Setting The Table Inspector General Levinson: IG Daniel Levinson, - - PDF document

IT’S ABOUT THE MONEY: FOUR GOVERNMENT PROGRAMS AIMED AT HOSPITAL POCKETBOOKS

Setting The Table

IG Daniel Levinson, DHHS

• Dr. Peter Budetti, CMS

Senate Finance Committee Chair The Honorable Max Baucus Inspector General Levinson:

• Health Care Task Forces

in the High Risk Areas

• Increase of

Investigators

• Exclusions
• Emphasis on Whistle

Blower False Calms Act

• OIG Audits
• Dr. Budetti
• Zone Program Integrity

Contractors

• Payment Suspensions
• Provider Enrollment

Scrutiny

• Recovery Audit

Contractor

• National Fraud

Prevention Program

Four Financial Hospital Sinkholes for 2012

• Whistle Blowers and the False Claims Act
• Recovery Auditors : Medicare and Medicaid
• OIG Audit Work Plan
• National Fraud Prevention and Other

Programs

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

• 3 Steps Managers Should Take When Hiring

Potential Staff:

• 1). Carefully Screen Job Applications
• 2). Develop Strong Internal Policies
• 3). Minimize Potential Problems with

Employee Termination

Careful Screening

• Whistle Blower Haven: Jobs with access to

information across all departments

– Controllers – Directors of Patient Business Offices – Cost Report – Directors of Compliance – Lab Technicians

Careful Screening

• Biggest Problem: Verifying Applicant

Information

– Education – Past Employment – References

Internal Policies

• Attestation by Employees
• Quick Response to Complaints and Self

Disclosure

• E‐mail Policies
• Data Security

RAC: $797 MILLION Recovered in 2011

• New Name; Recovery Auditors
• New Statement of Work;

– Medicaid in the mix – Audit Parameters based on high propensity for error – Claims Review Process: Semi‐automated review – Timing and Effect of Demand Letter; same date and discussion period – Time Limits regarding provider interaction – 01/2012 – Pre‐pay review on inpatient hospital claims

Preventative Procedures

• Chargemaster review audits
• Coding audits
• Process audits, such as audits of the revenue

cycle or patient flow

• Audits for a percentage of identified issues in

a specific department

Preventative Procedures

• Audits for specific service type or code that

may be an issue (e.g., evaluation and management codes, therapy codes)

• Audits of internal policies and processes, such

as patient transfers and bed assignment

• Audits of code pairs and related modifiers
• Cooperation /Collaboration and Conflict

– 5% appealed, 54% overturned

OIG Audits

• 2012 OIG Work Plan – Holistic approach
• Hospital Audit Hot Spots – Senior

management – Exclusions?

• Hospital Work Plan and Prevention – Does it

apply to your hospital.

Intensive Hospital OIG Audits

• Inpatient and Outpatient payment to acute‐

care hospitals: Data mining

• Review of present‐on‐admission indicators

submitted on claims

• Acute‐care hospital inpatient transfers to

inpatient hospice care

• Critical access hospitals

Office of Civil Rights Audit

• HIPAA Audits and Enforcement
• 150 audits of covered entities
• Target electronic health records

National Fraud Prevention Program

• Stop “Pay and Chase”: Scrutiny of payment to

physicians

• Daily analysis of

claims/provider/service/geographic area

• Claims tied to physicians for procedures and

prescriptions: surgeries, off‐label prescriptions

• Immediate on‐site and data gathering

procedures

• Individual providers and groups

Jim’s Crystal Ball: 2012 Enforcement and Compliance Issues

• Efficiency and quality:

hospital readmissions; acquired infections

• Target long term care,

home health and community care

• Park Doctrine use on

company executives

• Need for strong

compliance professionals

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.