Fraud, Abuse, Audits & Appeals: What Therapists Need to Know

 This text-based course is a transcript of the live seminar, “Fraud, Abuse, Audits & Appeals:What Therapists Need to Know,” presented by Mary R. Daulong, PT, CHC, CHP. >> Mary Daulong:  Before we begin, I would like to ask a few questions.  How many of you are physical therapists?  How many of you are business office managers or staff?  I wanted to get a feel for the audience to see if we have a vantage point one way or another. Today’s presentation will not be the answer-all for everything, but I will give resources for you to refer back to as needed.  Why the Focus on Fraud and Abuse?Why are we interested in fraud and abuse?  Why is the government in almost every single newspaper on a daily basis talking about fraud and abuse, especially as it relates to the federal programs?  We are looking at 1 trillion dollars of government spending on Medicare and Medicaid programs.  They are estimating 3% to 10%, with the extreme side being 100 billion dollars, of fraud.  Obviously, this is very important to focus on.  They have created a number of programs to combat fraud which are administered by the attorney general’s office and the secretary of health and human services.  They are working at a federal level as well as a state level to combat the fraud and abuse that exists throughout the nation.  Prior to 1986, we did not hear much about fraud and abuse.  Since they have put the numbers together, it has been a significantly important focal point for them.  Fraud and Abuse Control ProgramsThe first program is the Medicare Integrity Program.  It does have a number of functions.  They do a lot of data mining.  They are looking at detecting aberrant billing and coding behavior by the providers.  They do auditing with utilization reviews and requesting of charts.  Education is the proactive function that they do provide, and your MACs (Medicare Administrative Contractors) are responsible for providing education to the providers of the federal program services and beneficiaries as well.  You are seeing more and more information on how to do things correctly.  Primarily in the past, the MACs, who were called carriers and fiscal intermediaries, were responsible for education.  It varied quite a bit as far as what that function was because it is not something that is compensated to those particular contractors.  Now CMS is providing more and more resources to the MACs, so education has certainly improved. We also have the Beneficiary Incentive Program for people who may have seen a Medicare Beneficiary summary. It talks about what they can do to submit a suspected or known fraud, and also tells them of the financial benefit that it would be to them should there be some recovery.   This is the Qui Tam provision which is the whistleblower provision.  For example, many of our seniors with very limited finances would have a higher incentive to watch things very carefully.  We are hearing a lot more questions from our patients about their bills.  “You did this on one day and this on another day, but the bill was the same/different than I think were provided.”   You will probably continue to see that escalate. As mentioned, there is the notice to the beneficiaries, but there is also another important aspect called the Senior Medicare Patrol.  These are people who are being trained and educated on how to look at different aspects of provider services including the billing.  With those programs and forces together, we have quite a number of individuals, not so much Medicare and Medicaid, looking at what we do.  Who Investigates and Enforces?Who is involved in investigated and enforcing? That’s the job of the Office of the Inspector General.  One thing I learned from the assistant attorney general when at my annual conference for the Compliance Association was that there is a bell curve, and they are looking at the tails, whether it is the end tail or beginning tail. Any aberrance from the bell curve is being investigated.  If you are really bad and you are on the end tail, they are going to be auditing and doing more data mining on you.  If you are squeaky clean, they probably will look at you as well.  If people intentionally under-code or do not use therapy cap exception, they will look at that as aberrant. The Department of Justice is the department which prosecutes.  The FBI is investigating also.  They really know their stuff.  I have had an opportunity to work with the FBI on occasion, and they have been well educated.  They understand, not just the mechanics of billing and coding, but they also have been educated from a physiology and anatomy perspective.   When they are looking at things, they are asking in-depth questions about why we do what we do, not just how we bill or code.  The Center for Medicare/Medicaid is involved as well as the Office of Civil Rights.  This is a division of Health and Human Services that is specific to HIPAA.  I bring up HIPAA because HIPAA has very deep pockets to this particular regulation.  One thing that came about with this particular act was funding for fraud and abuse, not just the HIPAA provision for the administrative simplification. We also have the State Medicaid Fraud Control Units which are being activated now.  We have the Medicaid Integrity Program and the Qui Tam relators.  As I said with HIPAA, we have the ability to investigate and prosecute for fraud other than just at the federal level.  This will be at the individual commercial payer level.    We have a number of people, departments, and entities that are looking at us as providers. One of the things you will see is HEAT, the Healthcare Fraud Prevention & Enforcement Action Team, who has been very active in states such as New York, Florida, California and Texas.  I am from Texas and am sensitive to this because we have been in the news quite a bit unfortunately.  This is a very active, sophisticated team that is...