The Anatomy of an Investigation. AAPC Regional Conference Lisa L. Campbell, CPC, CPC-H Friday, October 8, 2010
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1 The Anatomy of an Investigation AAPC Regional Conference Lisa L. Campbell, CPC, CPC-H Friday, October 8,
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3 Your honor, my client would like to explain the difference between a financial incentive and a kickback. 3
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6 This could be a problem Presentation Overview Our Industry at Risk The Past The Present The Future The Investigation y Players y Key Case Study Presentation Questions 6
7 Our Industry at Risk - The Past Office of Inspector General (OIG) Medicaid id State t Fraud Control Units (MSFCU) Amendments to the Federal False Claims Act of 1863 (FCA) Medicare and State Healthcare Programs: Fraud and Abuse Anti-Kickback k Provisions Stark Law Our Industry at Risk - The Past Operation Restore Trust (ORT) DRG 72 hour window project Project Outreach National Correct Coding Initiative (NCCI) Physicians At Teaching Hospital (PATH) 7
8 Our Industry at Risk - The Past Health Insurance Portability and Accountability Act (HIPAA) Medicare/Medicaid Anti-Waste, Fraud and Abuse Act Compliance Program Guidance (CPG) Project Integrity Our Industry at Risk - The Past Balanced Budget Act (BBA) Provider Self Disclosure Protocol 1999 Who Pay? You Pay Campaign Pneumonia DRG Upcoding Project Civil Monterey Penalties (CMP) Comprehensive Error Rate Testing Program (CERT) Hospital Payment Monitoring Program (HPMP) 8
9 Our Industry at Risk - The Past Medicare Modernization Act (MMA) Permanent Error Rate Measurement (PERM) Recovery Audit Contractors (RAC) Deficit Reduction Act (DRA) Medicare Administrative Contractors Our Industry at Risk - The Present $13,426,803,373, Source: US Department of Treasurary Restoring the Medicare Trust Fund 9
10 Our Industry at Risk - The Future Our Industry at Risk - The Future Coders Billing Managers Physicians Mandatory Compliance Programs 10
11 Key Players in Investigations Government 11
12 Attorneys Consultants 12
13 Case Study Presentation Case #1 13
14 Case #1 - Background Medicare Specialist Matter Claims Appeal Matter Dr. Matter Case #1 - Methodology Interviews Review of Policies and Procedures Appointment Schedule Review Medical Record Review Claims Review 14
15 Case #1 - Results/Conclusion Medicare Specialist Matter Fired Possible jail term for Medicare fraud (case pending) Claims Matter FI reviewed 1192 claims 97% of the services were not medically necessary 3% contained insufficient documentation FI recovered $22,503 Dr. Matter OIG believed there was a potential overpayment of $553, Possible exclusion Hurricane Katrina 15
16 The Salesman & the Matrix Device Case #2 Case #2-Background Physician purchased a new device Sales representatives billing instructions Office staff billed Claims rejected Advice sought Physician wrote off all charges Physician refunds carrier 16
17 Case #2 - Background Charges were based on services rendered to 15 patients t Charged with 62 counts Insurance Fraud (Counts 1-41) Second degree theft (Counts 42-61) Unlawful ownership or operation of business by certain persons prohibited (Count 62) Case #2 - Methodology Interviews Review of Policies and Procedures Appointment Schedule Review Medical Record Review Claims Review 17
18 Case #2 - Results/Conclusion Whistleblower Insurance Fraud Division started an investigation, which included a subpoena of documents pertinent to the allegations Coding concerns Use of CPT code Injection, anesthetic agent, facial nerve Case #2 - Results/Conclusion Expert Witness Requirements Medical Coders CCA CPC CPC-H CCS-P CCS Medical Billers Several years of experience 18
19 Incident to Billing Case #3 19
20 Case #3 - Background Doctor/Owner Physician Assistant Case #3 - Methodology HR Paperwork Appointment Schedule Medical Records Claims Forms 20
21 Case #3 - Results/Conclusion Direct Supervision Plan of Care Corporate Integrity Agreement 21
22 Somethings you should know! Provider Corporate Integrity Agreements Data Mining Claims Comparison CMS 1500 versus CMS 1450 (UB-04) Thank you for your attention! Lisa L. Campbell, CPC, CPC-H Physician Practice Resources, Inc. 22
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