Medical Auditing Solutions LLC Angela Miller, CHC, CMC 1
We will discuss how providers are setup for failure out of the box. We will discuss ways to make the providers more successful. We will discuss creating a working relationship versus hostile relationship. We aren’t burying our head in the sand to fraud. We will discuss how miscommunication can happen from the point of provider application process. 2
More prevalent than given credit Even the providers with the best of intentions can have problems ◦ Still had employee that forged MD signatures 3
There are people that just are not good with business concepts in all industries Business owners, especially small business owners ◦ Do the work ◦ Do accounts payable ◦ Open mail ◦ Marketing ◦ Etc ◦ May only be great at one thing Bad at business but don’t usually have intent to do bad things 4
First, I am not naïve enough to believe there are no fraudulent providers ◦ Overall, based on experience this to be low number of all providers <20% ◦ Conferences I attend investigators think DME and Home Health are majority fraudulent It is easier to indentify fraud in those businesses Patients get a product from DME Patients get nursing and sometimes supplies from HHA Fraudulent providers don’t hire consultants! Setup secret shoppers ◦ Friend is detective in DFW area, they work with an agency to do secret shopper at pharmacies for “doctor hoppers” 5
Providers, especially Physicians and Dentists Do not believe people would lie to them They get “had” regularly! ◦ By equipment sales people ◦ Software vendors ◦ Other providers Immediately speculating that someone is a bad person never occurs to them Self Disclosure – Note discussion They have a completely different point of view 6
State licensing rules are different from Medicare, Medicaid and many times Commercial Plans ◦ DME – Custom Orthotics includes heat molding, Medicare does not ◦ Physicians – incident to; licensing board general supervision, Medicare/Medicaid and Commercial Plans “in the same suite” ◦ OSHA has rules more on clinical side that may conflict ◦ Accreditation Organizations – may not keep up with all the agencies either The compliance program required may not be a full compliance program 7
Training is lacking ◦ Providers can apply for a Medicare or Medicaid number ◦ Get the number/acceptance letter ◦ No training is provided Suggest a Required a Fraud and Abuse Training with Test prior to issuing provider numbers ◦ Require the owner to attend either online or in person Allow them to have employees go through it Must be on 5 th grade level ◦ Implement Secret Shopper Program and Make it clear they are subject to secret shoppers, without complaint 8
Software vendors ◦ Sell doctors on increasing revenue By click here check boxes and here, etc ◦ Create Templates, Click Boxes, etc. I wonder if trainers have any billing experience No real help to create templates Risk is captured in history Diagnosis captured prior to and may differ from assessments Physicians don’t use key words like stable, acute but have other words that mean same None like us! Remember, providers tend to trust everyone! May have been trained to “copy and paste” ◦ I firmly believe the providers go with the training, they don’t realize the fallout 9
Collaborate and come up with one set of rules ◦ Providers just want one consistent rule ◦ Fraudulent providers make up the information so rules don’t matter to them Training on the Provider business model ◦ E&M Coding ◦ Incident To (Supervising MD and True Incident to) ◦ Procedures and modifiers ◦ Must be easy enough for 5 th grader to understand ◦ Unfortunately, business owners don’t micromanage and cannot micromanage every employee 10
Owners, especially small business ◦ Cannot micromanage every employee ◦ They hire “experienced” employees ◦ Employees bill as they have been taught or by what they think rule says This is why rules need to be black and white 5 th grade level Consistent with state rules Errors happen, this is not fraud Example, I saw a machine that could operate as a CPAP, Bipap, Bipap ST, Invasive and non-invasive Vent; billed as a vent I said no; but low and behold that is the code assigned by the organization division that assigns HCPCS codes; I was wrong 11
Clearer definitions of expectations ◦ Compliance What you want Sanction Screen vs. Criminal Background Check ◦ Fraud & Abuse What is F&A Business Owner is responsible for employees too Hire good people Example of F&A I found as a compliance officer, it helped to associate examples to what people may see with the rules I also made it so simple they couldn’t tell me they didn’t understand. 12
Investigations ◦ Typically are hostile ◦ Self Disclosures are should be friendlier but are uncertain and lengthy. Providers fear of major ramifications Most providers are not trying to do wrong ◦ Most providers are much more cooperative than given credit ◦ Perform Audit ◦ Meet with them, discuss Provide education ◦ They might have an attorney 13
All speakers have similar version My method KISS (Keep It Simple Stupid) ◦ Commitment is all about perception First thing government wants to know is did owners/managers know and what they did about it ◦ Pick hardest guideline apply across the board All payers More work but less confusing for staff ◦ Keep your finger on the pulse before there is a problem Rule Changes, Proposed Rules, Be in the Know ◦ Consistent Discipline 14
My method KISS (Keep It Simple Stupid) ◦ Incident to in every state requires lots of discussion because different than medical board rules When I tell them medical board rules are really irrelevant if they are less than Medicare or Medicaid Rules ◦ Train staff constantly Compliance, OSHA, HIPAA, etc A 5 th grade should understand it Document and Sign off Shows commitment to do things right 15
◦ Inspect What You Expect Cash Flow Management – Monitor for problems & trends They don’t learn enough of this in medical school They don’t have to be experts, just reviewing various monthly reports will help keep staff honest Have clear rules for staff Because the provider nor the staff want “Orange to be their New Black” 16
Is there Fraud? We all know there is, but rules will not prevent Fraud Most providers want to do things right and try really hard! Training at the provider application process Clear Rules and Expectations is vital Trending to identify concerns earlier Audits with errors ◦ Errors happen ◦ provide required training programs 17
Angela Miller, President, BBA, CHC, CMC, Medical Auditing Solutions LLC 5004 Lake Vista Dr The Colony, TX 75056 (m) 409-673-7103 angela@MedicalAuditingSolutions.com www.MedicalAuditingSolutions.com 18
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