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Presented by -
Amanda Ward, Esq., CAC, CACO, CAPO
and
Steve Johnson, Director of Reimbursement Consulting, CAC, CACO,
CAPO
www.pwwemslaw.com
5010 E. Trindle Road, Suite 202 Mechanicsburg, PA 17050
717-691-0100 717-691-1226 (fax)
[email protected] [email protected]
© COPYRIGHT 2016, PWW MEDIA, INC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT THE WRITTEN
CONSENT OF PWW MEDIA, INC.
2016
Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050
www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226
Amanda Ward Attorney [email protected] Amanda Ward is an associate attorney at Page, Wolfberg & Wirth, LLC. She focuses on Reimbursement and Compliance issues and is a speaker at PWW’s signature abc3 conference series as well as other seminars and webinars. Amanda’s work for PWW includes representing private, public and nonprofit EMS agencies, billing companies and others that serve the nation’s ambulance industry. Amanda also helps to develop many of the firm’s articles, books, presentations and other programs that are widely used by EMS providers throughout the United States.
Prior to joining PWW, Amanda was the in house counsel and Compliance Officer for a large ambulance service where she created, implemented and oversaw the company’s first formal compliance program. Amanda has significant experience advising both public and private ambulance services and third party billing agencies concerning reimbursement and compliance issues. She also has experience reviewing claims and advising entities regarding best practices for reimbursement compliance. Amanda is familiar with the employment and contractual issues affecting the ambulance industry and is able assist ambulance services as they navigate those matters.
Amanda is admitted to practice law in California and holds a certification in healthcare compliance from the Compliance Certification Board. She graduated with honors from Millikin University in Decatur, IL with a degree in Marketing. Amanda is also a graduate of the University of Illinois College of Law where she was an Intellectual Property Moot Court competitor and editor.
Amanda is an avid Illini fan and lives in the suburbs of Chicago with her three children. She actively volunteers with various organizations in her local community including her children’s schools and the Junior League.
2016
Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050
www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226
Steven M. Johnson Director of Reimbursement Consulting [email protected] Steve began his career in the EMS industry in 1985, gaining valuable experience while serving as an EMT and later as Director of a municipal ambulance service in Minnesota. As an ambulance service manager, Steve established his expertise in areas of operations, billing and administration.
Steve also has significant EMS educational experience. He established and served as Training Coordinator and Lead Instructor for a State Certified EMS Training Institution for EMTs and First Responders.
Steve served on both the Rules Work Group and the EMS Advisory Council to the Minnesota State Department of Health.
He joined the staff of a large, national billing and software company, where he was a frequent lecturer at national events and software user group programs. For over seven years, Steve served as Director of a national ambulance billing service and was responsible for all aspects of managing this company, including reimbursement, compliance and other activities for ambulance services throughout the nation.
Steve served as founding Executive Director of the National Academy of Ambulance Coding (NAAC), overseeing all activities of the Academy, including the Certified Ambulance Coder program, the nation’s only coding certification program specifically for ambulance billers and coders.
As the Director of Reimbursement Consulting with Page, Wolfberg & Wirth, Steve is involved in all facets of the firm’s consulting practice. Steve works extensively on billing and reimbursement-related activities, performing billing audits and reviews, improving billing and collections processes, providing billing and coding training, conducting documentation training programs, and performing many other services for the firm’s clients across the United States.
Steve is also a licensed private pilot, and enjoys an active role in his church.
Attendee License Agreement
Once you (Licensee) register for and/or attend any PWW Media, Inc. (Licensor, hereinafter “PWW Media) Event (including but not limited to abc360, The PWW Executive Institute and any PWW Media webinars), you agree to be bound by the terms of this License. This License covers
any information, materials or training that PWW Media provides, whether written, electronic or oral, and whether accessed directly or indirectly through attendance at a conference or access via the Internet (Licensed Materials). Licensee is permitted to print one copy of the Licensed Materials and/or keep one electronic copy as backup. Unless Licensee obtains Licensor’s prior written permission, Licensee may not:
Permit anyone but you to use a password or share a link to access Licensed Materials; Provide or forward any Licensed Materials in whole or in part to anyone else; Copy, duplicate or in any manner reproduce or rebroadcast any Licensed Material or use it to train anyone; Copy, modify, sell, distribute, rent, lease, loan or sublicense any Licensed Materials; Record any PWW Media Event (including presentations, questions and answers, individual consultations, etc.)
by audio, video, electronic or any other means; Use any Licensed Materials for any commercial purposes whatsoever.
All Licensed Materials are the Copyright of PWW Media, Inc. unless otherwise noted. All rights are reserved. No claim is made with regard to any governmental works or the works of any third parties used by permission. No part of this material may be duplicated, reproduced or distributed by any means.
Although Licensor attempts to provide accurate and complete information at all PWW Media Events, Licensor cannot guarantee it. Errors and omissions may occur. Therefore, Licensor presents all Licensed Materials “as is” and disclaims any warranties of any kind, express or implied. The Licensee acknowledges that the Licensed Materials are subject to change based on changes in law and agrees that Licensor is not responsible to update and/or supplement any of the Licensed Materials at any time. None of the Licensed Materials constitute legal advice or a definitive statement of the law and are not a substitute for individualized legal advice under an attorney-client relationship. Licensed Materials are for educational purposes only. Licensee is instructed to consult the official sources of materials from governmental agencies. Licensor is not responsible in any manner for any billing, compliance, reimbursement, legal or other decisions you make based in whole or in part upon any Licensed Materials, and Licensee hereby forever releases Licensor from any and all claims and liability of any kind related to Licensee’s use of any Licensed Materials. Any examples of documentation, coding scenarios and other teaching illustrations contained in any Licensed Materials are examples for illustrative purposes only. Licensor waives any and all claims, lawsuits or other actions against PWW Media, its principles and employees and all related entities. In all cases, you agree that the liability of PWW Media, Inc. is limited to any amounts paid by Licensee for registering for the PWW Media Event. This Agreement is governed by Pennsylvania law and any disputes hereunder shall be brought exclusively in the Commonwealth of Pennsylvania, County of Cumberland.
Licensee acknowledges that Licensor, nor anyone else on its behalf, made any representations or promises upon which you relied that are not in this Agreement. This Agreement constitutes the entire understanding between Licensee and Licensor and cannot be altered unless signed in writing by the principals of PWW Media, Inc. If any part of this Agreement is declared invalid, it will not invalidate the remaining parts. If Licensor does not enforce any part of this Agreement for any reason, Licensor does not waive its right to enforce it later.
License and Limitations of Use
Copyright Statement
Disclaimer
Entire Agreement
© Copyright 2015-2016, PWW Media, Inc.
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2016 SERIES- PART 1 OF 3
July 27, 2016
WARNING
The unauthorized reproduction or distribution of this copyrighted work is
illegal. Criminal copyright infringement, including infringement without monetary gain, is investigated by the FBI, and is punishable by up to 5 years in federal
prison and a fine of $250,000.
DISCLAIMERS
This information is presented for educational and general information purposes and should not be relied upon as legal advice or definitive statements of the law.
Consult applicable laws, regulations and policies for officials statements of the law.
No attorney-client relationship is formed by the use of these materials or the participation in this seminar. The
user of these materials bears the responsibility for compliance with all applicable laws and regulations.
AUDIO OR VIDEO RECORDING OF THIS
WEBINAR IS STRICTLY PROHIBITED
Thank You to Our Webinar Sponsor!
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Questions During the Webinar
• Use the “Questions” feature on your GoToWebinar control panel
• Fax: 717-691-1226
Today’s Webinar:
To enter your CEUs log into your NAAC account at www.AmbulanceCompliance.com
Fall 2016- All NEW Content
Registration NOW OPEN!
www.abc360conference.com
Hershey 2016 Dates
October 18-19 October 17
October 15-17 October 15-16 October 15-16
Certifications
This Webinar covers the “big” items since the fall 2015
abc360 conference
© Copyright 2015-2016, PWW Media, Inc.
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Dates for Upcoming 2016 abc360
Update Webinars
• September 14, 2016 2 - 3pm
• December 14, 2016 2 - 3pm
Today’s Webinar
• ICD-10 Implementation Progress• New Medicare Payment Data• Recent Reimbursement and Compliance
News• The Final 60 Day Overpayment Rule• HIPAA Happenings• The Latest ACA Legal Challenge
MEDICARE AND REIMBURSEMENT UPDATE
2016 Ambulance Inflation Factor
• Negative 0.4%
MLN Matters Number: MM9412
Remember this?
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AMA and CMSAnnounced ICD-10 “Flexibility”• “[For 12 months]. . . Medicare review
contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule . . . based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right [family of codes]…”
Only 3 months left in the “flexibility” window
Assessing Your Progress
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf
Some KPIs to Track
Coder productivity Volume of records coders return to
providers for more documentation
Requests for additional information from payers
Some KPIs to Track
Use of ICD-10 codes on prior authorizations and referrals
Denial of unspecified codesDenial of claims specifically related to
ICD codes used
Ask Staff About…
• Specific parts of their workflow that are slowed by ICD-10
• Areas where more or different tools or training might be helpful
• Where they see opportunities for improvement
• Coding situations that cause the most difficulty
© Copyright 2015-2016, PWW Media, Inc.
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Are We Getting What We Need?
• Look at clinical documentation for services provided before and after October 1, 2015
• Issues with documentation might be a result of insufficient training on ICD-10 coding concepts and guidelines
CMS Released CY 2014 Part B Medicare Payment Data
Let’s take a quick look at CY 2014 nationwide ambulance
data . . .
ALS1‐E33%
ALS1‐NE2%
ALS2<1%BLS‐E
19%
BLS‐NE45%
SCT<1%
National Ground Breakdown 2014
ALS36%
BLS64%
National ALS/BLS Breakdown 2014
ALS1‐E64%
BLS‐E36%
National Emergency Transport Breakdown 2014
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ALS1‐NE5%
BLS‐NE95%
National Non‐Emergency Transport Breakdown 2014
Average Submitted Charges Nationwide 2014
• ALS1-NE $828.66• ALS1-E $963.00• ALS2 $1,166.71• BLS–NE $547.63• BLS-E $700.31• SCT $2,033.17• Fixed Wing $16,942.28• Rotary Wing $19,948.57
MAC HappeningsCycle 2 Revalidations. Here
we go again….
Cycle 2 Revalidation Program
• All providers and suppliers supposed to revalidate every 5 years
• CMS assigning revalidation due dates based on the last successful revalidation or the date of the initial enrollment e.g, if you revalidated in 2011 your new
revalidation date will be in 2016
Use CMS Revalidation Lookup Tool
• CMS has assigned due dates through fall 2016
• If you haven’t yet been assigned it will show “TBD”
https://data.cms.gov/revalidation
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Cycle 2 Revalidation Program
• First set of due dates was May 31, 2016• CMS will notify providers or suppliers
by email within 2-3 months of their due date
• Data last refreshed on 7/5/2016• Next data refresh tentatively scheduled
for 9/1/2016
Submitting Revalidations
• Permitted to submit revalidations up to 6 months prior to the scheduled due date
• Revalidations can be submitted either on paper or by using PECOS online
• For more information: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html
If You Fail to Timely Revalidate
• Medicare billing privileges will be deactivated
• Will be required to submit a complete enrollment application to “reactivate”
• CMS said no payments will be made for services provided during the interim period
Did You Hear About the Misinformation from some of
the MACs?
We agree! And we want to help with an ALL NEW
session…COMPLIANCE UPDATE
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OIG Updates Criteria it Uses to Determine Whether to
Impose Exclusion
http://oig.hhs.gov/exclusions/files/1128b7exclusion-criteria.pdf
IN OTHER WORDS… WHETHER OR NOT YOU END UP HERE
Remember…
• The OIG has the authority to exclude individuals and entities who engage in fraud or improper conduct
• It MUST exclude individuals and entities in certain circumstances like Conviction for patient abuse Felony conviction for healthcare fraud
But…
• But in all other situations it’s up to the OIG to determine if exclusion is warranted based on how likely it is that the individual or entity will engage in fraud or improper conduct again
The New Standard
• The OIG presumes that exclusion is necessary when fraud or improper conduct occurs unless the individual or entity can PROVE that exclusion is not necessary
The OIG Assesses Four Categories…
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Based on the Assessment the Likelihood of Future Risk is
Determined
And Then a Penalty is Imposed Based on the Risk Level
1. Transports to dialysis facilities that potentially Never occurred Were medically unnecessary
2. Improper ALS-E payments
“We will examine Medicare claims data [for]”
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Houston and Philadelphia Ambulance Moratoria Extended Again!
• Effective January 29, 2016 CMS extended moratoria for an additional 6 months
Are YOU Next on the Moratorium List?
Now You Can Predict It!
The Final 60 Day Overpayment Rule
• Published February 12, 2016
Effective:March 14, 2016
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Enforces Two Provisions in the ACA
1. Providers and suppliers must report and return identified overpayments from Medicare and Medicaid within 60 days
2. Retaining an overpayment after the deadline constitutes a violation of the Federal False Claims Act (FCA)
Regulations Apply to…
• Medicare overpayments • CMS said it will issue other rules for
Medicaid overpayments Even without Medicaid-specific rules, you
still have a duty under ACA to return Medicaid overpayments within 60 days of identification
Definition of “Overpayment”
• Any funds a provider has received or retained from Medicare to which the provider is not entitled
Examples of Overpayments• Claims paid at a higher level of service
than is justified by the documentation
• Claims paid for transports performed or billed by an excluded individual
• Claims paid without a valid signature are overpayments
• Invalid or missing PCS forms
Identified
• A provider has identified an overpayment if the provider has, or should have through the exercise of reasonable diligence Determined that an overpayment has been
received, and Quantified the amount of the overpayment
42 CFR § 401.305(a)(2)
Reasonable Diligence
• Reasonable diligence is BOTH: Proactive compliance activities conducted in
good faith by qualified individuals to monitor for the receipt of overpayments Investigations conducted in good faith and in
a timely manner by qualified individuals in response to obtaining credible information of a potential overpayment
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Here’s the Way it WorksYou determined
you’ve received an overpayment and
quantified it
You exercise “reasonable diligence”
You fail to exercise “reasonable diligence”
You have “identified” an overpayment
The overpayment is “identified” once you’ve determined
you’ve received it and you’ve quantified it
The overpayment is likely “identified”
when it was received
60 Day Time Frame
• When investigations are necessary, HHS says that the investigation should take at most 6 months from the receipt of the credible information
• Maximum time frame to complete the refund is 8 months - 6 months maximum for an investigation + 60 days to refund the overpayment
Best Practices - Investigation
• Where little or no investigation is required – report and return 60 days from date you discovered the issue
• If you need to investigate: Proceed with “reasonable diligence” Don’t take longer than 6 months to investigate Don’t take more than 8 months from discovery to
repay
Quantifying the Overpayment
• If actual amount can be readily determined, refund the actual amount
• In more complicated cases, like a two-step process:1. Probe sample2. Extrapolation
6 Year Lookback Period
• Overpayments must be refunded only if provider identifies the overpayment within 6 years of the date the overpayment was received
• When investigating potential overpayments – may need to go back 6 years!
Find Out More About the 60 Day Overpayment Rule by attending
• 2016 Compliance Update• ALL NEW session How to Navigate
the 60 Day Overpayment Rules
© Copyright 2015-2016, PWW Media, Inc.
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PRIVACY UPDATE
The Phase 2 HIPAA Audits are Underway!
Check Your Spam Filter!
• OCR will via email you• “If your spam filtering and virus
protection are automatically enabled, we expect you to check your junk or spam email folder for emails from OCR; [email protected].”
• 14 days to respond
Who’s Getting Audited?
• “Every covered entity and business associate is eligible for an audit.”
You Get a
HIPAA Audit
What if We Get Contacted?
• Must fill out audit pre-screening questionnaire online
• Will be asked for list of business associates
The Audit Protocol is Online
http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/protocol/index.html
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Recent Advice on Patient Rights Patient’s Have a Right to Get Records Via Email
Even, Unencrypted Email And, you Can’t Do This Stuff…
You Can’t Make the Patient
• Physically come in to request PHI• Use a web portal to access their
records• Mail a request for records• Notarize an access request
When it Comes to Patient Access:
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HEALTHCARE REFORM UPDATE
The Latest ACA Legal Challenge
• U.S. House of Representatives vs. Burwell• May 12, 2016 – U.S. District Court for
the District of Columbia • The court ruled that the federal
government cannot make payments to health insurers under the cost-sharing reduction program
The Latest ACA Legal Challenge
• The cost-sharing reduction program provides a subsidy for certain eligible individuals who purchase coverage through the health insurance exchanges
• The ACA requires the payments, but Congress didn’t appropriate the funds
• The court ruled that the Executive Branch cannot spend funds unless appropriated by the Legislative Branch
The Latest ACA Legal Challenge
• This case is working its way through the appeals process
• The court entered a stay of its injunction pending appeal, which means the government can continue to spend the funds – and insurers can continue to receive reimbursements – during the appeal
Questions
• Use the “Questions” feature on your GoToWebinar control panel
• Fax: 717-691-1226
Fall 2016- All NEW Content Registration NOW OPEN!
www.abc360conference.com
© Copyright 2015-2016, PWW Media, Inc.
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this
Certificate of Completionis presented as evidence of completion, by the Certified Ambulance Coder®, Certified Ambulance Compliance Officer™ or Certified
Ambulance Privacy Officer™ whose signature and Certification Number appear below, of the NAAC® approved Continuing Educationcourse entitled
2015-2016 abc360 Update Webinar Series Part 1 of 3
CEU Code: kGznFW
I hereby certify that I have completed the continuing education training as represented on this certificate.
Signed: ____________________ NAAC® Certification Number: ____________________
Jason J. LeetProgram Coordinator
07/27/16
Date of Training
Certificate is invalid without the signature and certification number of the attendee.
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