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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.

Does your hospice have the ‘right stuff’ to ace compliance in 2010?

The coming year will be as difficult as any the hospice industry has ever faced from a regulation and compliance perspective, the experts lament. Are you ready for the increased scrutiny that healthcare reform, the new conditions of participation (CoPs), and a slew of other regulation-related challenges will bring your way?

Many of the challenges you’ll face in the coming year are “oldies,” says attorney Connie Raffa with Arent Fox in New York, NY. But that doesn’t mean you can rest easy if things appear to be going smoothly at present. Make certain you’re on top of these key issues.

1. Watch Contracts with Nursing Facilities

Providing hospice care to nursing home patients continues to be a problem under the CoPs. Nursing homes still don’t have parallel CoPs holding them to the same regulations which is bound to create ongoing problems, says attorney Marie Berliner with Lambeth & Berliner in Austin, Texas.

As a result, hospice providers have a lot of the burden in making sure the nursing home complies with the regulations, but they don’t have a lot of leverage, Berliner adds.

Try this: Documenting coordination of care can show that you are following the CoPs, Berliner says. Any communication between hospice staff and nursing home staff constitutes coordination of care: meetings, conversation between the hospice nurse and the nursing home staff member, and so on.

The hospice agency staff needs to document that they did their part, even if they attempted to coordinate care but couldn’t, Berliner explains. Making record of late or unreturned phone calls and other unresponsiveness can help show that you did all you could to meet the requirements even if the nursing home takes action without following hospice procedures and protocols.

Watch out: Be wary of providing services that encourage a nursing home to refer patients to you for hospice care, Raffa warns. Don’t be tempted to provide services that the nursing home should be providing.

Also, make certain that the nursing home staff is clear about which drugs are related to the patient’s terminal illness. Only the hospice agency should bill for these, and if the nursing home does as well, you are double billing.

2. Manage Length of Stay

MedPAC is looking at patients with a long length of stay, recommending that for patients with a length of stay greater than 180 days, the hospice physician or advanced practice nurse (APN) make a face-to face visit with the patient to determine continued eligibility, Raffa says.

Eligibility requirements state that the patient is expected to live six months or less if the illness runs its normal course. The last part of that statement allows for outliers — patients who do live beyond six months, Raffa explains. Good documentation can be the key to making certain your care for long length of stay patients holds up under scrutiny.

Crack the books: Study the local coverage determination guidelines your Medicare Administrative Contractor (MAC) has in place, Raffa advises. Make sure you’re operating with these criteria in mind. Look especially close at their stand on patients with diagnoses of Alzheimer’s disease or failure to thrive. These diagnoses are piquing government curiosity.

3. Mind the Cap

Although recent court cases have called into question elements of Medicare’s hospice cap, don’t expect cap payments to go away. The caps themselves aren’t under fire as being potentially unconstitutional.

The question is instead whether the current regulations implement the statute in the way Congress intended, Berliner says.

Most likely, if there is any court order as a result of these cases, the regulations will be realigned to match up with the statute, Berliner predicts.

This will benefit those hospices with a lot of long length of stay patients and carry-overs from prior stays.

Don’t panic: If you think you might be facing cap liability, there are things you can do, Berliner says. For example, you could try to set money aside now for cap liability in the future. There may be tax implications with setting aside money, however, so consult your attorney before you take action.

Another idea: Use business and marketing practices that will help change your patient mix to stave off future cap problems. You can also look at ways to streamline your business and be more efficient

4. Be Prepared

Do what you should always be doing — know the regulations and check to see that your staff is following them before there’s trouble, says Samira K. Beckwith, president and CEO of Hope Hospice and Community Services in Fort Myers. Fla. Simply training employees isn’t enough, Beckwith says. You need to make certain your employees are upto date on all the latest compliance issues, and then put in place checks that check back to make sure they’re doing the right thing.

Survey says: If you have any repeat issues that have come up on surveys, make them part of your quality assurance program, Raffa suggests.

This will both improve the problem and demonstrate that you are addressing the issue. Take steps to fix things before the government comes knocking again.

© Eli’s Hospice Insider.

Available on CD: 2010 OIG Work Plan Update for Hospice Providers, with Mary Michal.

Coming soon: Do you know the top 10 compliance risk areas for hospice? Mary Michal tells you what they are & how to avoid them.

CMS instructs MACs to suss out sham health care operations.

A favorite tactic of some Medicare fraudsters is to set up ‘dummy’ storefront operations that have billing addresses, but no real health care going on. The feds are on to this trick, and that’s good. But well-meaning providers and suppliers that have moved recently need to take steps to make sure they don’t get caught in the dragnet.

Warning: Even if you voluntarily refund improper payments to your MAC, the RAC might still audit the claim.

If you’ve been sweating it out, waiting for the recovery audit contractors (RACs) to announce where they’ll focus their audit efforts, two RAC contractors have answers.

CMS appointed four RAC contractors to implement its program, but CMS must approve any review issues and the RACs must post them to their Web sites. At this point, only two contractors, Connolly Consulting Inc. (which handles Region C) and HealthDataInsights (Region D) have announced their review areas. The review areas are as follows:

• Blood transfusion codes 36430-36455, which should be billed once per session, despite how many units are transferred.

• Untimed codes, excluding modifiers KX and 59. You should bill one unit of these codes per date of service.

Knowledge Is Your Best Defense: Expert Advice for RAC, CERT and Private Payer Audits. Just one of the informative sessions at the Billing & Collections Conference in Orlando this December!

• IV hydration therapy (formerly code 90760, now 96360). You should report just one unit of this code per patient per date of service.

• Bronchoscopy codes 31625-31628, which you should bill just one unit per date of service (excluding claims with modifier 59).

• Once in a lifetime procedures, which should be billed just once in a beneficiary’s lifetime.

• Pediatric codes that are billed for patients who exceed the age limit defined by the CPT code.

• Pegfilgrastim injections (J2505), for which you should only bill one unit per date of service. Connolly Consulting announced that it will be reviewing the areas above for dates of service beginning on Oct. 1, 2007.

Tip: If you perform any of the seven listed review areas, you may want to start reviewing those records to ensure that you’ve billed properly. But keep in mind, “If you start looking at records retrospectively and find any problems, you create additional obligations on yourself to selfdisclose any wrongdoing,” advises Michael F. Schaff, Esq., with Wilentz, Goldman and Spitzer in Woodbridge, N.J.

Indeed, the CMS Web site notes that if your self-audit identifies improper payments, you should report the improper payments to your MAC, and remit any necessary refunds. “The RAC will be aware of the adjustment, but the refund does not preclude future review,” CMS notes in its RAC FAQs. Analysts advise practices in the other RAC regions to check their contractors’ Web sites regularly to determine whether they have posted their audit issues yet.

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Question:

Answer: Giving your claims a clean bill of health may be the best medicine for keeping the RACs off your case.

Since RACs can request records going back three years, “the sooner a provider identifies its issues and corrects them moving forward, the better,” says Steve Lokensgard, special counsel at Faegre & Benson LLP in Minneapolis.

Correction your best policy: Whenever a nursing facility discovers that it has made a billing mistake, it should seek to correct the problem and make repayment, advises attorney Paula Sanders, partner with Post & Schell in Harrisburg, Pa. If your facility thinks it has a systemic issue with billing, it should consult with counsel and decide whether a voluntary disclosure is the best way to proceed, Sanders says.

“If a provider does a self-audit, and identifies and self-reports the improper payments, those claims will be adjusted and excluded from RAC review,” says Sanders. This exclusion also applies to findings included in a self-disclosure, “as long as the Medicare Administrative Contractor confirms that a payment error exists and the sampling/extrapolation method was correct,” she adds.

AUDIO: Improve Medicare billing in your SNF by fixing these top 5 errors.

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