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1 Welcome to s Webinar and Audio Conference Training. We hope that the information contained herein will give you valuable tips that you can use to improve your skills and performance on the job. Each year, more than 40,000 physicians and office staff are trained by. For 30 years, physicians have relied on PMI to provide up-to-date coding, reimbursement, compliance and office management training. Instructor-led classes are presented in 400 of the nation s leading hospitals, healthcare systems, colleges and medical societies. PMI provides a number of other training resources for your practice, including national conferences for medical office professionals, self-paced certification preparatory courses, online training, educational audio downloads, and practice reference materials. For more information, visit PMI s web site at Please be advised that all information in this program is provided for informational purposes only. While PMI makes all reasonable efforts to verify the credentials of instructors and the information provided, it is not intended to serve as legal advice. The opinions expressed are those of the individual presenter and do not necessarily reflect the viewpoint of Practice Management Institute. The information provided is general in nature. Depending on the particular facts at issue, it may or may not apply to your situation. Participants requiring specific guidance should contact their legal counsel. CPT is a registered trademark of the American Medical Association Vicar San Antonio, Texas tel: fax: (210) info@pmimd.com

2 Welcome to PMI s Webinar Presentation Brought to you by: pmimd.com Meet the Presenter Lisa Maciejewski-West, MCS-P Faculty On the topic: Top Compliance Concerns for Medical Coding and Billing Staff

3 Top Compliance Concerns for Medical Coding and Billing Staff Presented by: Lisa Maciejewski-West, MCS-P pmimd.com What Is the OIG? Mission Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. Who We Are Since its 1976 establishment, OIG has been at the forefront of the Nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 100 other HHS programs. HHS OIG is the largest inspector general's office in the Federal Government, with approximately 1,600 dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs. A majority of OIG's resources goes toward the oversight of Medicare and Medicaid programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens. OIG's oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration. What We Do We carry out our mission using a multidisciplinary, collaborative approach, with each of our six components playing a vital role. A nationwide network of audits, investigations, and evaluations results in timely information as well as cost saving or policy recommendations for decision makers and the public. That network also assists in the development of cases for criminal, civil and administrative enforcement. SOURCE: oig/about us/ 11

4 The OIG WORK PLAN is the document used to identify top compliance concerns each year. The OIG Website contains a wealth of information pertaining to compliance, including articles and publications on individuals/entities who have committed fraud. Additionally the OIG maintains a database of individuals who have been EXCLUDED from the Medicare program. Individuals who suspect FRAUD in their organizations are also able to report such fraud through the OIG website The Seven Elements of a Compliance Program A brief description of the seven essential elements of an effective Compliance Program as suggested by the OIG is: 1. Implementing Written Policies 2. Designating a Compliance Officer/Contact 3. Conducting Comprehensive Training and Education 4. Developing Accessible Lines of Communication 5. Conducting Internal Monitoring and Auditing 6. Enforcing Standards through well publicized disciplinary guidelines 7. Responding Promptly to detected offenses and undertaking corrective action Source: Federal Register / Vol. 64, No. 192 / Tuesday, October 5, 1999 / Notices 22

5 Identifying Compliance Issues The OIG Identifies Compliance Issues within the Department of HHS in a number of ways: Data Mining Audits (CERT, RAC) Investigations Whistle Blowers (Qui Tam) OIG Work Plan Penalties for Non-Compliance Penalties for Non-Compliance vary, and depend on a number of factors. Penalties may include, but are not limited to: Recoupment of incorrectly paid claims Civil Money Penalties ($3,000 - $10,000 per incident/claim) Example: An organization that allows a provider excluded from Medicare to provide services to patients can incur a $10,000 PER INCIDENT fine. Criminal Fines imposed by Judge (Federal Sentencing Guidelines) 33

6 Federal Sentencing Guidelines Federal Sentencing Guidelines were established in 1991 to determine the extent of penalties for abuse and fraud. Mitigating Factors that could determine the severity of penalties: Did you pay back $$ that you owe? Do you self monitor (do you have a compliance program) Culpability Score (what did you do RIGHT?) Helps to calculate sentencing Did upper level employees participate in, or condone, or were willfully ignorant of offense? Did organization report offense promptly? Did organization cooperate with investigators? Did organization accept responsibility? Data Mining Software within Software Tracks information about provider Who rendered services (based on claim form) Who got paid Tracks errors Submission Errors (Clearinghouses and Carriers) Coding Errors Missing/incorrect modifiers ICD coding errors (not coding to highest level of specificity, dx to procedure coding errors) POS Errors NCCI (National Correct Coding Initiative) Edits Looks for invalid coding combinations Tracks codes that have been unbundled When claims submission errors reach a certain level on a consistent basis, it could and may trigger an audit. 44

7 CERT (Comprehensive Error Rate Testing) Audit SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT 55

8 SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT 66

9 SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT 77

10 SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT 88

11 SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT 99

12 SOURCE: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/CERT/index.html?redirect=/CERT RAC Audits-the Next Step SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1010

13 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1111

14 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1212

15 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1313

16 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1414

17 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ 1515

18 SOURCE: statistics data and systems/monitoring programs/medicare ffs compliance programs/recovery audit program/ QUI TAM (Whistleblowers) Most often someone within your organization Sometimes a patient Usually Anonymous (Providers won t know where allegations come from) however OIG compensates whistleblowers with % of recoupments if fraud is validated and prosecuted If employee comes to you with concern, don t blow it off! 1616

19 THE OIG WORK PLAN What Is the Work Plan? The Office of Inspector General's ( 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. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; the Administrations for Children & Families; and Administration on Aging. 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 of Health & Human Services (HHS). 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. SOURCE:

20 SOURCE: and publications/workplan/index.asp SOURCE: and publications/workplan/index.asp 1818

21 SOURCE: and publications/workplan/index.asp FOCUS OF TODAY S PRESENTATION SOURCE: and publications/workplan/index.asp 1919

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26 SOURCE: and publications/workplan/index.asp Questions? Thank you for your attendance! Get your questions answered on PMI s Discussion Forum: