Amper, Politziner & Mattia LLP Coders Day September 2009

2 Coding and Documentation Audit Index Overview of Coder’s role in HC litigation Case Study #1 Case Study #2 Case Study #3 Conclusion

3 Coding and Documentation Audit Coder’s role in HC litigation Coding specialist Gather evidence for HC attorney Expert witness in Court

4 Coding and Documentation Audit Case Study #1 Situation Medicare sends an audit letter to the practice No indication of the reason for nonpayment Payment for all Medicare services stopped Practice retains HC legal counsel Legal counsel retains Amper

5 Coding and Documentation Audit Case Study #1 Results of Amper Review All office visits billed at levels 4 or 5 Numerous lab tests per patient per visit Numerous procedures at every visit Numerous high risk diagnosis at every visit Medicare nurse reviewers requested additional documentation to complete their review

6 Coding and Documentation Audit Case Study #1 Results of Amper Review Additional documentation supplied to Medicare Medical Director states he has a medical necessity concern even though documentation is complete Audit is disruptive to the practice’s cash flow Importance of a Compliance Program Billing Company role for documentation

7 Coding and Documentation Audit Case Study #1 Results of Amper Review Managing partner to discuss clinical approach with Medicare’s Medical Director Healthcare attorney involvement for all discussions with Medicare Numerous coding and documentation corrections noted to the practice by Amper

8 Coding and Documentation Audit Case Study #1 Outcome of Efforts Negotiated settlement with Medicare No Fraud indictments issued Practice no longer services Medicare patients

9 Coding and Documentation Audit Case Study #2 Situation Private payor audit regarding consultations Payor requested an overpayment request in excess of $500,000 from the practice Payor threatened fraud indictment Practice retained HC legal counsel Legal counsel retained Amper

10 Coding and Documentation Audit Case Study #2 Results of Amper Review Consults billed for all visits including new and established visits Frequent and repetitive administration of testing procedures High number of procedures performed on family members Diagnosis did not support level of office visit or medical necessity

11 Coding and Documentation Audit Case Study #2 Results of Amper Review Practice invested in an electronic medical records system – HC attorney suggested to use this investment as a defense against the payor Inadequate documentation for any visit Missing patient chart information Missing documentation of procedures

12 Coding and Documentation Audit Case Study #2 Outcome of Efforts Overpayment request by payor reduced by 40% Physician no longer serviced patients from payor Fraud charges not brought against physician Physician sold practice

13 Coding and Documentation Audit Case Study #3 Situation Physician sued by an imaging management company for overpayment of professional services Portrayed as a contract dispute between management company and the physician Physician retains HC legal counsel Legal counsel retains Amper

14 Coding and Documentation Audit Case Study #3 Results of Amper Review Management company billed global charges under the physician’s provider number One owner of management company debarred from Medicare, but company continued to bill Billings under the physician’s name after he retires

15 Coding and Documentation Audit Case Study #3 Results of Amper Review The same series of ultrasounds and/or echocardiograms were performed on all patients Numerous billings for family members Incorrect reporting of diagnosis or procedures to maximize payments Billings also submitted incorrectly to all private payors

16 Coding and Documentation Audit Case Study #3 Outcome of Efforts HC attorney turned over Amper findings to U.S. Attorney’s office Criminal charges brought against owners of imaging management company Physician was not required to return any overpayments requested by the management company

17 Coding and Documentation Audit Conclusion Fraud and abuse is prevalent in healthcare Coder plays a key role in the proper billing of services Coder assists legal counsel defend providers in requests for overpayments Essential for all healthcare organizations to have Compliance Programs

18 Coding and Documentation Audit Contact Information Michael J. McLafferty CPA, MBA, FACMPE, CHFP Partner, Healthcare Services Group Amper, Politziner & Mattia LLP Office – Extension 1284 Cell “The material contained in this presentation is for general information and should not be acted upon without prior professional consultation.”