Overpayment and Compliance in Medicare Billing, Exams of Nursing

Download Overpayment and Compliance in Medicare Billing and more Exams Nursing in PDF only on Docsity! CPMA Chapter 1 Exam Prep with complete solutions 2024/2025 12.1% - ANSWER-# of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS - ANSWER-Fee-For-Service Prepayment Review - ANSWER-Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review - ANSWER-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 - ANSWER-A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment - ANSWER-A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: - ANSWER-*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 - ANSWER-Medicare Administrative Contractors MAC Responsibilities - ANSWER-Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (including identifying under- and overpayments). ZPICs - ANSWER-Zone Program Integrity Contractors PSCs - ANSWER-Program Safeguard Contractor ZPICs/PSCs - ANSWER-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 - ANSWER-Supplemental Medical Review Contractor SMRC Responsibilities - ANSWER-Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments Medicare FFS Recovery Auditors - ANSWER-Review claims to identify potential underpayments and overpayments in Medicare FFS, as part of the Recovery Audit Program Zone 6 - ANSWER-All PSCs transitioned to ZPICs with the exception of Zone 6 While all contractors focus on a specific area, - ANSWER-Each contractor conducting a claim review must apply all Medicare policies to the claim 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. Claim Review Programs - ANSWER-There are 5 claim review programs NCCI Edits - ANSWER-National Correct Coding Initiative Editor NCCI Edits are performed by - ANSWER-Macs, ZPICs, CERT, and Medicare FFS Complexity: Non-complex CMS developed the NCCI to - ANSWER-Promote national correct coding methods and to control improper coding that leads to inappropriate payment in Medicare Part B claims. NCCI Edits prevent improper payments when incorrect code combinations are reported. The NCCI Edits are updated quarterly. 3 types of corrective actions can result from a Medical Review (MR) - ANSWER- *Provider Education/Feedback *Prepayment review *Postpayment review. SMRC reviews are selected by - ANSWER-CMS Both Prepayment and Postpayment reviews may require - ANSWER-Providers to submit medical records To help prevent improper payments, the MAC's - ANSWER-Provider Outreach and Education (POE) department educates providers submitting claims Prepayment review - ANSWER-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 - ANSWER-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 - ANSWER-Performed by CERT Review Contractor (RC) and CERT Statistical Contractor (SC) COMPLEXITY: Complex CMS must calculate the - ANSWER-National Medicare FFS improper payment rate. CERT randomly selects a - ANSWER-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 - ANSWER-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 - ANSWER-Comprehensive Error Rate Testing CMS calculates a national Medicare FFS improper payment rate and improper payment rates by service type to - ANSWER-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 - ANSWER-How claim errors in the Medicare FFS Program impact the Medicare Trust Fund. The 5 error categories that CERT contractors identify - ANSWER-*No documentation *Insufficient documentation *Medical Necessity *Incorrect coding *Other No documentation - ANSWER-Provider or supplier fails to respond to repeated requests for the medical records or they do not have the requested documentation Insufficient documentation - ANSWER-Submitted medical documentation is inadequate to say payment for the services billed; the CERT contractor reviewers could not conclude that the billed service was actually provided, was provided at the level billed and/or was medically necessary; or a specific documentation element that is required as a condition of payment is missing Medical necessity - ANSWER-There is adequate documentation in the medical records to make the informed decision that the services billed were Medically necessary based upon Medicare coverage and payment policies. Incorrect coding - ANSWER-Provider or supplier submit s medical documentation supporting *a different code than was billed *the service was performed by someone other than the billing provider or supplier *the billed service was unbundled *a beneficiary was discharged to a site other than the one coded on a claim Claims selected for CERT Review are subject to potential - ANSWER- Postpayment denials, payment adjustments, or other actions depending upon the result of the review. Normal appeal rights and processes apply. CERT reviews have the following corrective actions - ANSWER-*Improving system edits *Increasing and focusing medical review on problem areas *Updating coverage policies and manuals *Conducting provider education efforts Recovery Audit Program is performed by - ANSWER-Medicare FFS Recovery Auditors Complexity : Complex Recovery Auditors - ANSWER-Review past Medicare FFS claim data for potential overpayments or underpayments, reviewing medical records when necessary to make appropriate determinations. Recovery Auditors follow - ANSWER-Medicare regulations, billing instructions, National Coverage Determinations (NCD), coverage provisions, and the respective Mac's Local Coverage Determinations (LCDs). Recovery Auditors do not - ANSWER-Do not develop or apply their own coverage, payment, or billing policies. In general, Recovery Auditors do not review a claim previously reviewed by another entity. Recovery Auditors analyze claim data - ANSWER-Using their proprietary software to identify claims that clearly or likely contain improper payments. CWF - ANSWER-Claims Working File ADR - ANSWER-Additional document request Prepayment Review Process: Macs and ZPICs/PSCs - ANSWER-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. The Federal False Claims Act (FCA) imposes - ANSWER-civil liability on any person who KNOWINGLY submits or CAUSES the submission of, a false or fraudulent claim to the Federal Government. The terms "knowing" and "knowingly" mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth, or falsity of the information No proof of specific intent to defraud is required to violate the Civil - ANSWER- False Claims Act (FCA) An example of violating the False Claims Act (FCA) may be a - ANSWER-a physician who knowingly submits claims to Medicare for medical services not provided. Civil penalties for violations of the False Claims Act (FCA), occurring on or after 11.25.2015, may include - ANSWER-fines of up to 3x the amount of damages sustained by the Government as a result of the false claims + up to $21,563 per false claim filed. Under the Federal criminal statutes, criminal penalties for submitting false claims may include - ANSWER-fines, imprisonment, or both. The Anti-Kickback Statute (AKS) - ANSWER-makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by a Federal health care program. Remuneration includes - ANSWER-anything of value, such as cash, free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. Civil penalties for violating the AKS may include - ANSWER-penalties of up to $50,000 per kickback + 3x the amount of kickback. Criminal penalties for violating the AKS may include - ANSWER-fines, imprisonment, or both. The Physician Self-Referral Law (Stark Law) prohibits - ANSWER-a physician from making a referral for certain designated health services payable by Medicare or Medicaid to an entity in which the physician (or an immediate family member) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Penalities for physicians who violate the Stark Law may include - ANSWER-fines, CMPs up to $15,000 for each service repayment of claims, and potential exclusion from all Federal healthcare programs. The Criminal Health Care Fraud Statute prohibits - ANSWER-knowingly and willfully executing, or attempting to execute, a scheme or artifice in connection with the delivery of or payment for healthcare benefits, items, or services to either.. defraud any healthcare benefit program Obtain by means of false or fraudulent pretenses, representation, or promises) any money or property of any healthcare benefit program Penalties for violating the Criminal Health Care Fraud Statute may include - ANSWER-fines imprisonment, or both Exclusion Statute requires - ANSWER-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 - ANSWER-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: - ANSWER-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 - ANSWER-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 for a variety of health care fraud violations. - ANSWER-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 - ANSWER-commercial insurers and the Federal and State Governments. When the Federal Government covers items or services rendered to Medicare beneficiares - ANSWER-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 - ANSWER-necessary cost-effective and quality care A physician's documentation describes what services they actually rendered. The Federal Government pays claims based soley - ANSWER-on the physician's representations in the claims documents. When you submit a claim for services performed for a Medicare patient, you are - ANSWER-filing a bill with the Federal Govt Certify you earned the payment requested complied with the billing requirements If a physician knows or should have known the submitted claim was false, then - ANSWER-the attempt to collect payment constitute a violation. Federal Anti-Kickback Statute prohibits.... - ANSWER-Asking for, or receiving anything of value to induce or reward referrals of Federal Healthcare business. Penalties apply to those who illicit referrals and those who make referrals. What are the penalties of the Anti-Kickback Statute? - ANSWER-There are criminal and civil penalties for violating the law. Criminal Penalties for violating the Anti-Kickback Statute (AKS): - ANSWER-It is a felony, which means violators can go to jail: 1) Conviction can mean fines up to $25,000/violation 2) and up to a 5-yr prison sentence 3) or both Civil and Administrative Penalties for violating the Anti-Kickback Statute (AKS): - ANSWER-Can lead to false claims liability The 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/claim May also lead to program exclusions Finally, Anti-Kickback Statute (AKS) violations can lead to administrative proceedings: - ANSWER-CMPs --Civil Monetary Payments of $50,000/violation And an assessment up to 3x the amount of the kickback payment Does the Anti-Kickback Statute (AKS) apply to all referrals? - ANSWER-No - only applies to Federal Healthcare Programs Are there any exceptions to the Anti-Kickback Statute (AKS)? - ANSWER-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 - ANSWER-a crime when talking about Medicare and Medicaid Program. Using the OIG Exclusions Database - ANSWER-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 - ANSWER-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 - ANSWER-in context across the industry. OIG's compliance programs in the CPGs refer to - ANSWER-principles and suggested practices Advisory Opinions offer protection from prosecution for - ANSWER-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: - ANSWER-1) Patient safety 2) Program Integrity 3) Provider Protection If someone is on the exculsion list, what can they do in the healthcare field? - ANSWER-1) Work in non-Federal Healthcare program payment settings 2) 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: - ANSWER-Mandatory and permissive Mandatory Exclusion List: The OIG is required to exclude individuals or entities when: - ANSWER-1) Conviction of a Program Related Crime 2) Conviction relating to patient abuse 3) Convicted of a felony related to controlled substances 4) Felony conviction of healthcare fraud Permissive Exclusion List: These are discretionary, and the OIG may chose to exclude entities under16 different statutory authorities: - ANSWER-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? - ANSWER-While the length can vary, depending on the case and the basis of exclusion. The period is generally for a set period of time. Exception: exclusion based on licensure action Minimum exclusion for mandatory exclusion is 5 years At the end of an exclusion term, reinstatement - ANSWER-is NOT automatic. The entity must apply for reinstatement, and must receive notice from the OIG that reinstatement has been granted. The False Claims Act (FCA) - ANSWER-When someone submits or causes to be submitted false or fraudulent claims for payment from the Government including Medicare and Medicaid. Examples of Healthcare claims that may be false are - ANSWER-1) The service billed is not rendered 2) The service billed is already covered under another claim (unbundling) 3) is miscoded (up coded) 4) Is not supported by the patient's medical record 5) Claims made by referral in violation of the Anti-Kickback Statute (AKS) or the Stark Law When the Government pursues Violations of the False Claim Act (FCA), it does not - ANSWER-target innocent billing mistakes. False claims are ones the provider knew or should have known were false or fraudulent. Should have known means deliberate ignorance, or reckless disregard of the truth