Slide 2 Objectives Series of Continuing Educational classes to
follow a laboratory sample from pre-analytical through analytical
to post analytical stages Define and identify a laboratory order,
requisition, and required written authorization Understand CMS
guidelines for medical necessity Define and indentify Medicare
Fraud and Abuse Understand HIPAA, and Billing requirements Explain
expectations for Compliance with Regulations Slide 3 Definition of
Order CMS defines an order as a communication from the treating
physician or practitioner requesting that a lab perform a
diagnostic test for a beneficiary. Orders may be conveyed via: A
written document signed by the treating physician/practitioner that
is hand delivered, mailed or faxed to the treating facility
Telephone call E-mail or other electronic means Slide 4 Types of
Orders Chart notes Script Orders Electronic Orders Verbal Orders
Client Encounter Forms Requisition Slide 5 Slide 6 Definition of
Requisition CMS says a requisition is the actual paperwork, such as
a form, that the physician provides the clinical diagnostic
laboratory to identify the test or tests he or she wants performed.
The requisition may contain patient information, billing
information, specimen information, and test selection. CMS stated
in the final rule that a requisition signed by a physician may
serve as an order, to minimize confusion about signed orders vs.
unsigned requisitions going forward. Slide 7 A Valid Requisition
May provide the laboratory with information necessary to collect
the correct specimen and perform testing, ie. Fasting Identifies
the patient, the ordering physician and the tests requested Should
include a diagnosis code(s), a narrative diagnosis code(s)and how
to bill May serve as an order when it includes the physicians
signature Slide 8 45CFR 493.1105 Standard Test Requisition The
laboratory must perform tests only at the written or electronic
request of an authorized person. Oral requests fro laboratory tests
are permitted only if the laboratory subsequently obtains written
authorization for testing within 30 days. Records of test
requisitions or test authorizations must be retained for a minimum
of two years. The patients chart or medical record, if used as the
test requisition must be retained for a minimum of two years and
must be available to HHS upon request. Slide 9 Requisition
Requirements The patients name or other unique identifier The name
and address or other suitable identifiers of the authorized person
requesting the test and if appropriate, the individual responsible
for utilizing the test results or the name and address of the
laboratory submitting the specimen including as applicable a
contact person to enable the reporting of imminent life threatening
laboratory results or panic values The test(s) to be performed The
date of specimen collection For Pap smears, the patient's last
menstrual period, age or date of birth, and indication of whether
the patient had a previous abnormal report, treatment or biopsy Any
additional information relevant and necessary to a specific test to
assure accurate and timely testing and reporting of results Slide
10 Slide 11 Slide 12 Definition of Medical Necessity Medical
necessity from a Medicare perspective is defined under Title XVIII
of the Social Security Act, Section 1862(a)1(a): No payment may be
made under Part A or Part B of expenses incurred for items or
service which are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member Slide 13 National Coverage Determination NCD
Slide 14 Advanced Beneficiary Notice (ABN) Frequency-limits the
number of times a test can be ordered per year Medically
Necessary-medically reasonable and necessary Investigational-tests
that have not been approved by CMS for reimbursement Slide 15 Slide
16 Billing How to Bill should be selected by physician; patient,
client, insurance, Medicare, or Medicaid Insurance information
should accompany the order to the laboratory to complete the
billing process Advanced Beneficiary Notices should be properly
executed prior to collection Slide 17 Health Insurance Portability
and Accountability Act of 1996 (HIPAA) Health information is
considered to be personally identifiable if it relates to a
specifically identifiable individual; under 45 C.F.R. 160.103, it
generally includes the following, whether in electronic, paper, or
oral format: Health care claims or health care encounter
information Health care payment and remittance advice; Coordination
of health care benefits; Health care claim status; Enrolment and
disenrollment in a health plan; Eligibility for a health plan;
Health plan premium payments; Referral certifications and
authorization; First report of injury; Health claims attachments;
Health care electronic funds transfers (EFT) and remittance advice;
and Other transactions that HHS may prescribe in future
regulations. Slide 18 Disclaimers I am not a lawyer and am not
providing you with legal guidance. It is always advisable to seek
the advice of counsel when making decisions about areas of
potential risk. Slide 19 Quick Facts Medicare and Medicaid made an
estimated $23.7 billion in improper payments in 2007. These
included $10.8 billion for Medicare and $12.9 billion for Medicaid.
(U.S. Office of Management and Budget, 2008) Slide 20 Quick Facts
Health Care Fraud is a serious offense. Those who believe that they
can defraud the government and easily get away with it will find
that they will be caught and prosecuted. The government both at the
state and federal levels, have investigators to seek out fraud,
when it occurs, and my office stands ready to prosecute those who
try to take advantage of the system (United States Attorney George
E. B. Holding) Slide 21 Definition of Fraud Fraud is intentional
deception or misrepresentation that an individual makes, knowing or
believing it to be false, and that the deception or
misrepresentation could result in some unauthorized benefit to that
individual or to some other person. Slide 22 Examples of Fraud
Billing for services or supplies that weren't provided Altering
claims to obtain higher payments Soliciting, offering or receiving
a kickback, bribe or rebate (example: Paying for referral of
clients) Provider completing Certificates of Medical Necessity for
patients not known to the provider Suppliers completing
Certificates for the physician Slide 23 Definition of Abuse
Behaviors or practices that, although normally not considered
fraudulent, are inconsistent with accepted sound medical, business,
or fiscal practices, that may directly or indirectly, result in
unnecessary costs to the program, improper payment, or payment for
services that fail to meet professionally recognized standards of
care or which are medically unnecessary. Slide 24 Examples of Abuse
Excessive charges for services or supplies Claims for services that
don't meet CMS medical necessity criteria Breach of the Medicare
participation or assignment agreements Improper billing or coding
practices Slide 25 Exercise 1 In-Office Phlebotomist has an order
for Glucose. The diagnosis flags for a diagnosis coder to cover
medical necessity. IOP assigns DX code 250.00 after asking client
office staff for code. IOP does not document information received
from client office staff. Slide 26 Exercise 1 Which of the
following is true? IOP committed Medicare Fraud. IOP committed
Medicare Abuse. Slide 27 Exercise 1 IOP committed Medicare Fraud.
IOP committed Medicare Abuse. IOPs action (lack of
documentation)was inconsistent with accepted, sound practice and
resulted in cost to the Medicare system Slide 28 Exercise 2 Its
late Friday afternoon and Susan, a billing analyst, is reviewing a
list of claims exceptions. She has a question about which test was
performed on the patient. Her supervisor has left for the day. She
asks a co-worker, Cathy, who suggests she wait and ask the
supervisor on Monday. Susan wants to finish her work and get home
so she lets the claim process with the more expensive test. Slide
29 Exercise 2 Which of the following is true? Susan committed
Medicare Fraud. Susan committed Medicare Abuse. Susan and Cathy
committed Medicare Fraud. Susan and Cathy committed Medicare Abuse.
Slide 30 Exercise 2 Which of the following is true? Susan committed
Medicare Fraud. Susan committed Medicare Abuse. Susan and Cathy
committed Medicare Fraud. Susan and Cathy committed Medicare Abuse.
Susans action was inconsistent with accepted, sound practice and
resulted in cost to the Medicare system. Slide 31 Exercise 3 The
HIM department of Hope All is Well Hospital has a procedure that
laboratory reports for respiratory cultures are to be reviewed for
all patients with pneumonia. When a respiratory culture is
positive, the procedure states that the coder should assign the
code for a bacterial pneumonia. Slide 32 Exercise 3 Which of the
following is true? This practice is acceptable The HIM department
is committing abuse The HIM department is committing fraud Slide 33
Exercise 3 Which of the following is true? This practice is
acceptable The HIM department is committing abuse The HIM
department is committing fraud Only the physician can determine a
diagnosis. The hospital is knowingly over-coding (up-coding) claims
to receive higher payment. Slide 34 Exercise 4 Good Care Hospital
has a protocol that requires all new admissions to have an EKG,
CXR, H&H, Chem-8 and U/A. The protocol was approved by the
Medical Executive Committee. Should the Compliance Officer be
concerned? Why or Why not? Slide 35 Exercise 4 Medicare coverage is
limited to items and services that are reasonable and necessary for
the diagnosis or treatment of an illness or injury. The physician
is required to consider the patients signs, symptoms and complaints
when ordering tests. A protocol that applies to all patients,
regardless of condition, is not appropriate. Slide 36 Medicare
Anti-fraud Efforts DHHS and DOJ Health Care Fraud and Abuse Control
Program Annual Report for Fiscal Year 2010 $2.5 billion in health
care fraud judgments and settlements $2.86 billion returned to
Medicare Trust Fund (from above an prior years) opened 1,116 new
criminal health care fraud investigations involving 2,095 potential
defendants excluded 3,340 individuals and entities from
participation Slide 37 Medicare Anti-fraud Efforts July 1, 2011:
Medicare implements new screening technology to head-off fraud.
Uses predictive modeling theory Monitors large numbers of claims
for patterns Similar to systems used by credit card companies Looks
at variables such as beneficiary, provider, type of service and
assigns a risk score. Claims will be investigated prior to payment
Slide 38 Medicare Expectations of a Provider Be informed-
understand Medicare eligibility, coverage, billing, and costs Be an
educator- keep beneficiaries properly informed Be a responsible
employer- review the OIG Sanction list Slide 39 Medicare
Expectations of a Provider Implement a Compliance Program Be a
Medicare Anti Fraud Team Member- Contact the OIG hotline @ 1-
800-HHS-TIPS Slide 40 References http://www.oig.hhs.gov
http://www.cms.hhs.gov http://www.stopmedicarefraud.gov
http://justcoding.com http://www.hcpro.com
http://medtraining.com
