Risk Assessment - 101

Documentation & Reporting Warning Flags & Bow Shots

UCSF Clinical Enterprise Compliance Program CECP Education Series Wanda T. Ziemba MFA RHIT CHCO CHCC CHC CPC Associate Compliance Officer & Clinical Enterprise Compliance Program Educator

MGBS Brown Bag Series May 19, 2006

Agenda n Brief presentation u Role of the HHS – Office of Inspector General u Target Issues u OIG Workplan u OIG Orange Book u OIG Red Book u Fiscal Intermediary Responsibility u What can you do? u Information Links u Questions

“How can you monitor potential red flags if you do not know what the issues are that are of importance to the Federal Government?”

Your Role n Awareness of the Government focus n Systematic observation and/or review of practice reporting patterns n Mechanism for providers to access information n “Red Flag” savvy

Big Brother is Watching n But not really watching the practices directly n Monitoring the Fiscal Intermediaries as a function of contract control n And who is the OIG anyway?

HHS – Office of the Inspector General n The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. n The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging.

n Issues developed are directed to the fiscal intermediaries, not the provider directly n Effort to reduce waste in the sponsor system n Will likely trigger FI focused medical reviews (FMRs) and/or systematic reductions in reimbursement

n Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. n Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

Target Issues

How Does a Service Become Targeted For Review? n Where billing or reporting expenditures have increased beyond projections or expectations

Example: Increased reporting of Care Plan Oversight 15 million reported in million in 2001

Example: Increased utilization of wound care CPT codes 98 million in million in 2002

n Sudden or increased changes in practice reporting patterns u CPT code level or type u Provider type

n Initiation of new or innovative technology

n Unexpected volume changes u Increased by carrier u Patient type u Revenue increases u Line item increase

n Deviation from the norm or usual for that medical specialty n Change in category of CPT codes reported n Radical changes in clinical procedure

n Patient-reported billing issues such as co-pay forgiveness, incentives, or irregular balance-billing

HHS – OIG Workplan n Published annually n Addresses all provider types n Develop patterns of target issues n Predict review patterns n Develop policy n Focused internal reviews n Target education

Specific Issues n Professional/Technical components of split services u Cardiography & electrocardiography u Office-based pathology services n Matching with other billing provider n Determination of duplicate billing for one component

n Duplicate reporting u IPPE – G0344 u Incentives to Patients u Previously performed services

Other Fun Publications n Orange Book u Significant, unimplemented changes in operations u Increased operational efficiencies u Conservation of government resources n Red Book u OIG cost-saving recommendations u Not fully implemented u May require legislative, regulatory or procedural changes

How Orange is Orange? n Orange Book Targets Counseling u Inappropriate payments for mental health u Provision of services in physician’s offices as well as behavioral health professionals F >200 million in overpayments noted

n Issues u Lack of documented Medical Necessity u Poor documentation u Entire missing records u Incorrect submission of CPT and ICD-9-Cm codes u Unqualified providers u Inappropriate or excessive testing u Provision of services to patients who may not benefit form the care rendered

n Recommendations u Develop list of mental health testing tools u Pre and post payment reviews u Education efforts u Data analysis of claims u Update MedLearn Matters

Are You Seeing Red Yet? n CCI u Recommendation that the CCI be implemented on a state level for Medicaid u Currently in use by all Medicare Fiscal Intermediaries u Federal Government projects a cost savings of 54 million n Become familiar win unbundling rules both CPT as well as CCI

n Nail Debridement & related services u Inappropriate Medicare payments u Medical necessity n When a nail debridement charge is denied, all related services will also be denied. n Last year 51.2 million inappropriate payments were reported; 45.6 related also denied

Summary n Know the rules n Be Aware of the billing patterns in your practice n Monitor changes n Develop policy n Educate n Check compliance with policy

Where Is the Information? n Workplan, Redbook, Orangebook u n Changes in Medicare Policy u n FI Policy Updates u w.shtml w.shtml

Questions & Next Steps