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Use these strategies to update your compliance plan before an auditor strikes if you can.

Although an audit is a routine function that the OIG and payers must perform, it can strike fear into the hearts of medical practices everywhere. If you get word that your practice will soon be audited, follow these basic tips to help put your best foot forward.

1. Prepare Far in Advance. Don’t wait until the OIG or your MAC alerts you that an audit is imminent before you get a handle on where you stand from a compliance standpoint, says Patricia Trites, MPA, CHBC, CPC, CEMC, CHCC, CHCO, CHP, CMP(H), CHAP, vice president of Healthcare Compliance Resources, LLC in Sherman, TX.

“Internal audits are the best way to prepare for an external audit,” Trites advises. “This process allows the practice to find errors and patterns of errors before someone else does.”

“The second step to internal auditing is just as important – education,” she says. “If the providers don’t know or don’t understand why something is incorrect or why another way is better, then the errors are never corrected going forward.”

2. Train Staff When Prepping for Auditor’s Visit. Once you know that an auditor will be paying you a visit, sit down with your staffers to fill them in on the details. Although it may be tempting to keep the audit a secret so you don’t make anyone nervous, it’s in your best interest to keep everyone apprised of the situation.

“I really do believe it is important that affected staff is trained before the auditor comes onsite or even if records are being requested for audit through the mail,” Trites advises. “Staff that knows what is going on are less likely to start rumors or listen to rumors.”

Let staffers know that they should be polite and respectful to the auditor, “and to always, always, always tell the truth,” Trites says. “There are so many types of audits that could be undertaken within a health care practice today it is hard to cover all the bases of what-ifs, but I suggest that staff understand that an audit does not mean that the organization or any of the providers have done anything wrong.”

Remember that many audits are conducted to determine if the carriers/MACs are doing their jobs correctly. Does that mean if they find something the practice has done incorrectly, they will get a pass? “No,” Trites says. “That is why it is important that each person understand their responsibility and liability in performing services, documenting those services, and then billing the services to the various payers.”

3. Follow a Pre-Audit Checklist. If your practice has never performed a self-audit, but you get word that you’ll soon be audited, Trites offers these four tips on how to prepare.

• Don’t panic! Auditors aren’t necessarily on a witch-hunt.
• Pull all encounters that have been selected for audit with all of the accompanying documentation.
• If you believe there may be a problem with your claims or how they were billed, contact an attorney to help you through the audit process.
• Perform an internal audit of the claims and if necessary, hire an external auditor to also review the claims. “It’s best to let the practice attorney engage the external auditor to protect the reports under attorney work product,” Trites notes.

If the attorney hires the consultant, the work performed during the audit falls under the attorney-client privilege, says Michael F. Schaff, a lawyer with Wilentz, Goldman and Spitzer in Woodbridge, NJ.

And remember: If you find a problem, do not alter documentation, alter billing records, destroy records, or in any other way compromise the information, Trites says.

Excerpted from Medicare Compliance & Reimbursement.

There is money to be given out to medical practices for using EMRs. AUDIO: Medical Coding 101: The Need-to-Know for CEOs.

Follow these 3 tips when handling patient privacy concerns at your organization.

Compliance officers may think that they’ve dotted all of their i’s and crossed all of their t’s, but if they miss even a small piece of the privacy puzzle, they can compromise their entire system. Take a look at these three reminders concerning protected health information (PHI) to ensure that your privacy program is on track:

1. Don’t Let Paper Get Lost in the Shuffle. You may think of patient privacy exclusively in terms of protecting electronic patient data, but paper files are just as likely to be compromised. “With the advent of the HITECH changes, breaches occurring with paper records will be treated the same way as electronic data,” says Gregory Michaels, manager of security and compliance solutions at BluePrint Healthcare IT in Cranbury, N.J.

“Doctors may take paper records home as opposed to USB keys, or they may take paper records in their car with them to the office or hospital, and obviously those things have the same value in terms of the information contained in them,” Michaels advises.

Even in facilities where paper records are stored securely, there’s still a chance that the information on them might be exposed. “In some hospitals, the main medical record area is very well secured, but other departments may have access to records, take them from the room, and store them temporarily while using them, and may not be keeping them secure,” he says.

“Even if we can move to 50 or 60 percent of medical practices being fully electronic in the next few years, we’re still looking at a long time before paper is eliminated, so make sure any PHI stored on paper in your office is secure.”

2. Know That Patients Are Aware. You’ve asked patients to sign a HIPAA privacy form, now they’re content, right? Not necessarily. “The HITECH Act imposed an affirmative obligation on the government agency overseeing the HIPAA program to investigate compliance breaches,” says Michelle Wilcox DeBarge, a lawyer with Wiggin and Dana LLP in Hartford, CT. “Previously it was driven by complaints only, but they now have an obligation to affirmatively audit and monitor.”

In addition, the government has been hiring people to ensure compliance and will be providing education programs to the public, “and we’re expecting a lot of awareness, and for patients to be asking more questions about the use of their private health information going forward,” says Peter Courtway, chief information officer for Danbury Health Systems in Connecticut.

“There is also a provision under HITECH that will allow individuals who have been harmed by a breach to have a share in the proceeds of the penalties,” DeBarge says. “We don’t have the details yet, but this is another reason that patients will have incentive to pay attention.”

3. Don’t Forget the Front Lines. You may be compromising patient data in other ways besides electronic and paper breaches. Perform a walkthrough in your practice or organization to ensure that no other leaks exist.

According to one HIPAA expert, a compliance officer walked through her practice and was pleased to see that computer monitors at the front desk had been turned so that patients in the waiting area could not see the screens. However, upon going to the elevators, she realized that the monitors were viewable through the glass entryway, and that anyone in the building’s lobby could see the data.

Excerpted from Health Information Compliance Alert.

There is money to be given out to medical practices for using EMRs – Don’t let your coding suffer. AUDIO: Medical Coding 101: The Need-to-Know for CEOs.

Death from prescription drug overdose has risen significantly over the years, becoming the second leading cause of unintentional injury death, after motor-vehicle injuries. Does your compliance program address how your organization or practice dispenses controlled substances?

Abuse of prescription drugs known as opioid analgesics — powerful, addictive drugs like OxyContin and Vicodin that produce heroin-like effects — can be common. In 2002, a Government Accountability Office (GAO) report disclosed that state monitoring programs help to deter addicts from gaining access to controlled prescription drugs.

Under the National All Schedules Prescription Electronic Reporting Act (NASPER), passed in 2005, the feds have only shelled out about $2 million of the $50 million that was supposed to be appropriated to develop programs that help doctors track “pharmaholics.” Now Congress is being pushed to reauthorize the bill and get that money flowing to help states without drug-tracking databases to establish such systems, and to standardize programs across state lines.

The fact that regulation of this area is a patchwork of state and federal regs, with states running different systems, means that more loopholes exist for offenders to exploit. The solution is to have a national prescription drug database that will monitor controlled substances, according to a Government Today article.

“Patients moving from one jurisdiction to another will typically be able to obtain multiple prescriptions by merely crossing state lines,” said the American Society of Interventional Pain Physicians. “The conscious and more prevalent unconscious misuse of Schedule II, III and IV (e.g., cocaine and anabolic steroids) controlled substances, are a national problem that cannot be effectively addressed on a state-by-state basis.” The ASIPP is pushing to get NASPER reauthorized.

Collect what your practice really deserves. AUDIO: You Can Use the Appeals Process Like a Pro.

Experts reveal three ways to stay compliant in this increasingly hot risk area.

Last week, we addressed how the feds will likely be increasing their scrutiny of financial relationships between physicians and DME manufacturers. buy cialis online The people who are looking for the best medicines that are used for the enhanced timing and stamina. While it may be hard to say whether prosecutions against individual practitioners will increase, it’s always good to see a risk area developing ahead of the game.

When prosecutors see cases that are not necessarily in a gray area, where intent won’t be difficult to prove, “I don’t think they will hesitate to bring them,” predicts John Oroho an attorney with Porzio Bromberg & Newman in Morristown, N.J.

The good news is that physicians can keep their financial dealings with manufacturers in the safety zone. Here’s how:

Strategy 1: Pay close attention to how you set up financial relationships. Of course physicians can still do deals with manufacturers, but they have to be careful about how the arrangements are structured, advises John Jones Jr., a lawyer with Pepper Hamilton in Philadelphia. The arrangements “need to be set at fair market value [and] be at arm’s length,” he says. “A physician consultant has to actually perform the services” for the company, he adds. And the physician cannot get paid for referrals.

For example, suppose a surgeon serves as a consultant to a device maker and has a royalty arrangement for helping to engineer the device-maker’s implantable orthopedic device. In that case, the physician can’t receive royalties on the devices used by the hospitals where he practices and implants the devices, says Jones. (The doctor can, however, receive the usual third-party reimbursement for performing the surgeries.) “This applies to any product,” Jones says.

“On the pharma side,” Jones adds, “we have seen doctors sometimes actually become an extension of a [drug company’s] sales force where they get into marketing a drug – that’s a big no-no.” But: “Just because a pharma company paid a physician $50,000 in consulting fees in a given year would not in and of itself be sufficient to prove that that physician” violated the anti-kickback statute,  counsels attorney Daniel Margolis, with Pillsbury Winthrop Shaw Pittman in New York City.

Neither should “the mere fact” that the physician serving as consultant to the company prescribes significant amounts of the company’s drug. Margolis notes that “oftentimes, companies retain physicians as consultants or speakers because they know the physician is familiar with the drug and … genuinely believes it has worked well in his or her practice.”

Strategy No. 2: Take the high road with self-disclosure. Jones advocates physicians disclosing their relationships with manufacturers/vendors to hospitals and their other practice sites. And “even if not required by state law, physicians should consider disclosing that [information] to the patient ….”

Wayne J. Miller, an attorney with The Compliance Group in Los Angeles, points out that “many doctor groups and facilities already require medical staff or member doctors to disclose arrangements with vendors as part of a conflict of interest review.”

Also, decisions about what product to use “should always be based on input from multiple doctors as to [the product’s] medical quality, cost and other appropriate facets,” says Miller.

Strategy No. 3: Consider unwinding problematic relationships with manufacturers, advises Miller. That may be appropriate to do, especially with ones that have already been under scrutiny, he says. Also consider whether to disclose a terminated relationship to the government or payors “to the extent there may be a legal or reimbursement impact.”

Excerpted from Medicare Compliance & Reimbursement.

Your case management struggles may have a simpler fix than you realize. AUDIO: Back to Basics: Case Management Roles and Models Revisited.

Transparency of prescriber-supplier relationships is increasing.

With the new health care reform law in place, the feds will soon be able to take a harder look at financial relationships between physicians and companies that make drugs, biologics, medical devices and supplies.

The feds are already hot on the trail of medical device manufacturers concerning mortality rates and quality. Here’s what you need to know and do to stay out of federal prosecutors’ crosshairs.

The PPACA incorporates provisions of the Physician Payment Sunshine Act, which requires manufacturers to report annually to HHS how much they’ve tendered of value to “covered recipients,” e.g., physicians and teaching hospitals.

The annual reporting requirement goes into effect on March 31, 2013 for payments made from Jan. 1 through Dec. 31, 2012. The companies have to report the date, amount, and form of payment (cash, stock, services, etc.), whatever the arrangement is – and the product involved, says attorney John Jones Jr., with Pepper Hamilton in Philadelphia. (Manufacturers don’t have to report anything under $10 unless the annual aggregate amount to a “covered recipient” surpasses $100.)

The government, says Jones, can look at the payment information reported by manufacturers and say, “‘Hey, wait a minute, Dr. A in Philadelphia got $15 million a year from this device maker for consulting services, whereas Dr. B in the same area got $2 million. What’s different about those two arrangements to explain the discrepancy?”

The primary areas where physicians could be vulnerable to prosecutions are “antikickback law and possibly violation of the Stark self referral prohibition,” says Wayne J. Miller, an attorney with The Compliance Group in Los Angeles. “The health care reform act also makes clear that anti-kickback and Stark violations are also to be considered a false claim violation. …”

Miller points out that “recent settlements involving large pharma and some DME suppliers are already resulting in action against facilities.” And he expects “the next tier of enforcement involving alleged kickbacks will move to individual or group providers.”

And device manufacturers are bracing for new guidelines from the FDA, which is getting worried about the safety of devices like infusion pumps, according to a recent piece in the New York Times. DME manufacturers could get hit with new taxes to cover the costs of health care reform, as HIT News reported last week. And where the money goes, so goes the federal nose…

Next week, we’ll cover three compliance strategies physicians can implement to keep their financial dealings with manufacturers in the safety zone, in the midst of increased oversight in this area.

Excerpted from Medicare Compliance & Reimbursement.

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HIPAA Refresher Week: June 21, 2010 to June 25, 2010. AUDIOS: Learn everything about HIPPA.

Be a funnel, not a tube, Tenet CEO tells audience at a recent compliance conference.

Tenet Healthcare Corporation’s now-legendary $900 million bust began with hospital divestiture trouble in 2002 and only ended in 2006 after upcoding and kickback allegations (among other things) resulted in a 5-year corporate integrity agreement between the Dallas-based health care giant and the HHS OIG.

Tenet learned its lesson and is now on the front lines of the compliance industry, spreading the word about how to make sure the upper echelons of health care organizations are clued in on compliance issues. That was the message delivered to the HCCA Annual Compliance Institute on April 19, 2010 in Dallas, where Tenet CEO Trevor Fetter’s presentation focused on the five top ways a compliance officer can best serve his or her CEO.

The theme of Fetter’s presentation was that CEOs are busy but they need to know key information about compliance in order to effectively lead. How they get that key information is the job of the compliance officer, whose job is not just to ferret out bad apples but to also collect, analyze and add value to the information she passes to the CEO.

Fetter was introduced at the HCCA conference by Tenet’s Chief Compliance Officer Audrey Andrews. After new management took charge in 2003, Tenet significantly expanded its compliance and ethics function by creating a separate corporate compliance department with a chief compliance officer who reports directly to the Tenet board, according to a 2006 Tenet press release announcing Andrews’ position as CCO.

Fetter’s five tips for COs included:

1. Be a funnel, not a tube. Don’t just pass information along wholesale, he said, with no discrimination as to what’s important and what’s not. COs need to distill information down into its most salient points, Fetter emphasized.

2. Analyze this. After whittling down the information to what’s crucial, Fetter added that COs should analyze what they send to the top. Again, don’t just pass it along; add value by contextualizing what you learn into the institutional knowledge an effective CO must have.

3. Make risk assessment, devote resources appropriately. Any issue that could put your organization’s federal health care program at risk should be reported to the CEO, Fetter said.

Part of analyzing the huge amounts of information a CO receives is knowing how to make those crucial risk assessments as to what’s really a compliance problem. “HR problems are not compliance problems,” he said, for example. As any CO knows, a compliance hotline can be a magnet for HR-related issues. “Be effective at making those distinctions. Your job as CO is to resolve issues that create real compliance problems,” he said.

4. Help your CEO “connect the dots.” Tenet has 50 hospitals, Fetter said, and it’s “impossible” for him to know what’s going on in detail at each one. “But I’m trying to pick things up and recognize patterns,” he explained, giving an example of a situation in which a problem at on hospital may seem like an isolated case but could be happening elsewhere as well. Take action before something seriously derails, he said, because the CO should be seeing such issues earlier than anyone.

And, acknowledging the problem every CO in the country has likely faced at one time or will at some point, be brave. It can be intimidating to have to give your CEO bad news in a strong opinion. Fetter said he’d rather hear a CO speak up about a hunch at the time rather than say, after it’s blown up into a full-on compliance problem, “I knew that was a problem…”

5. See it, say it, fix it. If a CO finds a problem and reports it, she shouldn’t stop there. Don’t just give it to someone else to deal with. Your job is to find, report and fix, Fetter said. “Your job as a compliance officer is to resolve issues that create real compliance problems,” he told the audience.

He used the example of “FYI e-mails,” saying that CEOs don’t want to read long e-mail chains, topped with a simple “FYI,” in order to find out who’s responsible and what’s going on. Which relates back to his original advice – that a compliance officer should funnel information, not just pass it along like a tube.

No one should take advantage of the new health care reform law, says HHS chief.

While many professionals in the health care industry worry over unintended or unpredictable costs brought on by the new reform laws, fraudsters are taking advantage of the confusion to make a fast buck.

That’s according to a recent letter by HHS Secretary Kathleen Sebelius, who warns attorneys general, insurance commissioners and the general public against scammers who offer bogus insurance policies.

The con artists are even going door-to-door convincing people there’s a limited open-enrollment period to buy health insurance now, the Wall Street Journal reports. “But the big expansion of coverage won’t come for another four years, and door-to-door salespeople are unlikely to be part of the plan then,” according to the report.

Seniors and the uninsured are special targets of these fraudsters, Sebelius noted. She has called on federal authorities to throw the book at anyone caught selling fake policies. She has also recommended that all insurance commissioners issue alerts to consumers in their respective states, warning of possible scams.

For the feds’ part, Sebelius has put the Senior Medicare Patrol on alert to watch for scams specifically targeting seniors in the Medicare program.

“Unfortunately, scam artists and criminals may be using the passage of these historic reforms as an opportunity to confuse and defraud the public,” Sebelius said in her letter.

The new health care law may be a blessing to the approximately 30 million uninsured, but the real perks will come in small doses. For instance, a new high-risk health insurance pool will be available as early as the summer to people who have been turned down for coverage because of a pre-existing condition. Two other benefits will take effect in the fall of 2010: (1) no more denying coverage to children with medical problems; and (2) parents can keep their adult kids on their policies until they are 26.

The HHS Office of Inspector General has published a brochure on recognizing Medicare scams. A recent article in The Examiner offers some additional tips:

• Don’t trust policies that claim to be “time limited.” Nothing like that exists.
• No policy should offer limited benefits that are available only because of the new law.
• Beware of policies that are “necessitated by the health care reform law.”

Most importantly, buy policies only from licensed agents. Check your state records for a list of people who are licensed to sell insurance. Every state has one.

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Get the most bang for your drug-billing buck: Tackle Oncology Drug Waste and Off-Label Use.

You might be too young to get benefits, but you’re never too old to commit Medicare fraud: That’s the latest message in the constant string of fraud indictments filed by federal investigators.

A 61-year-old Texas doctor faces two fraud cases on charges of engaging in organized crime in connection with the illegal distribution of painkillers, and conspiring with others to reimburse Medicare and Medicaid about $30 million in nonexistent physical therapy services.

Christina Clardy was indicted last year for her alleged participation in the physical therapy scam against Umawa Oke Imo, owner of City Nursing Services of Texas Inc on Bissonnet. The company billed Medicare and Medicaid some $45 million worth of services—and got paid $30M—despite not employing a single licensed physical therapist or physical therapy assistant, according to a report by the Houston Chronicle.

Clardy was one of the supervising physicians at City Nursing Services, along with Dr. Thaddeus Hume, who was also named in a previous indictment.

“She is disappointed that they have brought her into this now,” says Clardy’s lawyer Chris Downey. “We cannot comment further because we’re just getting a look at the indictment.”

According to federal investigators, Imo, a Richmond-based Nigerian native, paid recruits $100 to $150 to sign blank forms for therapy sessions that were never performed. They also discovered that Imo owns a lavish 25-room home in Nigeria, as well as several luxury vehicles.

With her alleged participation in the scam, the US Attorney has charged Clardy with conspiracy to commit health care fraud, health care fraud and mail fraud. Downey maintains that his client looks forward to proving her innocence.

Pre-signed illegal prescriptions

Clardy also worked at Uptown Medical Clinic in Humble and at Texas Medicine Direct (formerly known as S&G Clinic). Following an arson investigation at Uptown Clinic, the authorities grew suspicious of the clinic’s operations because it had no medical equipment and operated on a cash-only basis.

Clardy allegedly prescribed and dispensed more than 2.5 million tablets of Vicodin, Xanax and Soma last year alone, the Houston Chronicle writes. The investigators found in the clinic “thousands of prescription pads that had been pre-signed by the doctor,” says the article.

The doctor ranks as the ninth biggest prescriber of pain pills in Texas.

Click here to learn how to avoid trouble if the feds show up at your health care facility.

Know what the OIG’s watching to make sure you’re billing properly.

The OIG makes recommendations to CMS throughout the year explaining where they’ve found that the government is losing money on health care and offering recommendations on how to stop the leaks. And when CMS doesn’t follow up on those recommendations, the OIG doesn’t just forget about them.

The “Compendium of Unimplemented OIG Recommendations” lists several areas where the OIG’s suggestions have not yet been put into action. Following are three areas that the OIG identified as being of interest. Use this list to ensure that you are billing these services properly.

1. Facet joint injections. The OIG noted that in 2006, 63 percent of facet joint injection services that Medicare paid did not meet program requirements, resulting in $96 million in improper payments. Although CMS has tightened up its instructions on billing facet joint injections since the OIG’s audit, the OIG remains concerned that MACs won’t institute frequency edits noting how often facet joints should be administered.

2. Chiropractic services. During an audit of chiropractic procedures performed in 2006, the OIG found that Medicare inappropriately paid $178 million, “representing 47 percent of claims meeting our study criteria” – this represents a significant error rate among chiropractic services. In turn, the OIG recommended that CMS enforce policies that would prevent payments for maintenance therapy.

Since then, however, the OIG continues “to recommend that CMS implement and enforce policies to prevent future payments for maintenance therapy and that CMS ensure that chiropractic claims are not paid unless documentation requirements are met.”

3. Part B ultrasound services. During an audit of ultrasounds performed in 2007, the OIG found that 3.2 million claims “raised concern about whether the claims were appropriate,” representing $403 million in Part B charges.

The OIG recommended that CMS monitor ultrasound claims data to detect questionable claims, and the new report indicates that the OIG continues to review these claims “to reduce Medicare’s vulnerability to questionable claims for ultrasound services.”

© Part B Insider

Click here to find out what to do if the feds show up at your office or facility.