IT’S ABOUT THE MONEY : FOUR GOVERNMENT PROGRAMS AIMED AT HOSPITAL POCKETBOOKS Setting The Table Inspector General Levinson: IG Daniel Levinson, DHHS Senate Finance Committee Chair Dr. Peter Budetti, CMS The Honorable Max Baucus • Health Care Task Forces in the High Risk Areas • Increase of Investigators • Exclusions • Emphasis on Whistle Blower False Calms Act • OIG Audits Four Financial Hospital Sinkholes for 2012 Dr. Budetti • Whistle Blowers and the False Claims Act • Zone Program Integrity Contractors • Payment Suspensions • Recovery Auditors : Medicare and Medicaid • Provider Enrollment Scrutiny • OIG Audit Work Plan • Recovery Audit Contractor • National Fraud Prevention and Other • National Fraud Programs Prevention Program
Whistle Blowers and False Claims Act • 2011: $2.8 Billion Collected in FCA; $383 Million Paid to Whistle Blowers • $8.7 Billion over past 3 years • More Stark/Anti ‐ kickback enforcement re: hospital ‐ physician relationship • Physician Payment Sunshine Act – Payments for speaking engagements, travel, consulting if used as inducement to use sponsor’s product Whistle Blowers: Who Are They? • Employees • Disgruntled Employees • Former Employees • Competitors Protecting From Within Careful Screening • 3 Steps Managers Should Take When Hiring • Whistle Blower Haven: Jobs with access to Potential Staff: information across all departments • 1). Carefully Screen Job Applications – Controllers – Directors of Patient Business Offices – Cost Report • 2). Develop Strong Internal Policies – Directors of Compliance – Lab Technicians • 3). Minimize Potential Problems with Employee Termination
Careful Screening Internal Policies • Attestation by Employees • Biggest Problem: Verifying Applicant Information – Education • Quick Response to Complaints and Self Disclosure – Past Employment • E ‐ mail Policies – References • Data Security Preventative Procedures RAC: $797 MILLION Recovered in 2011 • New Name; Recovery Auditors • Chargemaster review audits • New Statement of Work; • Coding audits – Medicaid in the mix • Process audits, such as audits of the revenue – Audit Parameters based on high propensity for error cycle or patient flow – Claims Review Process: Semi ‐ automated review • Audits for a percentage of identified issues in – Timing and Effect of Demand Letter; same date and a specific department discussion period – Time Limits regarding provider interaction – 01/2012 – Pre ‐ pay review on inpatient hospital claims Preventative Procedures OIG Audits • Audits for specific service type or code that • 2012 OIG Work Plan – Holistic approach may be an issue (e.g., evaluation and management codes, therapy codes) • Hospital Audit Hot Spots – Senior • Audits of internal policies and processes, such management – Exclusions? as patient transfers and bed assignment • Audits of code pairs and related modifiers • Hospital Work Plan and Prevention – Does it • Cooperation /Collaboration and Conflict apply to your hospital. – 5% appealed, 54% overturned
Intensive Hospital OIG Audits Office of Civil Rights Audit • Inpatient and Outpatient payment to acute ‐ • HIPAA Audits and Enforcement care hospitals: Data mining • Review of present ‐ on ‐ admission indicators • 150 audits of covered entities submitted on claims • Acute ‐ care hospital inpatient transfers to • Target electronic health records inpatient hospice care • Critical access hospitals Jim’s Crystal Ball: 2012 Enforcement National Fraud Prevention Program and Compliance Issues • Stop “Pay and Chase”: Scrutiny of payment to • Efficiency and quality: hospital readmissions; physicians acquired infections • Daily analysis of • Target long term care, claims/provider/service/geographic area home health and • Claims tied to physicians for procedures and community care prescriptions: surgeries, off ‐ label prescriptions • Park Doctrine use on • Immediate on ‐ site and data gathering company executives procedures • Need for strong compliance professionals • Individual providers and groups ICD 10 Codes • W5612XA: Struck by a sea lion, initial encounter, • W5609XA: Other contact with dolphin, initial encounter. • X52: Prolonged stay in weightless environment. • Y34: Unspecified event, undetermined intent.
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