Compliance, Audit, Risk & Ethics (CARE) Issues Use of Data in an Effective Compliance Program

Healthcare Financial Management Association (HFMA) NJ Chapter

March 10, 2015

2

DISCLAIMERS

The opinions expressed are those of the presenter and are not intended to be

statements or reflections of the opinions or positions of their organizations/

employers

This presentation is general in scope, seeks to provide relevant background and

hopes to assist in the identification of pertinent issues and concerns. The

information is not intended to be, nor should it be construed or relied upon, as

legal advice

The presenter did not receive compensation from any vendor or consulting firm

referenced during this presentation

3

Today’s agenda

Use available data sources to identify those issues common to your facility

Explore how to:

• Create an internal PEPPER (Program for Evaluating Payment Patterns

Electronic Report)

• Maximize your business intelligence

• Create edits for data mining

4

Hospitals, Providers, & Health Systems in the Cross-Hairs:

Who’s Watching?

• Medicare and Medicaid Contractors

o Zone Program Integrity Contractors (ZPICs),

o Medicaid Integrity Contractors (MICs),

o Medicare Administrative Contractors (MACs),

o Recovery Audit Contractors (RACs)

• HHS Office of Inspector General

• Medicaid Fraud Control Units/ State Attorney Generals

• Whistleblower scrutiny

o Federal and state False Claims Act

• State Attorney General Scrutiny

• Competitor and Press Scrutiny

5

Compliance Officers Face Significant Challenges

• Creating and sustaining a culture of compliance throughout the organization

• Free-flowing communication on compliance and organizational follow-through

Building/Sustaining a culture of compliance

• Accurate relevant data

• Benchmarks/ Best Practices

Gathering and leveraging relevant data

• Regulatory and other healthcare policy programs

• Technology Advances and associated compliance concerns

Keeping Pace with External Changes

• Organizational Complexity creates training, monitoring and auditing challenges

• Geographic footprint

• Not just hospitals anymore

Compliance in the face of Organizational Complexity

• Limited Resources

• Limiting turnover in key positions Building and maintaining

competencies

6

Data Sources

OIG Annual Work plan Recovery Audit Contractors OIG Audits/Audit Reports Approved List

Specific Hospital Reviews Other region RAC approved items Internal Data PEPPER

Compliance Risk Review Dep

artm

ent o

f Ju

stic

e

OIG

Rep

ort

OIG

Wo

rkp

lan

CM

S C

om

pre

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Rev

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s

Med

icar

e R

AC

Med

iCai

d R

AC

CM

S-M

AC

, CE

RT

, Pro

bes

PE

PP

ER

Inte

rnal

Rev

iew

s

Pay

er A

ud

it - c

om

mer

cial

New

Ris

k A

rea

Iden

tific

atio

n

vBp

- V

aue

Bas

ed P

urc

has

ing

Met

ric

Oth

er

Lik

elih

oo

d S

core

Inpa

tien

t

Out

pati

ent

Prof

essi

onal

Bill

ing

Rese

arch

New

Ser

vice

s

EM

R B

uild

/Go

-Liv

es

Acq

uisi

tion

s

Fac

ility

Sco

re

OIG

Wor

kpla

n

NCD

/LCD

OIG

Com

plia

nce

Prog

ram

Gui

danc

e

OIG

Rep

ort

Dat

a M

inin

g

CMS

Qua

rter

ly

Regu

lato

ry C

hang

e

Bas

is o

f Act

ivity

Sco

re

Sub-

tota

l Ris

k Sc

ore

Sys

tem

Co

ntr

ol -

Pre

bill

ing

ed

it

Man

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Co

ntr

ol

- re

view

of

Pre

bil

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it c

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Sys

tem

Co

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Man

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Rec

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evie

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Mita

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Sco

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core

Compliance Coding Audit Categories

Hospital Admission Status

Short hospital stays (0 and 1 day/less than 2MN) 1 1 1 1 1 1 1 1 8 1 1 2 1 1 1 1 1 5 15 (1) (1) (1) (3) 15

Inpatient Hospital

High‐severity level MS‐DRGs

Inpatient claims mechanical ventilation - verify 96 hours. 1 1 1 1 1 1 6 1 1 1 1 2 9 (1) (1) 9

E&M services billed with surgical services (modifier 25) 1 1 1 3 1 1 1 1 1 3 7 0 7

E&M services billed with modifier 59 1 1 1 3 1 1 1 1 1 3 7 0 7

Outpatient Hospital

Outpatient dental services 1 1 1 3 1 1 1 1 1 3 7 0 7

High Risk Error Prone J codes 1 1 1 1 1 5 1 1 2 1 1 1 1 4 11 0 11

Professional Fee

E&M services billed with modifier 59 1 1 1 1 4 1 1 1 1 1 1 5 9 0 9

Anesthesia Personally Performed 1 1 1 3 1 1 1 1 2 6 (1) (1) 6

Data Mining

• Claims paid amount in excess of claims charged amount 1 1 1 3 1 1 2 1 1 1 3 8 (1) (1) (1) (3) 8

• Outlier payments - LOS > 14 days? 1 1 1 3 1 1 1 1 5 0 5

Basis of Activity Mitigating FactorsLikelihood Other Hospital/ Outpatient

• IP Claims with payments greater than $150,000 1 1 1 1 1 1 3 (1) (1) (1) (3) 3

• Outpatient claim payments greater than $25,000 0 1 1 1 1 2 (1) (1) (2) 2

• Facility E&M Coding - "New" vs "Established" Patient 1 1 1 1 4 1 1 1 1 1 1 1 5 10 (1) (1) 10

Non-Coding Compliance Initiatives

Provider Based Place of Service Location 1 1 1 3 1 1 1 1 1 1 4 8 0 8

Internal PEPPER The How and Why

8

Welcome to PEPPER Resources PEPPERresources.org is the official site for information, training and support related to

the program for Evaluation Payment Patterns Electronic Report (PEPPER)

PEPPER provides provider-specific Medicare data statistics for discharge/services vulnerable to

improper payments. PEPPER can support a hospital or facility's compliance efforts by identifying where

it is an outlier for these risk areas. this data can help identify both potential overpayments as well as

potential underpayments.

SHORT-TERM ACUTE CARE HOSPITALS

• User Guide (PDF, 16th Edition)

• Training & Resources

• PEPPER Distribution - Get your PEPPER

PEPPER Resources

Source: www.PEPPERresources.org

HOME PEPPER TRAINING &

RESOURCES DATA FAQ HELP/CONTACT US CMS/MAC

9

Data Reports

Short-term

Acute Care

Hospitals

Critical Access

Hospitals Hospices

Inpatient

Psychiatry

Facilities

Inpatient

Rehabilitation

Facilities

Long-term

Acute Care

Hospitals

Partial

Hospitalization

Programs

Skilled Nursing

Facilities

Target Area Analysis – Short-term Acute Care Hospitals

Top 20 Medical DRGs for Same- and One-day Stays for Short-term Acute Care Hospitals

Top 20 Surgical DRGs for Same- and One-day Stays for Short-term Acute Care Hospitals

Peer Group Bar Charts

HOME PEPPER TRAINING &

RESOURCES DATA FAQ HELP/CONTACT US CMS/MAC

National-level Data Reports

Source: www.PEPPERresources.org

Copyright © 2015 Deloitte Development LLC. All rights reserved. 10

Hospital PEPPER report

• The PEPPER DATA tab

• Finding and Using National Data

o Top 20 – One Day Stays

• New! PEER GROUP BAR charts

HUMC - Hypothetical University Medical Center

How to Create an Internal PEPPER

11

Purpose of Short-term acute care: PEPPER

Below is a visual representation of how PEPPER is run through Excel

Data Report through Q4 FY 2014

For illustrative purposes only

12

Purpose of Short-term acute care: PEPPER (cont’d)

Outlier Rank

For illustrative purposes only

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Purpose of Short-term acute care: PEPPER (cont’d)

Outlier Rank

For illustrative purposes only

14

PEPPER Dashboard

KEY >National 80%tile < Min 20%tile KEY >National 80%tile < Min 20%tile

>Juris 80%tile In Normal Range >Juris 80%tile In Normal Range

>State 80%tile No data (less than 11 cases) >State 80%tile No data (less than 11 cases)

Q1=Oct -Dec

Q2=Jan-Mar

Q3=Apr-June

Q4=July-Sept

Time Periods Str

oke I

ntr

acra

nia

l

Hem

orr

hag

e

Resp

irato

ry I

nfe

cti

on

s

Sim

ple

Pn

eu

mo

nia

Sep

ticem

ia

Un

rela

ted

OR

Pro

ced

ure

Med

ical

DR

Gs w

ith

CC

or

MC

C

Su

rgic

al

DR

Gs w

ith

CC

or

MC

C

Sin

gle

CC

or

MC

C

Excis

ion

al

Deb

rid

em

en

t

Ven

tila

tor

Su

pp

ort

Tra

nsie

nt

Isch

em

ic A

ttack

Ch

ron

ic O

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ulm

on

ary

Dis

ease

Perc

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ard

iovascu

lar

Pro

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ure

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co

pe

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Cir

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ry S

yste

m

Dia

gn

osis

Oth

er

Dig

esti

ve S

yste

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Dia

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osis

Med

ical

Back P

rob

lem

s

Sp

inal

Fu

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n

Th

ree-d

ay S

kil

led

Nu

rsin

g

Facil

ity-q

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g A

dm

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30-D

ay R

ead

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e

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30-D

ay R

ead

mis

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sp

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2D

S M

ed

ical

DR

G

2D

S S

urg

ical

DR

G

1D

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ed

ical

DR

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1D

S S

urg

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DR

G

Sam

e D

S M

ed

ical

DR

G

Sam

e D

S S

urg

ical

DR

G

Q4 GFY 2011 38.6

Q1 GFY 2012 20.2

Q2 GFY 2012

Q3 GFY 2012 46.2 13.5

Q4 GFY 2012

Q1 GFY 2013 56.4 60.9 31.9 19.7

Q2 GFY 2013 2.9

Q3 GFY 2013 2.4 7.4 14.3 14.5

Q4 GFY 2013 22.9 14.5

Q1 GFY 2014 61.6

Q2 GFY 2014 2.2.

Q3 GFY 2014 70.49

Avg Volume

GFY 2013/1445 <11 30 55 18 700 250 300 12 45 < 11 15 25 12 15 19 15 12 150 250 150 155 69 87 55 36 15

The Compare Targets Report displays statistics for target areas that have reportable data in the most recent time period. To prioritize Compare Worksheet findings, hospitals should consider their target area

percentile values for the nation, jurisdiction and state. Percentile values at or above the 80th percentile (for all target areas) or at or below the 20th percentile (for coding-focused target areas) indicate that

the hospital is an outlier. Outlier status should be evaluated in the priority order of 1) nation, 2) jurisdiction and 3) state. The higher (or lower, for coding-focused areas) the percentile, the greater the outlier

status. Hospitals should also consider the number of target discharges and the sum of payments in prioritizing their findings to maximize potential impact of their efforts.

DRG Validation & Coding MEDICAL NECESSITY - SHORT TERM STAY

CATEGORIESMEDICAL NECESSITY -

Admissions MEDICAL NECESSITY: Admission Rate Categories

For illustrative purposes only

15

Short-Term Acute Care PEPPER Visit PEPPERresources.org

Same- and 1DS Top Medical DRGs

HYPOTHETICAL UNIVERSITY MEDICAL CENTER

Hospital Top Medical DRGs for Same- and 1-Day Stay Discharges, Most Recent 4 Qtrs.

In Descending Order by Same- and 1-Day Stay Totals Per DRG NATION JURISDICTION

DRG Description

Same- and

1-Day

Stay

Count*

Total Dis-

charges

for DRG

Proportion

of Same-

and 1-Day

Stays to

Total Dis-

charges

for DRG

Hospital

Average

Length

of

Stay

for DRG

Same- and

1-Day

Stay

Count*

Total Dis-

charges

for DRG

Proportion

of Same-

and 1-Day

Stays to

Total Dis-

charges

for DRG

National

Average

Length

of

Stay

for DRG

Same- and

1-Day

Stay

Count*

Total Dis-

charges

for DRG

Proportion

of Same-

and 1-Day

Stays to

Total Dis-

charges

for DRG

Jurisdict.

Average

Length

of

Stay

for DRG

287 Circulatory disorders except AMI, w card cath w/o MCC 40 108 37.0% 2.1 19,358 82,690 23.4% 3.3 1,723 9,138 18.9% 3.8

310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 18 65 27.7% 2.5 26,124 83,347 31.3% 2.3 2,901 10,260 28.3% 2.4

392 Esophagitis, gastroent & misc digest disorders w/o MCC 17 99 17.2% 3.9 31,933 189,828 16.8% 3.3 3,155 21,277 14.8% 3.5

313 Chest pain 14 34 41.2% 2.2 28,727 71,154 40.4% 2.1 3,034 7,942 38.2% 2.3

192 Chronic obstructive pulmonary disease w/o CC/MCC 13 99 13.1% 4.4 10,245 71,629 14.3% 3.3 1,017 7,965 12.8% 3.4

191 Chronic obstructive pulmonary disease w CC 12 44 27.3% 5.0 10,639 115,883 9.2% 4.0 1,055 13,488 7.8% 4.4

638 Diabetes w CC 12 44 27.3% 2.9

309 Cardiac arrhythmia & conduction disorders w CC 12 44 27.3% 2.5 16,381 94,851 17.3% 3.3 1,672 11,134 15.0% 3.5

312 Syncope & collapse 12 62 19.4% 2.7 21,446 90,863 23.6% 2.9 2,599 12,120 21.4% 3.1

Top Medical DRGs 150 599 25.0% 3.1 315,810 2,159,767 14.6% 3.6 32,651 258,041 12.7% 3.9

All

Medical

DRGs 589 4,683 12.6% 4.7 698,068 6,852,549 10.2% 4.7 71,612 785,500 9.1% 5.0

*Excludes deaths (20), transfers to a short-term hospital for inpatient care (02), leaves against medical advice

(07), and transfers to a short-term general hospital with a planned acute care hospital inpatient readmission

(82).

Note: DRGs will display if they had at least 11 same- or one-day stay discharges in the most recent four

quarters.

Use the Data Tab to obtain detail and create reports:

For illustrative purposes only

16

Short-Term Acute Care PEPPER

PPS Hospitals for JL Novitas Solutions, Inc. (12001)

Same- and 1DS Top Medical DRGs

Jurisdiction Top 20 Medical DRGs for Same- and 1-Day Stay Disch., Most Recent 4 Qtrs.

In Descending Order by Same- and 1-Day Stay Totals Per DRG

DRG Description

Same- and

1-Day

Stay

Count*

Total Dis-

charges

for DRG

Proportion

of Same-

and 1-Day

Stays to

Total Dis-

charges

for DRG

Jurisdict.

Average

Length

of

Stay

for DRG

392 Esophagitis, gastroent & misc digest disorders w/ o MCC 3,155 21,277 14.8% 3.5

313 Chest pain 3,034 7,942 38.2% 2.3

310 Cardiac arrhythmia & conduction disorders w/ o CC/ MCC 2,901 10,260 28.3% 2.4

312 Syncope & collapse 2,599 12,120 21.4% 3.1

069 Transient ischemia 2,105 8,357 25.2% 2.7

641 Misc disorders of nutrition,metabolism,fluids/ electrolytes w/ o MCC 1,929 12,514 15.4% 3.6

287 Circulatory disorders except AMI, w card cath w/ o MCC 1,723 9,138 18.9% 3.8

309 Cardiac arrhythmia & conduction disorders w CC 1,672 11,134 15.0% 3.5

812 Red blood cell disorders w/ o MCC 1,577 9,303 17.0% 3.6

690 Kidney & urinary tract infections w/ o MCC 1,562 19,328 8.1% 3.9

292 Heart failure & shock w CC 1,437 24,868 5.8% 4.7

293 Heart failure & shock w/ o CC/ MCC 1,056 8,419 12.5% 3.2

191 Chronic obstructive pulmonary disease w CC 1,055 13,488 7.8% 4.4

603 Cellulitis w/ o MCC 1,047 16,047 6.5% 4.2

683 Renal failure w CC 1,034 16,139 6.4% 4.6

192 Chronic obstructive pulmonary disease w/ o CC/ MCC 1,017 7,965 12.8% 3.4

066 Intracranial hemorrhage or cerebral infarction w/ o CC/ MCC 999 6,480 15.4% 3.0

378 GI hemorrhage w CC 933 15,468 6.0% 4.1

291 Heart failure & shock w MCC 918 21,494 4.3% 6.2

101 Seizures w/ o MCC 898 6,300 14.3% 3.5

Top Medical DRGs Jurisdiction-wide 32,651 258,041 12.7% 3.9

All Medical DRGs Jurisdiction-wide 71,612 785,500 9.1% 5.0

Visit PEPPERresources.org

For illustrative purposes only

17

DRG DRG Description

Same- and

1-Day Stay

Count*

Total

Discharges

for DRG

Proportion of

Same- and 1-

Day Stays to

Total

Discharges

Average

Length of

Stay for DRG

392 Esophagitis, gastroent & misc digest disorders w/o MCC 31,933 189,828 16.8% 3.3

313 Chest pain 28,727 71,154 40.4% 2.1

310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 26,124 83,347 31.3% 2.3

312 Syncope & collapse 21,446 90,863 23.6% 2.9

641 Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC 19,379 112,339 17.3% 3.3

287 Circulatory disorders except AMI, w card cath w/o MCC 19,358 82,690 23.4% 3.3

069 Transient ischemia 18,456 64,033 28.8% 2.5

309 Cardiac arrhythmia & conduction disorders w CC 16,381 94,851 17.3% 3.3

690 Kidney & urinary tract infections w/o MCC 16,319 162,909 10.0% 3.7

812 Red blood cell disorders w/o MCC 14,662 77,131 19.0% 3.5

292 Heart failure & shock w CC 13,364 193,549 6.9% 4.4

683 Renal failure w CC 11,860 146,552 8.1% 4.3

378 GI hemorrhage w CC 10,888 139,745 7.8% 3.8

191 Chronic obstructive pulmonary disease w CC 10,639 115,883 9.2% 4.0

192 Chronic obstructive pulmonary disease w/o CC/MCC 10,245 71,629 14.3% 3.3

066 Intracranial hemorrhage or cerebral infarction w/o CC/MCC 10,090 53,366 18.9% 2.8

293 Heart failure & shock w/o CC/MCC 9,392 65,853 14.3% 3.1

603 Cellulitis w/o MCC 9,105 129,351 7.0% 4.1

640 Misc disorders of nutrition,metabolism,fluids/electrolytes w MCC 8,758 62,952 13.9% 4.5

194 Simple pneumonia & pleurisy w CC 8,684 151,742 5.7% 4.4

Top 20 Medical DRGs 315,810 2,159,767 14.6% 3.6

All Medical DRGs 698,068 6,852,549 10.2% 4.7

Short-Term National Q3FY14 Report − Top 20 Medical DRGs for Same- and 1-Day StaysDischarges for most recent 4 Quarters, ending Q3FY2014

In Descending Order by Same- and 1-Day Stay Totals Per DRG

*Excludes deaths (20), transfers to short-term acute care hospitals (02 and 82) and leaves against medical advice (07).

Source: www.PEPPERresources.org

For illustrative purposes only

18

7.4%

10.1%

13.5%

6.6%

9.4%

12.6%

0% 2% 4% 6% 8% 10% 12% 14% 16%

20th Percentile

50th Percentile

80th Percentile

Location

Urban Rural

6.8%

9.2%

12.7%

7.0%

9.9%

13.2%

6.5%

9.2%

12.3%

0% 2% 4% 6% 8% 10% 12% 14% 16%

20th Percentile

50th Percentile

80th Percentile

Teaching Status

Other Teaching Nonteaching Major Teaching

7.1%

10.0%

13.6%

7.7%

10.1%

13.9%

6.6%

9.4%

12.4%

0% 5% 10% 15%

20th Percentile

50th Percentile

80th Percentile

Ownership Type

Nonprofit/Church Government Forprofit/Phys

6.9%

9.6%

12.9%

0% 2% 4% 6% 8% 10% 12% 14% 16%

20th Percentile

50th Percentile

80th Percentile

Surgical Focus

Surgical Other

Percentiles by Peer Group - Short Term Q3FY14 Apr –June

One-day Stays for Medical DRGs

Source: Visit PEPPERResources.org

19

Example – ventilator support

For illustrative purposes only

20

Example – ventilator support (cont’d)

For illustrative purposes only

21

Short-Term National Q3FY14 Report − Target Area Summary Report

Target Areas and data for quarter and year Q4 FY 2013 Q1 FY 2014 Q2 FY 2014 Q3 FY 2014

Ventilator Support

DRGs 003, 004, 207, 870, 927, 933 with px code 96.72 on the claim 19,906 22,028 26,752 21,594

All DRGs 003-004, 207-208, 870-872, 927-929, 933-934 Discharges 165,399 177,835 191,225 182,114

Proportion of Target to Denominator Discharges 12.0% 12.4% 14.0% 11.9%

Average Length of Stay for Target 19.4 18.8 18.9 18.7

Average Medicare Payment for Target $61,601 $58,119 $56,934 $56,931

Sum of Medicare Payments for Target (in Millions) $1,226.226 $1,280.247 $1,523.111 $1,229.358

HUMC --Ventilator Support

DRGs 003, 004, 207, 870, 927, 933 with px code 96.72 on the claim 19 36 32 32

All DRGs 003-004, 207-208, 870-872, 927-929, 933-934 Discharges 48 87 85 116

Proportion of Target to Denominator Discharges 39.6% 41.4% 37.6% 27.6%

Average Length of Stay for Target 30.5 23.1 21.1 20.2

Average Medicare Payment for Target $100,519 $73,751 $70,376 $69,419

Target Sum Medicare Payments $1,909,861 $2,655,036 $2,252,032 $2,221,408

Using PEPPER in UM/Quality Conversations

For illustrative purposes only

22

PEPPER Compare Dashboard

For illustrative purposes only

Business Intelligence

24

Advancement in

technology Healthcare reform

Regulatory

mandates

Value-based payment

models

Predictive analytics

What drives

predictive

analytics?

Copyright © 2015 Deloitte Development LLC. All rights reserved.

25

• Shift away from using retrospective data

• Real time data to make prospective predictions

• Focus on the future: “What’s next?”, “What should we do

about it?”

Use of predictive analytics

Copyright © 2015 Deloitte Development LLC. All rights reserved.

26

Some benefits of using predictive analytics

Develop

Complex

Analyses (in

real time)

Enhance

Budget

Forecasting

Provides Business

Intelligence

Copyright © 2015 Deloitte Development LLC. All rights reserved.

27

Best Source for Hospital information and custom data services

The American Hospital Directory provides data and statistics about more than 6,000

hospitals nationwide.

AHD.com® hospital information includes both public and private sources such as

Medicare claims data, hospital cost reports, and commercial licensors.

AHD®is not affiliated with the American Hospital Association (AHA) and is not a source for

AHA Data. Our data are evidence-based and derived from the most authoritative

sources.

• Free hospital profiles

• Free state & national stats

Source:

http://www.ahd.com/

28

Number

Medicare

Inpatients

Average

Length

of Stay

Average

Charges

Medicare

Case Mix

Index (CMI)

Cardiology 2,120 5.05 $33,394 1.0654

Cardiovascular

Surgery 2,241 4.72 $80,827 3.8744

Gynecology 110 2.76 $26,716 1.0741

Medicine 4,568 7.14 $42,986 1.2459

Neurology 814 6.37 $36,001 1.0962

Neurosurgery 191 6.12 $68,321 3.0907

Obstetrics 21 3.24 $24,193 0.7287

Oncology 539 8.11 $71,482 2.0516

Orthopedic Surgery 1,327 4.98 $54,179 2.4552

Orthopedics 421 5.98 $33,828 1.0004

Psychiatry 574 12.69 $43,859 0.9202

Pulmonology 1,328 6.60 $35,341 1.3299

Surgery 2,426 10.46 $96,255 3.4254

Surgery for

Malignancy 294 3.82 $42,206 1.6938

Urology 1,135 5.37 $35,421 1.2231

Vascular Surgery 473 4.83 $53,262 2.2744

Total 18,583 6.73 $53,931 1.9696

HUMC -- Inpatient Utilization Statistics by Medical Service Definitions

Source: http://www.ahd.com For illustrative purposes only

29

Hospital #1 Hospital #2 Hospital #3

Number Average Average Medicare Number Average Average Medicare Number Average Average Medicare

Medicare Length Charges Case Mix Medicare Length Charges Case Mix Medicare Length Charges Case Mix

Inpatients of Stay Index (CMI)

Inpatients of Stay Index (CMI)

Inpatients of Stay Index (CMI)

Cardiology 836 4.39 $43,437 1.1197 1,531 4.64 $49,101 0.9991 954 5.76 $77,862 1.1645

Cardiovascular

Surgery 258 7.43 $166,433 4.1841

464 7.04 $166,418 4.3527

1,268 9.1 $296,179 5.2693

Gynecology 22 2.5 $45,042 1.0954 64 3.28 $62,691 1.1582 66 2.59 $65,016 1.0855

Medicine 2,474 8.24 $56,933 1.2093 3,136 5.83 $57,691 1.1608 2,189 7.25 $79,346 1.2382

Neurology 373 4.64 $45,804 1.1466 1,344 5.05 $60,377 1.1677 504 5.92 $87,932 1.1705

Neurosurgery 35 8.06 $142,486 3.1084 466 6.16 $144,136 3.4499 201 8.39 $191,160 3.2565

Obstetrics 32 2.91 $23,293 0.6986 26 3.58 $25,035 0.7216 29 3.69 $40,102 0.8185

Oncology 150 4.67 $52,317 1.4369 556 5.71 $77,046 1.6555 603 9.45 $133,063 2.2359

Orthopedic

Surgery 210 6.19 $111,276 2.5026

2,022 4.18 $93,184 2.6664

493 6.74 $140,947 2.4504

Orthopedics 135 4.96 $42,896 0.9842 365 5.56 $50,134 1.0353 163 6.05 $80,243 1.1756

Psychiatry 371 14.68 $52,937 0.913 280 12.6 $63,906 0.8971 42 4.98 $60,698 0.8865

Pulmonology 604 4.28 $43,554 1.3308 930 5.99 $57,824 1.2491 532 6.02 $82,930 1.4219

Surgery 526 10.42 $160,880 3.8038 1,798 8.61 $147,021 3.3287 1,702 10.21 $212,650 3.7798

Surgery for

Malignancy 33 4.97 $94,970 1.8987

179 4.53 $91,220 2.0197

210 5.65 $117,328 1.9099

Urology 591 4.56 $46,107 1.191 1,009 5.18 $58,962 1.2355 524 5.85 $81,923 1.4269

Vascular

Surgery 111 9.16 $121,542 2.6366

220 6.47 $124,373 3.0117

242 8.17 $157,446 2.3085

Total 6,761 7.13 $67,352 1.5777 14,391 5.86 $81,652 1.8636 9,722 7.7 $142,850 2.4198

Inpatient Utilization Statistics by Medical Service

Source: http://www.ahd.com For Illustrative purposes only

30

APC

Number APC Description

Number

Patient

Claims

Average

Charge

Average

Cost

0656 Transcatheter Placement of

Intracoronary Drug-Eluting Stents 539 $10,339 $1,700

0080 Diagnostic Cardiac Catheterization 1,652 $7,585 $1,247

1327 Imiglucerase injection 183 $99 $62

0605 Level 2 Hospital Clinic Visits 26,733 $223 $138

0927 Factor viii recombinant 25 $2 $1

0948 Gamunex-C/Gammaked 710 $92 $57

8000 Cardiac Electrophysiologic Evaluation

and Ablation Composite 139 $22,678 $3,730

0932 Factor IX recombinant 31 $2 $1

0108 Level II Implantation of Cardioverter-

Defibrillators (ICDs) 46 $15,743 $2,614

0107 Level I Implantation of Cardioverter-

Defibrillators (ICDs) 59 $15,373 $2,528

0082 Coronary or Non-Coronary Atherectomy 154 $6,018 $2,506

0039 Level I Implantation of Neurostimulator

Generator 46 $5,128 $2,189

0606 Level 3 Hospital Clinic Visits 10,931 $265 $164

9295 Injection, carfilzomib 802 $71 $44

0325 Group Psychotherapy 6,977 $175 $109

9119 Injection, pegfilgrastim 6mg 380 $4,987 $3,105

2616 Brachytx, non-str,Yttrium-90 72 $30,000 $20,049

0229 Level II Endovascular Revascularization

of the Lower Extremity 96 $7,799 $2,194

0412 Level III Radiation Therapy 195 $3,100 $408

0440 Level V Drug Administration 3,409 $1,018 $134

Outpatient Utilization Statistics by APC Source: http://www.ahd.com

Definitions

For illustrative purposes only

Physician Practice Compare

32

Source: MDAudit Demo Slide

33

http://www.aapcps.com/resources/em_utilization.aspx

Where to find the data – Free!

34

35

36

37

Creating Edits for Data Mining

39

Prioritizing edits

– Inpatient LOS less than 2 Midnights

Post Payment Review – Weekly Monitor Reports

– Payment greater than Charges

– Inpatient Payment greater than $150,000

– Outpatient Payment greater than $25,000

– Medically Unlikely Edits

• Pharmacy Units

• Units > 1

Monthly or Quarterly Review

– Place of Service

– New vs Established Patients

40

2015 OIG Work Plan

Nationwide review of cardiac catheterizations and endomyocardial biopsies

We will review Medicare payments for right heart catheterizations (RHC) and endomyocardial

biopsies billed during the same operative session and determine whether hospitals complied with

Medicare billing requirements. Previous OIG reviews have identified inappropriate payments when

hospitals were paid for separate RHC procedures when the services were already included in

payments for endomyocardial biopsies. To be processed correctly and promptly, a bill must be

completed accurately. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 1,

§80.3.2.2.) (OAS; W-00-14-35721; various reviews; expected issue date: FY 2015)

Bone marrow or stem cell transplants

We will review Medicare payments to hospitals for bone marrow or stem cell transplants to

determine whether the payments were made in accordance with Federal rules and regulations.

Bone marrow or peripheral blood stem cell transplantation includes mobilization, harvesting, and

transplant of bone marrow or peripheral blood stem cells and the administration of high-dose

chemotherapy or radiotherapy before the actual transplant. When bone marrow or peripheral

blood stem cell transplantation is covered, all necessary steps are included in coverage.

(CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 3, §90.3.) Bone marrow or stem

cell transplants are covered under Medicare only for specific diagnoses. Procedure codes must be

accompanied by the diagnosis codes that meet specified coverage criteria. Prior OIG reviews have

identified hospitals that have incorrectly billed for bone marrow or stem cell transplants. (OAS;

W-00-14-35723; expected issue date: FY 2015)

http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

41

Billing Edits

42

Increased scrutiny by governing bodies

Utilizing PEPPER and creating your own PEPPER

• How to get started

• Need for real time data analytics

Physician practice compare

• Take advantage of free data

‒ Establish goals, prioritize, develop a plan

Importance of the use of edits and data mining

Summary

Appendix

44

45

46

MD

47

48

49

50

Today’s presenters

Nancy Toll Perilstein, Sr. Manager nperilstein@deloitte.com

Deloitte & Touche LLP +1 609 870 2102

Nancy is a Senior Manager in the Deloitte healthcare advisory practice with over 30 years’ experience in

healthcare management and administration. She has a diverse clinical background as a Registered

Nurse, with broad experience in critical care, maternal child health, and home care. Nancy is considered

an industry leader when it comes to level of care for the hospitalized patient and CMS guidelines

regarding the two-midnight rule. Nancy and her team assist health care providers with OIG investigations,

by conducting reviews to evaluate compliance and identify opportunities for the appropriate utilization of

observation and outpatient services. This includes analyzing and remediating internal controls related to

utilization management, case management activities, physician advisor services, registration and

admission processes and revenue cycle functions. Nancy is a national speaker on regulatory topics

including documentation requirements, leading case management practices and medical necessity. Nancy

has served as an expert witness on litigation concerning the medical necessity of inpatient and outpatient

claims.

Angela M Melillo, Chief Compliance Officer Melillo-angela@.cooperhealth.edu

Cooper University Health System 856-536-1303

Angela is the Chief Compliance Officer for the Cooper University Health Care in Camden NJ.. With 25

years of progressive healthcare administration experience in integrated delivery systems, acute care

hospitals, business development and physician practice management, Angela’s previous experience

includes serving as the VP- Chief Compliance Officer at Saint Peter's Healthcare System in New

Brunswick, New Jersey; the Executive Director of Community Medical Associates, a primary care MSO,

and as the Executive Director-Chief Operating Officer of Kimball Medical Center. A graduate of Rutgers

College with MBA in Healthcare Administration from CUNY-Mt Sinai School of Medicine, Angela is

certified in healthcare compliance and healthcare research compliance and a member of HCCA, ACHE,

AAPC and HFMA.

This presentation contains general information only and Deloitte is not, by means of this presentation, rendering accounting, business, financial, investment,

legal, tax, or other professional advice or services. This presentation is not a substitute for such professional advice or services, nor should it be used as a basis

for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a

qualified professional advisor.

Deloitte shall not be responsible for any loss sustained by any person who relies on this presentation.

About Deloitte

Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee (“DTTL”), its network of member firms, and their

related entities. DTTL and each of its member firms are legally separate and independent entities. DTTL (also referred to as “Deloitte Global”) does not provide

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regulations of public accounting.