Medical Auditing Solutions LLC Angela Miller, CHC, CMC 1 We will - - PowerPoint PPT Presentation

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

• wners
• 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 5th 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

• ther 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 5th 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  5th 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

• wners/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 5th 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