The document outlines the Office of Inspector General's (OIG) focus areas for auditing Medicare compliance, including reviewing physicians and suppliers for incorrectly billed amounts, high cumulative payments, physician-owned distributors of spinal implants, place-of-service coding errors, and use of incident-to billing. It then discusses the seven key elements of an effective compliance plan according to OIG: having policies and procedures, designating a compliance officer, conducting training, effective communication, internal monitoring, enforcement, and responding to issues. The presentation emphasizes establishing a culture of compliance, keeping plans up-to-date, ongoing training, investigating reports, and conducting audits.

1. Building a Practice Compliance Plan
Presented by:
Shelley Garrett, CPC, CMC, CMOM, CMIS

2. OIG 2012
www.oig.hhs.gov

3. OIG
Physicians and Suppliers: Compliance
With Assignment Rules
Reviewing for Inappropriately billed in excess
of amounts allowed by Medicare and to
assess beneficiaries’ awareness of their rights
and responsibilities regarding potential billing
violations and Medicare coverage guidelines.

4. OIG
Physicians and Other Suppliers: High
Cumulative Part B Payments
Reviewing for a high cumulative payment defined as
an unusually high payment made to an individual
physician or supplier, or on behalf of an individual
beneficiary, over a specified period. Prior OIG work
has shown that unusually high Medicare payments
may indicate incorrect billing or fraud and abuse.

5. OIG
Physician-Owned Distributors of Spinal
Implants
Reviewing to what extent to which physician-owned
distributors (POD) provide spinal implants
purchased by hospitals and analyzing Medicare
claims data to determine whether PODs that have
been identified in review are associated with high
use of spinal implants. Congress has expressed
concern that PODs could create conflicts of interest
and safety concerns for patients.

6. OIG
Physicians: Place-of-Service Errors
Reviewing physicians’ coding on Medicare Part B
claims for services performed in ambulatory surgical
centers and hospital outpatient departments to
determine whether they properly coded the places of
service. Federal regulations provide for different
levels of payments to physicians depending on
where services are performed.

7. OIG
Physicians: Incident-To Services
Medicare Part B pays for certain services billed by
physicians that are performed by non-physicians
incident to a physician office visit. A 2009 OIG
review found that when Medicare allowed
physicians’ billings for more than 24 hours of
services in a day, half of the services were not
performed by a physician. We also found that
unqualified non-physicians performed 21 percent of
the services that physicians did not perform
personally.

8. OIG
Physicians: Impact of Opting Out of Medicare
Reviewing the extent to which physicians are opting
out of Medicare and determining whether physicians
who have opted out, are permitted to enter into
private contracts with Medicare beneficiaries.
As a result of entering into private contracts,
physicians must commit that they will not submit a
claim to Medicare for any Medicare beneficiary.

9. OIG
Chiropractors: Part B Payments for Services
Reviewing Medicare Part B payments for
chiropractic services to determine whether such
payments were in accordance with Medicare
requirements. Medicare chiropractors’ services
include only treatment by means of manual
manipulation of the spine. Chiropractic maintenance
therapy is not considered to be medically reasonable
or necessary and is therefore not payable.

10. OIG
Evaluation and Management Services: Use of Modifiers
During the Global Surgery Period
Reviewing the appropriateness of the use of certain claims
modifier codes during the global surgery period to determine
whether Medicare payments for claims with modifiers used
during the global surgery period were in accordance with
Medicare requirements.
The global surgery payment includes a surgical service and
related preoperative and postoperative E/M services
provided during the global surgery period.

11. Steps to a Compliance Plan
The OIG has established a list of
Seven key elements when
establishing your Compliance
plan.

12. Step One…
Have a written policy
and procedure manual

13. Step Two…
Designate a Compliance
Professional to oversee
the plan

14. Step Three…
Conduct an effective training
program

15. Step Four…
Provide an effective
communication program

16. Step Five…
Develop an internal
monitoring program

17. Step Six…
Enforce your standards with
a corrective action plan

18. Step Seven…
Promptly respond to issues

19. Keys to Success
 Foster a Culture of Compliance
 Besure that policies are updated and
user friendly
 Make training a part of the job

20. Keys to success
 Stay current
 Be visible and approachable
 Take appropriate corrective action
 Conduct regular audits

21. Address Areas of Concern
 Coding
 Contracts
 Quality of Care

22. False Claims Act
This act addresses any entity who
submits or causes to be submitted a claim
for services that are:
 Not rendered
 Miscoded
 Already covered under another claim
 Not supported in the medical record
 Violates Stark Law

23. Penalties
If a claim is submitted by an individual
who "knows or should know“ (termed
deliberate ignorance) that they are filing
a false claim, civil sanctions may be
imposed.

24. Penalties
Civil sanctions may be as much as $11,000
per claim ($50,000 for an anti-kickback
violation) plus an assessment of up to three
times the amount improperly claimed.
Each claim for payment could cause a
separate penalty.

25. Qui Tam Suits
Whistle blower suits pay 30% of the
recovered amount. Who are known
whistleblowers:
 Patients
 Patients family members
 Competitors
 Past and Present Employees
 Ex-Business Partners

26. Code of Conduct
Each compliance plan should begin with a
code of conduct.
All employees, physicians, and any member of
practice oversight should be educated. As a
record of education you should have a signed
copy of acknowledgement on file.

27. Comprehensive Plan
 Coding and Billing Compliance Plan
 HIPAA
 OSHA
 CLIA

28. Training
Annual training should be conducted on
all areas of compliance and a record of
attendance should be kept and readily
available.

29. Ongoing Training
 Keep up with changes and communicate with
all staff
 New Employees need intense training and all
employees need refreshers
 Make sure all training complies with state and
federal regulations.

30. Ongoing Training
Be sure that all employees know the
compliance plan, as well as, who should be
notified when an issue arrives.
If you are the compliance professional: Be
approachable and always have a no retaliation
policy.

31. Follow-up on Reports
 Conduct investigation
 Document the areas of concern and
how the issue was resolved
 Self report, when necessary

32. Policies to Keep in Mind
Patient Discounts
 Routine Waiver of Co-pays/Deductibles
 Attempt to collect policy
 Bad debt write-offs
 Discounts and processional courtesies

33. Policies continued…
Coordination of Benefits
 Medicare/Medicaid
 Medicare as a Secondary Payer
 Liability or No-Fault Insurance

34. Policies…
Business Relationship
 Stark Law
 Private Contracting
 Physician Coverage Arrangements

35. Policies…
Documentation Guidelines
 1995 and 1997
 Proper Documentation for
Consultations
 Global and Bundled Services
 Care Plan Oversight
 Screening Services

36. What steps have you taken
toward compliance?

37. Audit Program
 Establish a realistic audit schedule
 Decide if all audits will be done in-house, if
you will seek outside help, or will use a
combination of both
 Decide if you need additional auditing or
training based on what you discover
 Self report on your findings
 Implement corrective action to promote
compliance

38. Audit Program
 Random sample vs targeted
 Sample all types of service provided
 Review the encounter form (charge ticket)
and EOB in addition to the medical record.
This will help you locate missed charges or
inappropriate payments.
 Take the opportunity to begin proactive
education approach to ICD-10

39. Shelley Garrett
mycodingconsultant@yahoo.com

40. Questions?