Dust Off that Code of Conduct and Give Ethics Center Stage

Have you had one of those re-energizing moments where you want to take something you heard and act upon it right away? That was my experience at the recent Health Care Compliance Association (HCCA) Annual Institute in late April. Participating in a discussion with a room full of compliance and ethics professionals on the topic of business ethics, I found myself wanting to bring ethics more to the forefront of my daily interactions at work.

I read last year’s Wall Street Journal article, “Why We Lie,” to learn an important point: People are less apt to cheat or lie when given reminders of the right things to do at the time they are making a decision. Although we think our ethics training is fabulous, it appears to have less impact on the decisions that good people make every day to do the right thing (or not). The author, a professor of Behavior Economics at Duke University, goes on to describe the contagious nature of cheating, where others may follow the lead of the cheater.

A New Team: Utilization Review and Coding for Medical Necessity?

On March 21, I told you about the new regulation from CMS – 1455R, which is an exciting opportunity for hospitals to recoup some dollars otherwise lost on denied inpatient stays.  Specifically, CMS says,

The hospital may submit a Part B inpatient claim for payment for the Part B services to the extent the services furnished were reasonable and necessary,  that would have been payable to the hospital had the beneficiary originally been treated as an outpatient rather than admitted as an inpatient, except when those services specifically require an outpatient status.

The hospital could re-code the reasonable and necessary services that were furnished as Part B services, and bill them on a Part B inpatient claim. This proposed policy would only apply to denials of claims for inpatient admissions that are not reasonable and necessary, and would not apply to any other circumstances in which there is no payment under Part A, such as when a beneficiary exhausts Part A benefits for hospital services or is not entitled to Part A.

CMS Follows the Money with New Audits

When I read recently about the new pre-payment audit plan to assess accuracy of the Medicare Electronic Health Record (EHR) Incentive Program payments, I was not surprised at all. In fact, I expected these audits would have been conducted sooner. CMS has indicated for years that they are stopping pay and chase (paying claims and then chasing to recoup errors) and will attempt to eliminate inappropriate payments from being made in the first place. That method of stopping the pay and chase has been introduced into the Medicare EHR Incentive Program starting with the attestations made in January 2013. Providers are now subject to pre-payment audits, yet not all providers receiving a letter from the contractor, Figliozzi and Company, for a pre-payment audit will be under suspicion. Some providers will be randomly selected in addition to those that have been targeted.

RAC Audit Relief May Be On the Horizon

There is some good news on the horizon for HIM professionals buried in RAC audit requests and appeals. Last week, the much-anticipated Medicare Audit Improvement Act of 2013 was introduced into Congress. Hooray!

We all know the problem. :  According to the AHA, 75 percent of appealed RAC denials are overturned in favor of hospitals and providers. That is three out of four denials!  Unfortunately, these appeals can take months (or even years) before a decision is made. As HIM professionals know, the inefficiencies of the RAC program are resulting in a significant waste of valuable resources.

1455R Part B Medical Necessity – Getting it Right is More Important than Ever

In case you haven’t heard, CMS released 1455R on March 13, 2013. This interim notice of ruling is targeted at the current CMS regulations regarding Part B billing of medically unnecessary admissions identified on RAC/MAC or CERT audits. Basically, a large percent of denials that are appealed to ALJ (Administrative Law Judge) and the Medicare Appeals Council are being upheld for inappropriate admissions. However, the ALJs are supporting payment for medically necessary Part B outpatient services provided during those inpatient stays. The problem is, many of the appeals that finally reach the ALJs are older than the CMS current timely filing rules. So, the ALJ decisions are bumping into the CMS’ current rules – something had to change.  According to CMS, “Until the final regulations entitled ‘Medicare Program; Part B Inpatient Billing in Hospitals’ are promulgated, CMS, through this Ruling acquiesces to the approach taken in the aforementioned ALJ and Appeals Council decision on the issue of subsequent Part B billing following the denial of a Part A hospital inpatient claim on the basis that the admission was not unreasonable and necessary.”  Click here to read more.

Testing for Waste and Mismanagement in the Medicare Program

In its role to protect the integrity of the Department of Health and Human Services (HHS) and the welfare of program beneficiaries, the Office of Inspector General (OIG) aims to combat fraud, waste, and abuse, as well as to improve the efficiency of HHS programs. We all know of the efforts to detect and prevent fraud and abuse, but what about waste and inefficiency?

Each year, the OIG conducts inspections to provide information to HHS, Congress, and the public; the resulting recommendations could impact future laws and regulations. Additionally, the OIG audits the performance of HHS programs.

Regulatory Update: Physician Practice Management – E/M Documentation

Last month, I blogged my thoughts on the top ten compliance problem areas for physicians; this month, I am sharing a few thoughts on how practice managers can help with these problem areas.  Yes, I know physicians may not be fond of being “managed,” but there are some things you can do to help yours—even  the reluctant ones.

Documentation

Billions have been invested in EHRs/EMRs in the hope they will improve healthcare and reduce costs. Yes, I know the jury is still out on that, but documentation is super-important now more than ever before. With liability still squarely on the physician— and yes, I agree it’s not fair—it remains very important for your physicians to document really, really well. They know all the reasons why they need to do this from a liability standpoint, so I’m not going to repeat them here, but I suggest you remind them anyway.

Documentation and Compliance Risk: Top Areas to Watch

As the country moves to automated record-keeping in health care, there are certain areas that need to be scrutinized prior to assigning codes for billing. Compliant coding is of utmost importance, not only for healthcare providers, but also for government auditors. While new technologies are being introduced daily, the government has warned that it will not tolerate providers who try to “game the system.”

The top areas that must be evaluated by providers in determining how to use technology include:

Should We Be Concerned about the New HIPAA Omnibus Rule?

Well, that all depends. Just the sound of it could create fear in anyone, and to know that it introduced some of the most significant changes to HIPAA in years, one could easily be concerned. And before they published it in the Federal Register, over 500 pages to review seemed to be a daunting task. However, if you followed the changes to HIPAA within the Health Information Technology for Economic and Clinical Health (HITECH) Act and in the Proposed Rule modifying HIPAA for the HITECH Act, you are less likely to be caught by surprise with most of the Final Rule and may have already started to implement some of the provisions.

Modifications were made to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the HITECH Act and the Genetic Information Nondiscrimination Act. Just understanding when the Rule takes effect is important. The Department of Health and Human Services has determined an effective date with a compliance date six months later, offering organizations time to bring their processes within compliance with the new Rule.

Compliance and Physician Coding: Top 10 Problem Areas

When I first started thinking about this topic, a million things came to mind. Should the oldest compliance challenge—what is most expensive—be number one on the list, or should the top issue be the one that could cause the most problems?  Having to narrow it down to ten became more of a challenge than I anticipated. Here goes—my opinion of the Big Ten compliance challenges facing physicians in 2013.

1. Documentation (or the lack thereof) –Those of you who read my blogs know my position on this, but let me say it again: As the old adage goes, “if it wasn’t documented, it didn’t happen.” This is true in paper as well as electronic records. And even if you are using an EMR that literally will not let you enter another digit until you complete a document step, it’s still a problem. I have seen cloned EMR documentation that says the patient had the same flu at every visit since 2009. And the OIG has noticed too. Beware the cloned EMR. Remember, coders populate your claims with your documentation and the RAC and other auditors are watching intently.