7/19/2018 1 Fill Your Audit Toolkit for Today’s Practice Presented by: Kathy Mills Chang, MCS-P, CCPC, CCCA What’s An Audit….Really….? Known Violations: Per OIG Submitted claims for services that were never provided Submitted claims for medically unnecessary services Offered incentives to patients to receive unnecessary services Provided services without a valid chiropractic license Falsified patient records, and Billed for chiropractic services but provided services not covered by Medicare (e.g., massage and acupuncture) Inducement Violations • Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law] • No more than $15 per item or $75 in the aggregate annually • Even one free examination, x-ray, or therapy is a risk OIG Makes Recommendations to CMS Through Findings and Published Reports CMS Takes Recommendations Under Advisement CMS Does or Doesn’t Pressure MACs to Manage Errors MACs Audit and Put Pressure Downward on the Providers Providers Don’t Heed Advice and Show Improvements The Process When Something Smells Fishy!
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Transcript
7/19/2018
1
Fill Your Audit
Toolkit for Today’s Practice
Presented by:Kathy Mills Chang, MCS-P, CCPC,
CCCA
What’s An Audit….Really….?
Known Violations:
Per OIG
Submitted claims for services that were never provided
Submitted claims for medically unnecessary services
Offered incentives to patients to receive unnecessary services
Provided services without a valid chiropractic license
Falsified patient records, and
Billed for chiropractic services but provided services not covered by Medicare (e.g., massage and acupuncture)
Inducement Violations
•Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law]
•No more than $15 per item or $75 in the aggregate annually•Even one free examination, x-ray, or therapy is a risk
OIG Makes Recommendations
to CMS Through Findings and
Published Reports
CMS Takes Recommendations Under Advisement
CMS Does or Doesn’t
Pressure MACs to Manage
Errors
MACs Audit and Put Pressure
Downward on the Providers
Providers Don’t Heed Advice and
Show Improvements
The Process When Something Smells Fishy!
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Outliers Are Audited & Made Example
The Collection Coach
2013 2014 2015 2015
“Establish adequate policies and procedures
to ensure that chiropractic services billed to
Medicare are medically necessary, correctly
coded and adequately documented.”
2016
First…Just a Few Charts or Visits
•They’ll ask for a representative sample
•That looks like a simple records request
•Fumbling this ball has grave consequences
You May Hear Nothing….Until…
Then, They Ask for it All!!
A Records Request…Now What?
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Why Me?
• Payment Recovery/Recoupment
• Overpayment results in excess expenditures due to
• duplicate submission of the same service or claim,
• payment to incorrect payee,
• payment for excluded or medically unnecessary services, or
• a pattern of furnishing and billing for excessive or non-covered services, as determined in an audit or review. First….Breathe!
• It’s not if…it’s when
• Roll with it
• Medicare is mandated to do CERT Reviews
• Expect them to affect up to 75% of the profession
Ask Yourself These Questions
• Hmmmm…why would they be asking for these records?
• What has the billing looked like to them?
• Is the coding out of order?
• Have I sent them anything yet?
• Could there be external factors?
• What’s KMC University’s phone number?
What Might Be the Trigger?
• Overutilization
• Unspecified codes
• Unusual errors
• Billing errors, like lack of Box 14 changing
• Patient compliants
• Your number came up
Why It LOOKS Fishy…
Steps to Be a Ninja with Records Requests
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1) Know What The Carrier Expects
Each carrier can list specific requirements like:
• P.A.R.T• Mechanism of Trauma
• Any documentation supporting Medical Necessity
• Contraindications
• Copy of ABN
• Non-covered or experimental codes
Aetna Medical Review Policy
Aetna’s Deeper Dive on ART
2) Get The Request Into Proper Hands It’s OK to Ask for Help!
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3) Review the Request for Records
• Pay close attention to the information that is requested.
• Does it meet HIPAA guidelines?
• Are there restrictions in the patients chart?
• What are the dates of service being requested?
• Do you need an extension?4) Carefully Review the Documentation
• Always review documentation prior to sending
• Never alter records after the fact but OK to add dated addenda
• Make sure your documentation shows the patient’s progress or clearly explains why there is no progress yet
• Is it obvious yet?
5) Organize the Materials
• Include all appropriate documentation to support your treatment
• Organize your materials so the chronology of the story is easy to follow with an obvious conclusion –they must allow the service! Organize Your Thoughts
and Your Material
• Episodes of care in the time period are from oldest to newest