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OIG Audit

VIEWS: 11 PAGES: 52

									    Karen Wilson, Executive Director
University of Utah Health Care Compliance




                                            1
University of Utah




                     2
University of Utah Stats
 4 hospitals, 10 community clinics, 80 clinical and
  research centers
 Specialties: 120
 396 staffed beds @ U hospital , 532 staffed inpatient
  beds system-wide
 Active physicians: 920
 Allied health providers (PA, NP, physical &
  occupational therapists, etc.): 440
 Gross Revenue: $877,608,035

                                                          3
Objective for Today’s Presentation
 Share our experiences with an unannounced federal
  auditor
 Share our lessons learned
 Share our processes developed from the experience




                                                      4
UUHSC Structure
 Compliance office responsible for all billing
  compliance; to ensure the office conducts internal
  audits – technical and professional as well as manage
  all federal compliance audits

 Current structure: 6 Compliance Officers, 3 Support
  staff, and Executive Director. This office reports to
  Senior Vice President and Compliance Oversight
  Committee


                                                          5
   Compliance Office
     Monthly Compliance Oversight Committee
     Bi-weekly meetings which include Billing and Health
      Information Directors
     Monthly web-ex training
     Departmental Education
     Scheduled audit calendar




University healthcare Compliance office                     6
           Organizational Compliance
                Responsibilities
 Registration
 Clerk
 Provider
 Coder
 Biller
 Management and Executive Levels
 Everyone



                                       7
Compliance is not just for the Compliance
                Office…..
 Example of a department’s commitment:
  We handle all coding by CPC certified coders are
   utilized in assigning codes.
  For the departments that submit charge tickets with
   codes assigned – in conjunction with the University
   Compliance office we audit for correct levels.




                                                         8
Department Compliance Continued
 New provider audit are conducted to ensure accuracy
 Any patient complaints related to potential coding
  issues are reviewed by CPC certified coders to ensure
  accuracy
 Monthly compliance meetings with management staff
 Continuous training




                                                          9
Audits and Auditors
• RAC
• MIC - NAMPI
• PERM
• CERT
• Medi-Medi
• OIG
• DOJ
• And the list continues


                           10
Areas of Focus
 Do you know what has been identified nationally?
   http://www.oig.hhs.gov/
   2010 OIG Workplan


 Do you know what areas are being targeted?
   Local Contractor Bulletins
   Med Learn Articles
       http://www.cms.hhs.gov/mlnmattersarticles/



                                                     11
Background for our OIG Visit
 CMS changed the billing requirements
 CMS published notifications
    Local Intermediary
    Med Learn Articles
 Required system modification
 The Western Integrity Center indicated that our
 organization continued to over bill and the State OIG
 was contacted……..


                                                         12
OIG Audit Scenario
 OIG Agent arrived May 2007
 Extrapolated back to 2001
 Original request for documentation went to Health
 Information
   Location of documentation problematic
   Not everything was sent




                                                      13
Arrival…
 Receptionist said someone with a badge wants some
  billing records…
 Held off auditor – to contact compliance
 Agent didn’t want us to involve legal counsel, this is
  not a big deal….
 Unable to get counsel on phone
 No idea on reason he was arriving – very vague and
  casual
 Don’t assume they know what they are talking about

                                                           14
Common Law Enforcement Tactics:
 Intimidation
 Acting overly friendly
 Asking for information very casually
 Making the audit material seem like it is “no big deal.”




                                                             15
OIG Agent Discussion
 Indicated that we had incorrectly billed and he wanted
  just over $400k.
 He also wanted to know:
    Who made the decision to not refund
    Why did you continue to bill while edit was being
     worked on?
    Why didn’t we read CMS notifications and take
     appropriate steps to correct
    Who is responsible for reading and disseminating
     information
    Civil vs. Criminal

                                                         16
OIG Agent Requested:
   Documentation of our processes
   Compliance plan
   A list of names with work phone and home address
   and phone numbers who were involved in any part
   of the billing, system update, etc. related to this
   scenario




                                                         17
Initial Outcome
 Due to creation of new compliance office agent
  provided a list of accounts audited.
 Allowed us opportunity to re-pull and audit
  documentation
 WIC re-audited with additional information




                                                   18
Final Outcome
 Treated as a settlement letter instead of a False Claims
  Act settlement agreement
 No Corporate Integrity Agreement
 No fraud identified
 Repaid the claims – with interest
 No penalties




                                                             19
Key Lessons Learned
 Documentation on decisions which relate to rebill
 and/or refund scenarios.
   Who is making decision to not reprocess
   Reasoning, methodology
 Ensure staff know the appropriate steps to take for an
  unannounced federal audit
 All Federal audits – OIG, WIC, probe audits, CERT’s,
  Perms managed through Compliance (documentation
  requests multiple records)

                                                           20
Organizational Preparedness
 Protocol for unannounced federal auditors
 Review of communication for CMS or FI changes
 Effective Compliance Plan
    Education
    Audit
    Repayment
    Communication




                                                  21
CMS Guidance
 http://www.cms.hhs.gov/MedicareContractingReform
  /Downloads/compliance.pdf
1. Written Policies and Procedures
2. Designation of Compliance Officer and Committee
3. Conducting Effective Training and Education
4. Effective Lines of Communication
5. Auditing and Monitoring
6. Enforcement
7. Response to Offenses and Corrective Action

                                                     22
 Effective Compliance Program – with a
 Medicaid Twist
 Jim Sheehan, NY Attorney General –
    http://www.omig.state.ny.us/data/
    THE NEW LAW
     Chapter 442 of the Laws of 2006, which established the
     New York State Office of the Medicaid Inspector
     General (OMIG) in statute, also created a new Social
     Services Law § 363-d which requires that Medicaid
     providers develop and implement compliance programs
     aimed at detecting fraud, waste, and abuse in the
     Medicaid program.
                                                              23
The New Law Requires:
 To be effective, any compliance program must reflect a
  provider’s size, complexity, resources and culture. It
  must also be designed to be compatible with any given
  provider’s characteristics.
 A set of minimum core requirements that are
  applicable to all providers, regardless of size, that are
  subject to its provisions.




                                                              24
At a minimum, what must a compliance
plan contain?
 Provider compliance programs shall, at a minimum,
  be applicable to billings to and payments from the
  medical assistance program but need not be confined
  to such matters.
 ….(NY OMIG) is authorized to impose additional
  requirements for compliance plans beyond the basic
  statutory requirements which are as follows.



                                                        25
Continued
 Written policies and procedures
 Designate an employee vested with responsibility for
  the day-to-day operation of the compliance program
 Training and education of all affected employees and
  persons associated with the provider




                                                         26
Continued
 Communication lines to the responsible compliance
  position, accessible to all employees
 A system for routine identification of compliance
  risk areas
 Internal audits and as appropriate external audits, self-
  evaluations and audits




                                                          27
Compliance Office Annual Report
Table of Contents
 Overview
 Appendix 1 – Compliance Office Web Page
 Appendix 2 – Compliance Plan
 Appendix 3 – University Ethical Standards and Code
               of Conduct




                                                       28
Continued
 Appendix 4 – Policies and Procedures
 Appendix 5 – Training & Education
 Appendix 6 – Monthly Update Webpage
 Appendix 7 – Monthly Update Agenda and
               Presentation




                                           29
Continued
 Appendix 8 – DRG Audit Calendar
 Appendix 9 – Non-DRG Audit Calendar




                                        30
Website




          31
Monthly Updates
 Compliance Office Meeting Agenda
 10:45 – 10:50 - All Services
   Amended Medical Records
   Signature Requirements
 10:50 – 11:10 - Physician Services
   Consultation Services
   Counseling and Coordination of Care
   Prolonged Services
   Initial Observation Care for Patients Seen the Next Day

                                                              32
Ethical Conduct
 CONDUCT
 Those acting on behalf of the University have a general
 duty to conduct themselves in a manner that will
 maintain and strengthen the public’s trust and
 confidence in the integrity of the University and to
 take no actions incompatible with their obligations to
 the University.




                                                          33
Policies and Procedures
              Chapter       Section                  Policy Title

General Information

1                       1             General Compliance Information

1                       2             Policy Update and Review

1                       3             Signatures

1                       4             Shared Services

1                       5             Incident-to Services

1                       6             Modifier 21

1                       7             Modifiers 22 & 52

1                       8             Modifiers TC & 26




                                                                       34
Training and Education
Subject Matter                                     Month/Year


2007 Coding Changes                                 January-07

2008 Coding Changes                                 January-08

Admission Status                           January-07 - present

Adult Urology                                    December-07

Advanced Beneficiary Notice                            April-08

Central Line/Port/Catheter             January-07 and March-07

Consultations                                          April-08

Counseling and Coordination Training                   June-07

Critical Care                                    November-07




                                                             35
   Example of Audit Calendar
                                    September-08                        October-08                     November-08                    December-08
    Service Line
      Audits
                                  Infectious Disease/ O,P,C
                                                                   Infusion Services/ O (facility      Podiatry/ O,P (CT/SE)           UNI/ O facility (MD)
           300 total                         (CT)
                                                                          only) (CT/DO)                       20-Nov                 No pre-audit mtg needed
  encounters/month for                  30-September
   initial audits and 100                                                                                                         Thrombosis Center E/M/ O, P
                                 Pulmonology (201) / O,P,C                                           Baclofen Trial/ O,P (MD)               (DO)
encounters/month for post
                                                                                                                                    moved from September due to
            audits                        (CT)                                                       No pre-audit mtg needed
                                                                                                                                               Probe
                                                                                                                                               3-Dec
  Globerian can audit 65 line                                                                        Madsen Internal Med/ O,P
                                 Acuity Level (Internal) / I,C                                                                     Wound Care/ O, P (DO/DS)
 items/FTE/day, so days are                                                                                    (CT)
                                           (DO)                                                                                    No pre-audit mtg needed
 calculated by line items/130                                                                                12-Nov
                                                                                                      PT Probe Follow-up / O           5-West/P (75) (MD)
                                Infusion of Saline (Internal)/ O                                                                  (run from documentation for DRG
                                                                                                             (MD/SE)                           Audit)
                                      (facility only) (CT)
                                                                                                     No pre-audit mtg needed                  2-Dec
                                                                                                    Hematology Oncology/ O,P
                                        UNI/ O,P (MD)
                                                                                                             (CT)                 Baclofen Trial (33) / O,P (MD)
                                        23-September
                                                                                                            18-Nov
                                Moran Intraocular Lens/ O,P,
                                                                                                     Infectious Disease (136) /      RAC - Inpatient Rehab
                                    Chargemaster (CT)
                                                                                                             O,P,C (CT)            (Consultant) / I (MD/DS/SE)
                                       19-September
                                HCH/ Hosp Endo Post / O,P
                                                                                                    Infusion Services/ O (facility PT Probe Follow-up (Internal)
                                            (CT)
                                                                                                           only) (CT/DO)                   / O (MD/SE)
                                        No Meeting
                                 Cardiology Post / O,P (CT)                                                                        Madsen Internal Med / O,P
                                        No meeting                                                                                           (CT)
                                    Ortho-Overlapping
                                                                                                                                   Hematology Oncology / O,P
                                    Procedures / (CT)
                                                                                                                                             (CT)
                                       10-September
                                                                                                                                                                   36
Unannounced Federal Audit Protocol
 If regulatory auditors and/or agents show up in your
    area:
 Page the Compliance Office at 339-8092 (24/7)
  Ask the auditor to wait until the appropriate University
    representative arrives
  If the auditor will not wait and has a search warrant,
    accompany him/her and write down all information
    accessed or removed


                                                          37
Continued
 Respond in a courteous manner.
 University Health Care fully cooperates with all
  regulatory officials while maintaining our rights to
  ensure inspections are lawful and to have agency
  officials accompanied by appropriate University
  representatives.
 Request that the inspectors refrain from conducting
  their inspection until you contact a University official
  who can be present at the inspection.


                                                             38
Continued
 You can politely state that you do not have authority to
  authorize an inspection and that you will contact the
  appropriate university officials who can provide the
  necessary consent.
 Typically, someone will arrive to accompany the
  investigators within 15 to 30 minutes. If there is break
  room or waiting area nearby, ask the inspectors to wait
  there.



                                                         39
Continued
 Refrain from answering any specific questions until
 someone from the Compliance Office or Office of
 General Counsel arrives.
   Do not speculate, just provide the facts.
   It is acceptable to say that you do not know the answer
    to a question, but will forward it to the appropriate
    person for a response




                                                              40
Continued
 If the inspectors have a search warrant and/or insist
  on proceeding immediately, do the following:
 Request identification from the inspectors. Obtain
  their business cards
 Call the number on the card to verify that the person is
  an employee of the organization noted on the business
  card.




                                                          41
Continued
 Request a copy of the warrant; or if there is no warrant,
  ask them to explain the legal authority under which
  they are acting, e.g. the specific legal statutory
  authority
 If you are presented with a search warrant,
  immediately contact the University Health Care
  General Counsel's Office at (801)585-7002 and fax a
  copy of the search warrant to (801) 585-7007.



                                                          42
Continued
 Ask the official if they are responding to a specific
  issue.
 Accompany the official, take notes concerning what is:
   Searched
   Reviewed
   Removed from the premises
 Ask for an inventory or copy of all items removed from
  the premises.
 You have the right to speak or not to speak with the
  inspectors
                                                           43
Continued
 You can choose to have a University lawyer present, if
  you decide to speak to the inspectors
 Do not interfere with the search or inspection
  (cooperate but do not consent)
 University Health Care has a similar policy for all
  outside auditors and investigators.




                                                           44
Continued
 Unannounced visits at a home or personal residence
  are a possibility, (although very unlikely).
 If this occurs, unless the governmental official has a
  search warrant, you are not required to participate in
  the interview or allow the person access to your home.




                                                           45
Continued
 You can choose to have a lawyer present if you decide
  to speak with the inspectors.
 Protect your rights!




                                                          46
Preparing for the Defense
 Begin to prepare for the institution’s defense
   Prepare the institution’s public position on the “raid” and
    the underlying criminal investigation
       An appropriate, measured response, with input from public
        relations expert and legal counsel
   Carefully document/evaluate any improprieties with
    regard to the execution of the search
       This can form the basis for a motion to suppress the evidence
        seized in the event the institution is prosecuted
Preparing for the Defense
 Begin to prepare for the institution’s defense
   Start collecting materials
     Materials that appeared to be of interest to the investigators

     Other materials that might be helpful

   Consider seeking return of the documents seized
     Federal Rules of Criminal Procedure provide that a person who is
      “aggrieved by an unlawful search and seizure or by the
      deprivation of property” may file a motion with the court seeking
      return of the property
More on External Investigations
 Subpoena
 Request for Information / Records
    Office of Inspector General
    State Attorney General Office
    Department of Justice
    CMS / HHS
    Carrier / Intermediary / Contractors
    Program Safeguard Contractors
My Final Thoughts…..
 START WITH A PLAN NOW
 START WITH A PLAN NOW
 START WITH A PLAN NOW
Role Playing
 Prepare Staff for Interactions with External
  Auditors




                                                 51
Working Together


         Karen.wilson@hsc.utah.edu
                801-213-3801




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