Presenting a live 90 ‐ minute webinar with interactive Q&A Medicare and Medicaid Audit Sampling Strategies Creating Sampling Plans and Challenging Flawed CMS Audit Samples THURS DAY, JULY 7, 2011 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific T d Today’s faculty features: ’ f l f Patricia L. Maykuth, Ph.D, President, Research Design Associates , Decatur, Ga. Edward M. Roche, Ph.D., J.D., Director of S cientific Intelligence, Barraclough Ltd. , New Y ork The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
Continuing Education Credits FOR LIVE EVENT ONLY For CLE purposes, please let us know how many people are listening at your location by completing each of the following steps: • In the chat box, type (1) your name , (2) your company name and (3) the number of attendees at your location number of attendees at your location • Click the arrow to send
Tips for Optimal Quality S S ound Quality d Q lit If you are listening via your computer speakers, please note that the quality of your sound will vary depending on the speed and quality of your internet connection. If the sound quality is not satisfactory and you are listening via your computer speakers, you may listen via the phone: dial 1-866-443-5798 and enter your PIN when prompted Otherwise please send us a chat or e mail when prompted. Otherwise, please send us a chat or e-mail sound@straffordpub.com immediately so we can address the problem. If you dialed in and have any difficulties during the call, press *0 for assistance. Viewing Qualit y To maximize your screen, press the F11 key on your keyboard. To exit full screen, press the F11 key again press the F11 key again.
Presenters Presenters Pat MAYKUTH, Ph.D. Research Design Associates, Inc . Edward M. ROCHE, Ph.D.,J.D. Barraclough Ltd. 4
5 “Defending Health Care Providers” Medicare Audits
6 The problem of Medicare fraud
A Agenda d ✤ Introduction (ER) ✤ Statistics (PM) ✤ Statistics (PM) ✤ Appeals Checklist (ER) ✤ Discussion 7
What is a Recovery Audit Contractor (RAC)? Contractor (RAC)? • Subcontractor to the Federal S b t t t th F d l Government • Auditor of Medicare claims A dit f M di l i • Paid as percentage of what is recovered recovered • Method used to select targets is "trade secret" trade secret 8
Problems Problems • Most health care providers have a doctorate in medicine, not in bureaucracy, or coding, or in documentation • Health care provider is unaware of the dangers of extrapolation • Failure to seek legal counsel soon enough -- tries to do early F il t k l l l h t i t d l stages of appeal by self • Financing of litigation - is there a calculated market "sweet spot"? 9
Typical violations Typical violations • Medical necessity • Documentation Documentation • Cloning • Missing • Inaccurate or insufficient documentation I t i ffi i t d t ti 10
11 How estimation of overpayment is done is done
Calculated Statistics of Sample p B f Before claim review l i i Af After claim review l i i Choice of Choice of methodology methodology Calculate overpayment Per claim Per claim Si Si Si Simp mple l For sample Stratified Stratif Proportion of claims in error Proportion of claims in error Sample size determination based Sample size determination based on on Calculate point estimate Universe size Unive size Mean Mean Standard deviation or Standard deviation or probe probe Error rates Precision Precision Precision for confidence interval Confidence i onfidence interval al Upper and low er CI 12
When an auditor may use y Inferential Statistics Sustained or high level of payment error determined by: Error rate determinations by MR unit, PSC, ZPIC Probe samples, Data analysis, Provider/supplier history Information from law enforcement investigations I f i f l f i i i Allegations of wrongdoing by current or former employees of provider or supplier provider or supplier Audits or evaluations conducted by the OIG Medicare Program Integrity Manual § 3.10.1.4 13
Overview of the sampling process Overview of the sampling process Sample Universe Definition Definition Frame (dates; Frame (dates; Sample Size (who; why; (simple; units; criteria) what data) stratified) Seed & Pick Out Random Sample p Numbers Numbers 14
Definitions Definitions Universe All claims that were submitted to Medicare Sampling Unit What was sampled: by claim, by patient, etc. Frame Frame A part of the universe A part of the universe Sample A randomly chosen set of (usually) claims Overpayment How much the health care provider must pay back Extrapolation RAT-STATS DHHS software often used to make calculations 15
Basic statistical terminology Basic statistical terminology Mean (average) the arithmetic sum of all scores divided M ( ) th ith ti f ll di id d by the number of cases Median – the middle most real score M di th iddl t l Mode the score that occurs most frequently in the data set (does not have to be unique – sometimes more than 1 (d h b i i h 1 value is equally likely) Measures of variability, precision and confidence interval 16
17 Normal Distribution Normal Distribution
18 Confidence Interval
Precision and Lower Bound Precision and Lower Bound Point estimate $1,000,000 Precision amount at 90% two-tailed confidence $140,000 Lower bound at 90% two-tailed confidence = $860 000 $860,000 Point estimate minus Precision amount Precision percent = Precision amount divided Precision percent Precision amount divided 14% 14% by Point estimate 19
The point estimate, precision and p , p lower bound Confidence Interval Point Estimate Refund Demand Refund Demand 20
Stratification Stratification (numbers are illustrative only) Universe File All claims for the provider for audit time period time period 152,480 claims Stratum 1 S S Stratum 2 S Stratum 3 S Stratum 4 >$10 <$68 >$69 <$200 >$201 <$500 >$501 107,466 claims 30,387 claims 10,969 claims 3,658 21
22 22
RAT STATS Sample Size Determination RAT-STATS Sample Size Determination # S # Strata MEAN STD DEV UNIVERSE MEAN STD.DEV. UNIVERSE RATIO 1 <$150 76.37 43.97 8,882 45% 2 $150-$350 216.06 55.08 3,070 20% 3 $350-$600 482.87 91.72 1,370 15% 4 >$600 4 >$600 962 65 253 59 962.65 253.59 681 681 20% 20% - TOTALS - 189.87 227.17 14,003 23
RAT-STAT Defined Proportion Stratum 4 20% Stratum 1 45% Stratum 3 15% Sample Proportion Used in Audit Sample Proportion Used in Audit Stratum 2 20 Sratum 4 Stratum 1 25% 25% Stratum 3 Stratum 2 25% 25% 24
The statistical extrapolation The tremendous magnification is why the statistics must be so statistics must be so The Extrapolation The Extrapolation The Extrapolation The Extrapolation accurate - multiple years of claims - multiple years of claims - interest and penalties - interest and penalties - US Treasury is the collection - US Treasury is the collection agent agent The The Sample Sample Sample Sample - "In case you are filing for - In case you are filing for - "In case you are filing for - In case you are filing for bankruptcy" forms included with bankruptcy" forms included with all demand letters all demand letters $978 00 $978.00. $1,369,000. 25
26 The appeals strategy
The appeals process The appeals process Contractor QIC ALJ ALJ Re-Determination Re-Consideration Determination 27
The Administrative Law Judge The Administrative Law Judge • Federal administrative law • Medicare Program Integrity Manual (MPIM) • Not adversarial hearing d l h • Discovery Rules -- use of FOIA (Freedom of Information Act) 28
The appeals strategy Strategy Strategy Attack Attack Dispute claims Dispute claims extrapolation extrapolation review review 29
30 Checklist to “audit the auditors”
When Auditor Uses Expert p ✴ Obtain the statistical experts’ written approval of the methodology (dated) ✴ Obtain the policies and procedures for auditors processes and quality controls ✴ Obtain evidence that anyone examined the appropriateness of the findings (signed) ✴ Obtain complete written notes statements and documentation of any statistician used by QIC 31
Data Necessary for Statistical Review y ✤ Audit methodology and logs, signed & dated A di h d l d l i d & d d ✤ Readable electronic data files for universe, frame, sample selection, R d bl l i d fil f i f l l i sample and overpayment at claim line level ✤ Sample selection methodology, size estimation, seed, file sorted as applied and output ✤ Sufficient information to collapse data into CCN, strata or overpayment at every level 32
Recommend
More recommend
