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CMS Fraud Definition - ANSWER-Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Abuse Definition - ANSWER-An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Examples of Fraud - ANSWER-Billing for services and/or supplies that you know were not furnished or provided, altering claim forms and/or receipts to receive a higher payment amount, billing a Medicare patient above the allowed amount for services, billing for services at a higher level than provided or necessary, misrepresenting the diagnosis to justify payment CMS Examples of Abuse - ANSWER-Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, billing Medicare patients a higher fee schedule than non- Medicare patients False Claims Act - ANSWER-Any person is liable if they knowingly present or cause to be presented a false or fraudulent claim for payment or approval; knowingly makes, uses, or causes to be made or used, a false record or material to a false or fraudulent claims Current False Claims Act penalties - ANSWER-$5,500-$11,000 per claim
When does the False Claims Act allow for reduced penalties? - ANSWER-If the person committing the violation self-discloses and provides all known info within 30 days, fully cooperates with the investigation, and there is no criminal prosecution, civil action, or administrative action regarding the violation Qui Tam or "Whistleblower" provision - ANSWER-If an individual (known as a "relator") knows of a violation of the False Claims Act, he or she may bring a civil action on behalf of him or herself and on behalf of the U.S. government; the relator may be awarded 15-25% of the dollar amount recovered Stark or Physician Self-Referral Law - ANSWER-Bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationship; bans the entity from billing Medicare or Medicaid for the services provided as a result of the self- referral Anti-Kickback Law - ANSWER-Similar to the Stark Law but imposes more severe penalties; states that whoever knowingly or willfully solicits or receives any remuneration in return for referring an individual to a person for the furnishing or arranging of any item or service for which payment may be made in whole or in part under a federal healthcare program or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a federal healthcare program is guilty of a felony Penalty for violating the Anti-Kickback Law - ANSWER-Up to $25,000 fine and/or imprisonment of up to 5 years Stark Law vs. Anti-Kickback Law - ANSWER-Anti-Kickback applies to anyone, not just physicians; the Anti-Kickback Law requires proof of intention and states that the person must "knowingly and willfully" violate the law. Exclusion Statute - ANSWER-Under the Exclusion Statute, a physician who is convicted of a criminal offense—such as Medicare fraud (both misdemeanor and felony convictions), patient abuse and neglect, or illegal distribution of controlled substances—can be banned from participating in Medicare by the OIG. Physicians who are excluded may not directly or indirectly bill the federal government for the services they provide to Medicare patients. List of Excluded Individuals/Entities (LEIE) - ANSWER-Produced and updated by the OIG; provides information regarding individuals and entities currently
Office of the Inspector General (OIG) - ANSWER-Detects and prevents fraud, waste, and abuse and improves efficiency of HHS programs; most resources are directed toward the oversight of Medicare and Medicaid, but also extend to the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA) OIG Work Plan - ANSWER-Published annually; lists the various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General; summarizes new and ongoing reviews and activities that OIG plans to pursue during the next fiscal year and beyond Why should an auditor know what is in the OIG Work Plan for the current year? - ANSWER-It allows an auditor to inform providers and facilities of services or issues of which to be especially mindful in the coming year; may be helpful in forming the scope of an audit for a provider or facility or may influence recommendations given to a practice Corporate Integrity Agreements - ANSWER-Required by the OIG s a condition of not seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases; typically last 5 yrs but can be longer; most have the same core requirements along with specific steps for the individual or entity that are related to the conduct that led to the settlement Core requirements in CIAs - ANSWER-Hiring a compliance officer/appointing a compliance committee; developing written standards and policies; implementing a comprehensive employee training program; retaining an independent review organization (IRO) to conduct annual reviews; establishing a confidential disclosure program; restricting employment of ineligible persons; reporting overpayments, reportable events, and ongoing investigations/legal proceedings; providing an implementation report and annual reports to the OIG on the status of the entity's compliance activities Independent review organization (IRO) - ANSWER-Acts as a 3rd party medical review resource that provides objective, unbiased audits and reports How many sampling units are selected for review in a Discovery Sample under a CIA? - ANSWER-
Purpose of a Discovery Sample - ANSWER-Used to determine the net financial error rate; if the error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review What is the name of the statistical sampling program provided by the OIG to randomly select and determine the size of the Discovery Sample? - ANSWER- RAT-STATS What percent of precision and confidence are required to estimate the overpayment? - ANSWER-90% confidence and 25% precision level Certificate of Compliance Agreement (CCA) - ANSWER-Require the provider to certify that is will continue to operate its existing compliance programs and to report to OIG for a lesser period of time (usually 3 years); introduced in Inspector General Janet Rehnquist's An Open Letter to Healthcare Providers in November 2011 Compliance Plan - ANSWER-Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it Voluntary compliance plan guidance (CPG) documents - ANSWER-Developed by the OIG for a variety of healthcare settings; indicate the comprehensive framework, standards, and principles by which an effective internal compliance program may be established and maintained Are compliance plans mandatory? - ANSWER-No, they are currently voluntary. The Affordable Care Act makes compliance programs mandatory for providers and other healthcare providers but there is not yet an implementation date How many elements has the OIG identified that should be present in every compliance plan? - ANSWER- Elements identified by the OIG that should be present in every compliance plan (except for individual or small group practices) - ANSWER-Implementing written policies, procedures and standards of conduct; designating a compliance officer and/or compliance committee; conducting effective training and education; developing effective lines of communication; enforcing standards through well- publicized disciplinary guidelines; conducting internal monitoring and auditing; and responding promptly to detected offenses and developing corrective action
Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS) - ANSWER-Established in 1977 to administer the Medicare and Medicaid programs; renamed the Centers for Medicare and Medicaid Services (CMS) in 2001; largest agency within the Department of Health and Human Services; administers Medicare, Medicaid, and the Children's Health Insurance Program CMS transmittals - ANSWER-Communicate new or changed policies or procedures that will be incorporated into the CMS Online Manual System; each one has a transmittal number, an issue date, an implementation date, a Change Request number, and a subject name Medicare Learning Network (MLN) - ANSWER-Provides education, information, and resources for the healthcare professional community; offers educational products, national provider calls, provider association partnerships, provider eNews, and provider electronic mailing lists Conditions of Participation (CoP) and Conditions for Coverage (CfC) - ANSWER- Standards set forth in the Federal Register that must be met to participate in Medicare and Medicaid Programs; they include Ambulatory Surgical Centers (ASCs), Critical Access Hospitals (CAHs), and hospitals Conditions of participation for medical record services - ANSWER-The conditions include that each patient should have a medical record; medical records must be organized to allow for prompt completion, filing, and retrieval; medical records must be retained for at least 5 years; and patient confidentiality should be protected Definition from the 1995 guidelines regarding types of exam - ANSWER-The levels of E/M services are based on 4 types of examination that are defined as follows: Problem-Focused-a limited examination of the affected body area or organ system; Expanded Problem Focused-a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); Detailed-an extended examination of the affected body area(s) and other symptomatic or related organ system(s); Comprehensive-a general multi-system examination or complete examination of a single organ system Definition from the 1997 guidelines regarding general multi-system examination - ANSWER-To qualify for a given level of general multi-system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of one to
five elements identified by a bullet in one or more organ system(s) or body area(s); Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet in one or more organ system(s) or body area(s); Detailed Examination-should include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. A detailed examination may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas; Comprehensive Examination-should include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by a bullet is expected Definition of the 1997 guidelines regarding single organ system examinations - ANSWER-Variations among these examinations in the organ systems and body areas and in the elements of the examinations reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of 1- elements identified by a bullet, whether in a box with a shaded or unshaded border; Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet, whether in a box with a shaded or unshaded border; Detailed Examination-examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, whether in a box or unshaded border. Eye and psychiatric examinations should include the performance and documentation of at least 9 elements identified by a bullet, whether in a box with a shaded or unshaded border; Comprehensive Examination-should include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. Can a provider choose from either 1995 or 1997 guidelines for each E/M service? - ANSWER-Yes Why is it important for an auditor to be familiar with both sets of guidelines? - ANSWER-A provider can choose either the 1995 or the 1997 guidelines and they must determine which will be more advantageous to the provider
review results letter is sent to the provider that includes the decision and rationale for that decision How long can FFS Recovery Auditors go back and request claims after the date the claim is paid? - ANSWER-3 years 3 types of review performed by FFS Recovery Auditors - ANSWER-Automated, semi-automated, and complex Automated review - ANSWER-no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals Semi-automated review - ANSWER-claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claim identified by data analysis as an improper payment Complex review - ANSWER-medical record required Medicare Administrative Contractor (MAC) - ANSWER-Adjusts a claim and sends a demand letter to the provider for the amount of the overpayment What happens after the provider receives the demand letter during a RAC audit? - ANSWER-If the provider agrees with the letter, he/she may submit payment; ask for a recoupment of future payments; or ask for an extended payment plan. If the provider disagrees with the demand letter, he/she may submit a discussion period request to the Recovery Auditor within 15 days from the date of the demand letter; submit a rebuttal to the MAC within 15 days from the date of the demand letter; or submit a redetermination request to the MAC within 120 days from the date of the demand letter (first level of appeal) CMS advice to prepare providers for RAC audit - ANSWER-Know where previous improper payments have been found and look to see what improper payments were found by the Recovery Auditors and in OIG and Comprehensive Error Rate Testing (CERT) reports; know if you are submitting claims with improper payments and conduct an internal assessment to identify if you are in compliance with Medicare rules and identify corrective actions; appeal when necessary (the appeal process for a Recovery Audit denial is the same as the appeal process for MAC denials)
Why is it beneficial for an auditor to review the Recovery Auditors' websites for issues currently being reviewed? - ANSWER-This info can be used to target reviews to help providers determine if they are in compliance What changes will be effective within the next Recovery Audit Program contracts? - ANSWER-Recovery Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment and providers will not have to choose between initiating a discussion and an appeal; Recovery Auditors must confirm receipt of a discussion request within 3 days; Recovery Auditors must wait until the second level of appeal is exhausted before they receive their contingency fee; CMS is establishing revised ADR limits that will be diversified across different claim types; and CMS will require Recovery Auditors to adjust the ADR limits in accordance with a provider's denial rate. Providers with low denial rates will have lower ADR limits while providers with high denial rates will have higher ADR limits Concerns raised by the Recovery Audit Program - ANSWER-Upon notification of an appeal by a provider, the Recovery Auditor is required to stop the discussion period; providers don't receive confirmation that their discussion request has been received; Recovery Auditors are paid their contingency fee after recoupment of improper payments, even if the provider chooses to appeal; Additional Documentation Request (ADR) limits are based on the entire facility, without regard to the differences in department within the facility; and ADR limits are the same for all providers of similar size and are not adjusted based on a provider's compliance with Medicare rules What is the most significant difference between the 1995 and 1997 documentation guidelines? - ANSWER-Examination You are performing an audit of evaluation and management services for a family practice office. In the encounter, you read the physician ordered and reviewed a differential WBC. Which of the following best describes what you would expect to see in the medical record? - ANSWER-Patient identification, assignment of benefits, patient's medical history, immunizations, physical examination, lab report, clinical impression, and physician orders. What is the minimum requirement for the signature of the author of an entry in the medical record? - ANSWER-The first initial, last name and credentials
What falls under the responsibility or oversight of an organization's compliance committee? - ANSWER-Regularly reviewing and updating policies and procedures, assisting with the development of standards of conduct and policies and procedures, and determining the appropriate strategy to promote compliance What will be one of the focuses of OIG audits in 2014? - ANSWER-Evaluation and Management New Patient Visits An infectious disease provider has been notified by the MAC (Medicare Administrative Contractor) in his region that their data shows he is billing level 99214 more frequent than any other provider in the same specialty and same geographic region. The provider requests that you audit a sample of his claims that were coded as 99214 to determine if he is coding appropriately. What supporting references will you need to conduct the audit? - ANSWER-1995 and 1997 CMS Documentation Guidelines The Stark Statute applies to: - ANSWER-Only physicians who refer Medicare and Medicaid patients to entities for designated health care services with which the provider or immediate family member has a financial relationship When can a RAC extrapolate the overpayment(s) on claims? - ANSWER-If a RAC can demonstrate a high level of error, the RAC can then extrapolate the findings and request a refund. Example: Column 1 Code/Column 2 Code 45385/45380 CPT Code 45385 - Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Policy: More extensive procedure Modifier -59 is: - ANSWER-Only appropriate if the two procedures are performed on separate lesions or at separate patient encounters. Dr. Jones performed a femoral-femoral bypass graft in the morning on June 1, 20xx. Later that day, the graft clotted and the entire procedure was repeated. Dr. Jones was not available so Dr. Martin who is with a different group repeated the procedure in the evening. The auditor reviewed the documentation for Dr. Martin. The following was reported by Dr. Martin: Date of Service Procedure 06/01/20xx 35556-76 What procedure should Dr. Martin report? - ANSWER-35558- A family physician requests that you perform a post payment audit on claims from a particular commercial payer he is receiving denials from. Whenever the provider performs a minor procedure with an E/M service, the minor surgery is
reimbursed but the E/M service is denied. You review 10 charts and all cases are documented and coded correctly. What could be the reason for the denial? - ANSWER-The payer contract may bundle the E/M service when performed on the same day as the minor surgery. A provider receives a denial on a Medicare claim due to lack of medical necessity. What resource is a valuable tool for providers to limit denials for medical necessity? - ANSWER-LCDs A comprehensive audit is: - ANSWER-A large number of claims are selected for review that might be focused on specific procedure and/or diagnosis codes. What is RAT-STATS used for by an auditor? - ANSWER-Software used in performing statistical random samples and evaluating results What are the recommended number of charts to audit per provider and the minimum frequency of the audit? - ANSWER-10 records per provider each year Evaluation and Management documentation is often captured in SOAP format, which is the acronym for: - ANSWER-Subjective, Objective, Assessment, Plan Failure to have which form in the medical record will result in payment being sent to the beneficiary? - ANSWER-Assignment of benefits form Prior to undergoing a specific medical intervention, law requires the provider to obtain an informed consent for treatment signed by the patient. In addition to the nature or purpose of the treatment and risks and benefits involved, the informed consent must include what information? - ANSWER-Alternative treatment options and the risks and benefits of alternative treatment options. Outpatient physical therapy services cannot be initiated until: - ANSWER-an initial plan of care has been established. When auditing operative reports, the header describing the procedure: - ANSWER-may not fully support the procedure documented in the body of the report. During an audit of a paper medical record, the auditor finds a correction was made using white-out and initialed by the nurse. This method of correction is: - ANSWER-unacceptable because the original content is not readable.
An audit of 20 family practice charts for code 20552-20553 reveals that the provider used fluoroscopic guidance when performing trigger point injections. In reviewing claims data for these charts, it is found that 76942 was reported with 20552-20553. What should be stated on the audit findings report? - ANSWER- Coding is incorrect, code 77002 should be reported for these cases. A provider performs two procedures that NCCI edits state should not be reported together. However if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the documentation supports and qualifies as an unusual procedure, the physician may report the column one HCPCS/CPT® procedure code of the NCCI edit with what modifier? - ANSWER- An auditor identifies a procedure that has a modifier appended. This is an indication that: - ANSWER-the procedure performed was altered, but the definition of the code has not changed. Sarah Smith works for an emergency physician group. She has been given the responsibility to perform a baseline E/M audit for the physicians in the group. What is the first step she should take to begin this process? - ANSWER-Run a utilization report of E/M services An audit performed on one provider would be considered a: - ANSWER-Focused audit When performing a retrospective audit, the auditor will need to have what materials? - ANSWER-Medical record, audit form, coding manuals, EOB or Medicare RA, payer policies and CMS-1500 form. A sample is gathered of the CPT®/HCPCS codes that have the highest dollar charges. This would be considered which type of sampling? - ANSWER- Proportional Using RAT-STATS to create a Discovery Sample for a CIA Claims Review serves what purpose? - ANSWER-Identify the financial error rate of the selected sample A provider receives denials from a private payer for E/M services performed on the same date as a minor procedure. You review documentation for 25 records and the payer contract which states the provider must follow CMS coding guidelines. You determine that 20 of the records have appropriate documentation to support both E/M and the procedure and were coded correctly when the claim
was originally submitted. You submit an appeal for the 20 dates of service that are supported by documentation. To support you findings, you will include in the appeal a letter reporting your findings, claim forms, copies of documentation, EOB copies and: - ANSWER-NCCI policy manual for modifier 25. Nancy prepares to begin a focused audit for Dr. Jacobsen, a general surgeon.The resources that she will gather in addition to the CPT®, HCPCS Level II and ICD-9- CM codebooks, that will be needed to accurately complete the audit will be: - ANSWER-Medical terminology book, surgical package definition, global days, surgery audit tool, insurance carrier rules and NCCI edits. In reviewing claims for an ENT provider, you identify that he is consistently billing Medicaid for four units of 69641. Which of the following resources would support your findings that this provider is billing too many units? - ANSWER-Medically Unlikely Edits An annual audit is the minimum requirement an IRO must conduct under what agreement? - ANSWER-Corporate Integrity Agreement When conducting a compliance audit your findings identify that one of the providers is signing chart entries in the EMR three days after seeing patients. What steps should be taken to address this finding? - ANSWER-Prepare a summary of findings that include number or percentages of compliant vs. non- compliant charting; discuss with the provider, including recommendations for improvement; re-audit according to criteria established by the practice. Audit findings are of little value unless the findings are shared with the provider to: - ANSWER-Offer recommendations for improvement, illustrate compliant documentation, and address problem areas. According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), an outside auditor must sign which of the following agreements prior to reviewing and auditing any medical records? - ANSWER-Business Associate Agreement The HIPAA Privacy Rule defines "minimum necessary" as typically requiring healthcare employees to: - ANSWER-Follow policies and procedures developed by the covered entity which limit use and disclosure of PHI to that which is needed to accomplish the intended purpose to perform the duties of their job.
appended, only the intraoperative percentage is paid and no new global period begins What is an example of a scenario that would support medical necessity for critical care services? - ANSWER-Care given to a patient in renal and respiratory failure As an auditor you are tasked with performing a random selection of the medical and surgical services performed by the three new providers who joined the practice six months ago. This would be considered what type of audit? - ANSWER-Baseline audit Sandra Keller works for an internal medicine practice. As part of the practice's compliance plan, she has been given the responsibility to perform an audit of the top five surgeries performed by the group at Hill Dale Hospital in the past year. How will Ms. Keller determine what types of services to review for this physician group? - ANSWER-Run a utilization report of all surgeries performed by the group's physicians during the past year at Hill Dale Hospital. To identify patterns of undercoding and upcoding among physicians in a practice as compared to another practice of the same specialty would best be identified through which type of analysis? - ANSWER-Aggregate analysis The practice manager has requested an audit of all E/M services for all the providers. The practice manager has determined the: - ANSWER-Scope As an auditor, you identify that Dr. Jones consistently codes 99212 more than the other providers in his group practice. This was determined by reviewing Dr. Jones': - ANSWER-Utilization pattern You are preparing to perform a surgical chart audit. What resources would you need in order to accurately conduct the audit? - ANSWER-ICD-9-CM, CPT®, HCPCS Level II code books, NCCI edits, medical terminology book, global days, surgery audit tool, rules of insurance carriers Karen has reviewed denials from payers. Out of the 25 denials reviewed, 23 of them were found to be denied in error based on NCCI guidelines. Karen is preparing her appeal for the erroneous denials. In addition to her appeal letter, she should include in the appeal package: - ANSWER-Original claim forms, copies of documentation and copies of EOBs and supporting documentation from NCCI
Under the Office of the Inspector General CIA, an Independent Review Organization (IRO) reports audit results to: - ANSWER-the compliance officer in the organization under the CIA Education and training to reinforce recommendations regarding a physician's deficiencies and problematic areas is best addressed through: - ANSWER-Direct follow-up with the physician. The OIG CIA agreement states that the IRO's minimum requirement to perform an audit is: - ANSWER-Annually Medical record - ANSWER-Chronological documentation of a patient's medical history and care Entries included in a medical record - ANSWER-Identification information, a patient's health history, medical examination documentation and findings, and test results, among other information When was HIPAA enacted? - ANSWER-August 21, 1996 What was the original intent of HIPAA? - ANSWER-To provide rights and protections for participants and beneficiaries of group health plans; limited exclusions for pre-existing conditions and prohibited discrimination against employees and dependents based on their health status Health Care Fraud and Abuse Control Program - ANSWER-Established by HIPAA to combat fraud and abuse in healthcare, including both public and private health plans HIPAA Administrative Simplification provisions - ANSWER-Required that sections of the law be publicized to explain the standards for the electronic exchange, privacy, and security of health information Privacy Rule standards - ANSWER-Address how an individual's protected health information (PHI) may be used Purpose of the Privacy Rule - ANSWER-To protect individual privacy, while promoting high quality healthcare and public health and well-being HIPAA covered entities - ANSWER-Health plans, healthcare clearinghouses, and any healthcare provider who transmits health information in an electronic format
