” and “PTs Rise to 2013 G code Challenge” in March 2013 Cutting Edge.
March 14th, 2013
By Ida Landry, MBA, CPC
Knowing coding and billing rules, and following them with integrity, is key to success.
Compliance is an important part of medical coding. Novice coders are instructed early on that “correct coding is the No. 1 objective,” and “if it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding and billing regulations and have a solid code of ethics.
Know How Compliance Fits into Today’s Coding and Billing
Payment is generated or denied by the guidelines, rules, and federal laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the Tax Relief and Health Care Act of 2006 and the Affordable Care Act of 2010 have mandated more oversight regarding documentation and coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808.
A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to meet the growing need for proper coding and documentation.
Key Compliance Principles
To understand fully coding compliance and be an effective medical coding compliance professional, you must have a commitment to the core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.
These core elements can be realized through successful instruction, education, and guidance of compliant coding and documentation requirements.
Compliance Means Trust, Not Opinion
As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on appropriateness of coding or documentation. If established guidelines, specifications, and/or legislation cannot provide validation, than any guidance given is considered opinion.
Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding community where trust is destroyed.
Trust also is abused when a compliance professional tells a coder one thing and the health care provider something different. This behavior can stem from provider pressure or a provider’s inability to comply with rules and guidelines. To prevent inconsistent information from being disseminated, present the same guidelines, rules, and regulations to all parties involved. Using information consistently also shows ethics and integrity. To maintain consistency throughout an organization, consider following a code of ethics.
Code of Ethics
AAPC has a code of ethics which addresses coding professionalism and compliance integrity. The eight components of AAPC’s Code of Ethics are:
- Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
- Respect the privacy of others and honor confidentiality.
- Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.
- Advance the profession through continued professional development and education by acquiring and maintaining professional competence.
- Know and respect existing federal, state, and local laws, regulations, certifications, and licensing requirements applicable to professional work.
- Use only legal and ethical principles that reflect the profession’s core values, and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
- Accurately represent the credential(s) earned and the status of AAPC membership.
- Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.
Other places to look for a code of ethics are your compliance or coding departments. Human Resource departments also may assist you if your company has a written code of ethics.
Use Compliance Tools at Your Fingertips
You can easily find useful tools to help you attain your goals. Here is a list of some typical resources you use:
- Office of Inspector General (OIG) website – On the “Compliance Guidelines” page, there are links to “Compliance 101 and Provider Education” and “Compliance Resource Material,” as well as other useful tools.
- Coding books - CPT® codebook, CPT® Assistant, ICD-9-CM, HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor, DRG Expert, and the AAPC website
- Government coding/billing resources – Centers for Medicare & Medicaid Services (CMS) manuals; National Coverage Determinations; Medlearn Matters; the Federal Register; 1995 and 1997 Documentation Guidelines for Evaluation and Management Services; Medicare administrative contractors, Local Coverage Determinations, etc.
- Freedom of Information Act – Used to request federal agency records not publicly available.
- Federal acts - Health Insurance Portability and Accountability Act (HIPAA); Health Information Technology for Economic and Clinical Health (HITECH) Act; the Affordable Care Act; Tax Relief and Health Care Act of 2006; False Claims Act; Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Stark law; anti-kickback statute, etc.
- Commercial payer resources – Look to company manuals, websites, webinars, and newsletters for guidance.
- Company compliance manuals – Your employer should be anxious to share its compliance manuals and plans with coding and billing staff.
Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines, and trust and validation at the core of its foundation. If you think you have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.
Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care industry since 1995. She acquired CPC® certification in 2004. Ms. Landry holds a Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge of coding.
March 1st, 2013
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