Download Medicare Claim Overpayments and Fraud Prevention and more Exams Nursing in PDF only on Docsity! Chapter 1 CPMA Exam Prep questions with answers 12.1% - ANSWERS✔✔ # of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS - ANSWERS✔✔ Fee-For-Service Prepayment Review - ANSWERS✔✔ Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review - ANSWERS✔✔ Review of claims after payment. May result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment. Underpayment - ANSWERS✔✔ A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment - ANSWERS✔✔ A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: - ANSWERS✔✔ *Billing for excessive and subsequent payment of the same service or claim. *Duplicate submission and payment for same service or claim*Payment for excluded or Medically unnecessary services. *Payment for services in setting not appropriate to pt's needs or condition*Payment to an incorrect payee. MACs - ANSWERS✔✔ Medicare Administrative Contractors MAC Responsibilities - ANSWERS✔✔ Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (including identifyingunder- and overpayments). ZPICs - ANSWERS✔✔ Zone Program Integrity Contractors PSCs - ANSWERS✔✔ Program Safeguard Contractor ZPICs/PSCs - ANSWERS✔✔ Perform investigations that are unique and tailored to specific circumstances and occur only in situations where there is potential fraud, and take appropriate corrective actions SMRC - ANSWERS✔✔ Supplemental Medical Review Contractor SMRC Responsibilities - ANSWERS✔✔ Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments Medicare FFS Recovery Auditors - ANSWERS✔✔ Review claims to identify potential underpayments and overpayments in Medicare FFS, as part of the Recovery Audit Program Zone 6 - ANSWERS✔✔ All PSCs transitioned to ZPICs with the exception of Zone 6 While all contractors focus on a specific area, - ANSWERS✔✔ Each contractor conducting a claim review must apply all Medicare policies to theclaim under review. Additionally, once a claim is reviewed, a different contractor should not reopen it. Therefore, it is important when conducting claim reviews, contractors review each claim in its entirety. MUEs - ANSWERS✔✔ Medically Unlikely Edits Message are performed by - ANSWERS✔✔ Macs (noncomplex) CMS developed MUEs to - ANSWERS✔✔ Reduce the paid claim error rate for Medicare Part B claims. Unlike NCCI Edits, the MUEs - ANSWERS✔✔ Are automated prepayment edits An MUE for a HCPCS/CPT code - ANSWERS✔✔ Is the maximum units of service that a provider would report, under most circumstances, for a singlebeneficiary on a single date of service. MUEs do not exist for all HCPCS/CPT codes - ANSWERS✔✔ While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUEs because of fraud and abuse concerns. Providers should NOT interpret MUE values as utilization guidelines. - ANSWERS✔✔ MUE values do not represent units of service that providers may report and avoid further medical review. Providers should continue to report only services that are Medically reasonable and necessary. Medical Review Program is performed by - ANSWERS✔✔ Macs, ZPICs/PSCs, and SMRCs Complexity : Complex Claim Review contractors identify suspected improper billing through - ANSWERS✔✔ Error rates produced by the CERT Program, vulnerabilities identified through the Recovery Audit Program, claim data analysis, and evaluation of other information (for example, complaints). Generally, claim review contractors focus Medical Review (MR) activities onidentified - ANSWERS✔✔ problem areas and select appropriate action for the severity of the problem. 3 types of corrective actions can result from a Medical Review (MR) - ANSWERS✔✔ *Provider Education/Feedback*Prepayment review *Postpayment review. SMRC reviews are selected by - ANSWERS✔✔ CMS Both Prepayment and Postpayment reviews may require - ANSWERS✔✔ Providers to submit medical records To help prevent improper payments, the MAC's - ANSWERS✔✔ Provider Outreach and Education (POE) department educates providers submitting claims Prepayment review - ANSWERS✔✔ Providers with identified problems may be placed on prepayment review, in which a selection of their claims undergo MR before the MAC authorizes payment. Once providers reestablish the practice of billing correctly, Prepayment review ends Postpayment review - ANSWERS✔✔ Contractors perform postpayment claim reviews most commonly by using statistically valid sampling. Sampling allows estimation of an underpayment or overpayment (if one exists) without requesting all records on all claims from providers. CERT Program - ANSWERS✔✔ Performed by CERT Review Contractor (RC)and CERT Statistical Contractor (SC) COMPLEXITY: Complex CMS must calculate the - ANSWERS✔✔ National Medicare FFS improper payment rate. CERT randomly selects a - ANSWERS✔✔ Statistically valid sample of processed Medicare FFS claims, and requests medical documentation from the provider or supplier that submitted the sampled claim. CERT performs a complex - ANSWERS✔✔ Medical Review of the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, payment, coding, and billing rules. CERT - ANSWERS✔✔ Comprehensive Error Rate Testing CMS calculates a national Medicare FFS improper payment rate and improper payment rates by service type to - ANSWERS✔✔ Accurately measure the performance of the Macs and gain insight into the causes of error. CMS publishes the results of these reviews annually. The FFS Improper Payment Rate is a good indicator of - ANSWERS✔✔ How claim errors in the Medicare FFS Program impact the Medicare Trust Fund. The 5 error categories that CERT contractors identify - ANSWERS✔✔ *No documentation ADR - ANSWERS✔✔ Additional document request Prepayment Review Process: Macs and ZPICs/PSCs - ANSWERS✔✔ The reviewer determines which claims to review and checks the claim processing system or Common Working File (CFW) If the reviewer needs additional documentation, it will send an ADR. The provider must respond in 45 days. Late or Insufficient documents result in denied claim. ZPIC/PSC will - ANSWERS✔✔ Make and document review determination and notify the MAC within 60 calendar days MAC will - ANSWERS✔✔ Make and document review determination within 30 calendar days of receiving requested documentation. Postpayment Review Process - ANSWERS✔✔ The reviewer determines which claims to review and checks the claims processing system or CWF Postpayment Review Process: If the reviewer needs additional documentation - ANSWERS✔✔ Will send an ADR. Provider must respond in 45 calendar days (30 days for an ADR from ZPIC/PSC). The reviewer may grant an extension at his/her discretion. Late or Insufficient documentation results in a denial. Postpayment Review Process: includes - ANSWERS✔✔ CERT, Macs, Medicare FFS Recovery Auditors, SMRC, and ZPICs/PSCs Postpayment Review Process for Medicare FFS - ANSWERS✔✔ Medicare FFS Recovery Auditors conduct automated reviews or may determine a claim clearly contains an improper payment or payment error. In this case, a demand letter is sent. Postpayment Review Process : If the reviewer detects potential fraud - ANSWERS✔✔ It may refer the issue to the appropriate ZPIC /PSC Postpayment Review Process : If the reviewer receives all documentation timely - ANSWERS✔✔ MAC will make a review determination and mail a results letter to the provider within 60 days of receiving the requested documentation. Other reviewers will make and document the review determination and communicate results to the provider within 30 calendar days of receiving requested documentation. This does NOT apply to ZPICs/PSCs or CERT Postpayment Review Process: If there is an error on the claim, - ANSWERS✔✔ The provider may resubmit a corrected claim if the timely deadline has not passed. If an overpayment was paid on the claim, the provider will receive a demandletter for the amount overpaid This does not apply to CERT. CERT and Postpayment Review Process: If there is an error on the claim - ANSWERS✔✔ This does not apply to CERT, although CERT will accept additional documentation and signature attestations, signature logs, and electronic signature protocols received prior to the deadline for the annual report. The 3 types of business relationships that may raise fraud and abuse concerns. - ANSWERS✔✔ Relationships with payers Relationships with fellow physicians & other providers Relationships with vendors Federal fraud and abuse laws that apply to physicians include all of the following - ANSWERS✔✔ False Claims Act (FCA)Anti-Kickback Statute (AKS)Physician Self-Referral Law (Stark Law)Social Security ActUnited State Criminal Code Violating Federal fraud and abuse laws may result in - ANSWERS✔✔ nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from all Federal healthcare programs (including Medicare), and criminal and civil liability. What agencies enforce the laws against Federal fraud and abuse - ANSWERS✔✔ Government agencies, including the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS). Exclusion Statute requires - ANSWERS✔✔ OIG (Office of Inspector General)to impose exclusions from participation in all Federal healthcare programs on health care providers and suppliers who have been convicted ..... Exclusion Statute imposes exclusions from participation in all Federal Healthcare programs for the following - ANSWERS✔✔ Medicare fraud, as well as any other offenses related to the delivery of items or services under Medicare;Patient abuse or neglect;Felony convictions for other health care-related fraud, theft, or other financial misconduct;&/or Felony convictions for unlawful manufacture, distribution, Rx, or dispensing of controlled substances. Under the Exclusion Statute, the OIG also has discretion to impose permissive exclusions on other grounds including: - ANSWERS✔✔ Misdemeanor convictions related to health care fraud other than Medicare/Medicaid fraud;Suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity;Provision of unnecessary or substandard services;Submission of false or fraudulent claims to a Federal health care program;Engaging in unlawful kickback arrangements;Defaulting on health education loan or scholarship obligation Excluded physicians may not - ANSWERS✔✔ bill directly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice. Civil Monetary Penalties Law (CMP) aurthorizes the imposition of CMPS fora variety of health care fraud violations. - ANSWERS✔✔ Different amounts of penalties and assessments may be authorized based on the type of violation. Penalties range from $10,000 to $50,000/violation CMPS also may include an assessment of up to 3x the amount claimed for each item or service or up to 3x the amount of remuneration offered, paid, solicited or received. Third party payers include - ANSWERS✔✔ commercial insurers and the Federal and State Governments. When the Federal Government covers items or services rendered to Medicare beneficiares - ANSWERS✔✔ Federal fraud and abuse laws apply. Many similar State laws apply to your provision of care under State-financed programs & to private-pay patients. The issues discussed here may apply to the care you provide to all insured patients. As a physician, payers trust you to provide - ANSWERS✔✔ necessarycost-effectiveand quality care A physician's documentation describes what services they actually rendered. The Federal Government pays claims based soley - ANSWERS✔✔ on the physician's representations in the claims documents. When you submit a claim for services performed for a Medicare patient, youare - ANSWERS✔✔ filing a bill with the Federal Govt Certify you earned the payment requestedcomplied with the billing requirements If a physician knows or should have known the submitted claim was false, then - ANSWERS✔✔ the attempt to collect payment constitute a violation. Examples of improper claims include - ANSWERS✔✔ Services you did not actually render;services not medically necessary;services by an improperly supervised or unqualified employee;services by an employee excluded from participation in Federal Healthcare programs;Services of such low quality = worthlessUnbundling global fees (E/M day after surgery) Two (2) examples of Up Coding - ANSWERS✔✔ Billing for a higher level of E/M than rendered (I.E., billing a New Patient code when the patient is Established) Misuse of modifier -25 Modifier -25 - ANSWERS✔✔ allows additional payment for an E/M service provided on he same day as a separate procedure or service. Upcoding and E/M by using Modifier -25 - ANSWERS✔✔ When a provider uses modifier -25 to claim payment for an E/M service when the patient care rendered was not medically necessary, was not distinctly separate fromthe other service provided, and was not above and beyond the care usually associated with the procedure. Good medical record documentation ensures - ANSWERS✔✔ your patients receive appropriate care from you and other providers who may rely on your records for patients' medical histories. Criminal Penalties for violating the Anti-Kickback Statute (AKS): - ANSWERS✔✔ It is a felony, which means violators can go to jail: 1) Conviction can mean fines up to $25,000/violation2) and up to a 5-yr prison sentence3) or both Civil and Administrative Penalties for violating the Anti-Kickback Statute (AKS): - ANSWERS✔✔ Can lead to false claims liabilityThe False Claims Act (FAC) is a civil statute: It provides the government a way to recover money through a lawsuit in federal court when someone submits false or fraudulent claims to government. Penalties include 3x the govt. program loss, plus $11,000/claimMay also lead to program exclusions Finally, Anti-Kickback Statute (AKS) violations can lead to administrative proceedings: - ANSWERS✔✔ CMPs --Civil Monetary Payments of $50,000/violationAnd an assessment up to 3x the amount of the kickback payment Does the Anti-Kickback Statute (AKS) apply to all referrals? - ANSWERS✔✔ No - only applies to Federal Healthcare Programs Are there any exceptions to the Anti-Kickback Statute (AKS)? - ANSWERS✔✔ Yes - avoid violating the Anti-Kickback Statute by fitting into a "safe harbor", which protects you from liability. What is often a common practice in other industries can be - ANSWERS✔✔ a crime when talking about Medicare and Medicaid Program. Using the OIG Exclusions Database - ANSWERS✔✔ Be sure to screen the owner of the company, managers, and officers. Once Identified, use the employee number or SS# to verify CPGs (Compliance Program Guidance) are organized by - ANSWERS✔✔ industry sector. The OIG has issued 11 originals & 2 supplementals to date The principles and risk areas in the CPGs (Compliance Program Guidance) can be useful - ANSWERS✔✔ in context across the industry. OIG's compliance programs in the CPGs refer to - ANSWERS✔✔ principles and suggested practices Advisory Opinions offer protection from prosecution for - ANSWERS✔✔ the party who made the request and only to that party and no one else. Proper documentation in the medical record is important for 3 main reasons: - ANSWERS✔✔ 1) Patient safety2) Program Integrity3) Provider Protection If someone is on the exculsion list, what can they do in the healthcare field? - ANSWERS✔✔ 1) Work in non-Federal Healthcare program payment settings2) Provide care to non-Federal Healthcare program beneficiaries 3) Non-patient care program options (such a management or graphic design) There are two (2) types of Exclusions: - ANSWERS✔✔ Mandatory and permissive Mandatory Exclusion List: The OIG is required to exclude individuals or entities when: - ANSWERS✔✔ 1) Conviction of a Program Related Crime2) Conviction relating to patient abuse3) Convicted of a felony related to controlled substances4) Felony conviction of healthcare fraud Permissive Exclusion List: These are discretionary, and the OIG may chose to exclude entities under16 different statutory authorities: - ANSWERS✔✔ Lying on an enrollment application; certain misdemeanors; loss of state license to practice; failure to repay health education loans; failure to provide quality care. Just about anyone can be excluded -- from licensed physicians to unlicensed personnel(such as administrators, billers and secretaries. The OIG might even exclude corporate entities and officers) How long does an exclusion last? - ANSWERS✔✔ While the length can vary, depending on the case and the basis of exclusion. The period is generally fora set period of time. Exception: exclusion based on licensure action