Government audits: ‘big brother’ is monitoring you

What does an oncologist need to know about OIGs, RACs, and ZPICs? Plenty. They are some of the auditors who can make life difficult if a practice is not in compliance with Medicare and Medicaid billing and utilization procedures, Roberta L. Buell said at this journal’s annual Community Oncology Conference in Las Vegas.

The government is financing health¬care reform in part through audits to recover stolen and misused money, she explained. Thus far, it has recovered impressive sums, suggesting that the auditors are here to stay no matter how reform plays out. Anyone who runs a practice could be audited, cautioned Ms. Buell, a principal and coding and reimbursement specialist at onPoint Oncology in Sausalito, California. She discussed some of the key types of auditors and their roles.

Acronyms with a mission

Office of Inspector General auditors (OIGs) are responsible for ensuring appropriate use of Medicare funds. Their activities range from conducting basic audits to arranging arrests if a practice is deemed to have done something criminal.

OIGs will be scrutinizing a host of issues in 2011 and 2012, according to Ms. Buell. One is “place-of-service” errors, whereby a claim indicates a patient was treated in an office, where reimbursement is higher, but treatment actually took place in a hospital or ambulatory surgical center. This can be tricky for oncologists who sell their practices to a hospital but maintain a separate office. When physicians see patients in the office, “they’re…billing Part B. But if they walk across the hall to the infusion center and they see [patients] over there,…their place of service will be the hospital,” she said.

The OIGs will also be taking a close look at evaluation and management (E/M) codes to assess whether the codes accurately reflect the type, setting, and complexity of services provided as well as patient status—new or established. Also within the E/M category, auditors will be on the look out for identical (boilerplate) documentation across patients, sometimes a result of use of electronic medical records.

Error-prone providers, such as those with high numbers of duplicate claims, will catch the auditors’ attention as well. To avoid this, Ms. Buell recommended following up with a phone call when a claim goes unpaid, rather than resubmitting the claim. Medicare incentive payments for use of electronic medical records will also feature in the auditors’ work plan. “People are going to be randomly audited to make sure that they had 90 days of consecutive meaningful use—and it has to be for all patients, not just for Medicare patients,” Ms. Buell said.

Compliance with the Health Insurance Portability and Accountability Act will also be assessed. Some large fines have already been levied because of data-security breaches, so practices need to be especially vigilant about not leaving records around or losing laptops.

The OIGs will also scrutinize a variety of issues related to the Part D prescription drug program, such as inclusion of Part A and B claims with Part D claims. Ms. Buell cited billing practices for erythropoiesis-stimulating agents and pegfilgrastim (Neulasta) as an example: a practice might bill through Part D for Neulasta because it is “under water” on it, but “that is going to come back to haunt [you], because that’s not supposed to happen.”

A related aspect of Part D billing is the duplication of drug claims for hospice patients. “If somebody is in the hospice and is getting a drug through the hospice, but comes to your practice and gets it again, that’s going to be looked at,” she explained.

Zone Program Integrity Contractors (ZPICs) “are the [auditors] you really have to worry about. These are the folks who are looking for fraud.” Their data-analysis program is intended to identify provider billing practices and services that pose the greatest financial risk to the Medicare program, for example, high-volume and high-cost services that are being widely overused. But they also investigate credible whistle-blower (qui tam) complaints.

ZPICs can send a practice two types of letters. One is a request for records within 30 days, which usually means the practice was flagged by the screening program and the auditors want to take a closer look at the documentation. In this case, an attorney is not necessary. “But you have to have people look very hard at those records…[so] that everything that is done is justified in the record,” she said. The other type of letter usually arrives by fax and states that auditors will be on site within a few days. “That means that they have a complaint, either by a patient or more likely by a disgruntled physician or employee,” Ms. Buell noted. Here, the stakes are criminal penalties, and there should be an attorney on site during the visit.

Recovery Audit Contractors (RACs) “are bounty hunters,” she said. They are focused on recovering misspent Medicare funds and are paid a contingency fee of 9%–12% of the amount recovered. However, they are not active in practices because they have enjoyed such success in hospitals. At present, they do automated screening of practices’ Part B payments. “If you fall out of the screen, they ask for the money back and that’s the end,” Ms. Buell said. She cautioned, however, that RACs might start doing complex reviews later this year. And if they do, drugs are likely to be an early focus “because there is so much money involved and they have seen that [in the hospitals].”

Medicaid Integrity Contractors (MICs) review Medicaid claims for inappropriate payments and fraud, using a data-driven approach to identify aberrant billing practices. Unlike RACs, who receive a contingency fee, MICs are paid for their services and receive a quality-related bonus. Their look-back period for medical records varies by state. At present, they target mainly hospitals and, to a lesser extent, skilled nursing facilities, nursing homes, and hospices. Physicians are low on the list of priorities, “but…if you have a heavy Medicaid load, you do have to worry about [it],” Ms. Buell said.

Medicare Administrative Contractors (MACs) process claims for both Part A and Part B services and therefore can review discrepancies between the two sets of claims, revise payments, and increase denials. Some ongoing MAC activities include audits regarding usage of the 99204 and 99205 procedure codes for new patients.

Minimizing the risks

Given this environment, what can oncology practices do to minimize their risk? “Have a compliance [program] and make it a priority,” Ms. Buell recommended, adding that it is also a requirement of healthcare reform. Be sure to fix anything the program identifies, because auditors will take a much stiffer stance if they discover issues that were known but not resolved.

Practices can refer to a set of components that the OIG has set forth as the foundation of an effective compliance and ethics program (www.oig.hhs.gov/authorities/docs/physician.pdf). For example, there should be standard policies and procedures in the practice for things such as documentation, education and training, and updates on Medicare regulations. The enforcement of these policies is also a key element of an effective compliance program, as is a prevention component that anticipates mistakes and prevents them from occurring whenever possible.

The healthcare reform legislation requires that practices report and return Medicare and Medicaid overpayments. “If you find that you have been overpaid, for any reason, even if it’s their mistake, give the money back,” Ms. Buell said, because there is a good chance that auditors will eventually discover it.

Any practice that is concerned about being at risk for whistle-blower incidents should obtain legal help. “If you think there is…someone out there who can hurt you, you need to have your compliance program administered by an attorney.”

Finally, “educate, educate, educate,” she advised, to keep physicians and other practice members current on compliance issues.

What does an oncologist need to know about OIGs, RACs, and ZPICs? Plenty. They are some of the auditors who can make life difficult if a practice is not in compliance with Medicare and Medicaid billing and utilization procedures, Roberta L. Buell said at this journal’s annual Community Oncology Conference in Las Vegas.

The government is financing health¬care reform in part through audits to recover stolen and misused money, she explained. Thus far, it has recovered impressive sums, suggesting that the auditors are here to stay no matter how reform plays out. Anyone who runs a practice could be audited, cautioned Ms. Buell, a principal and coding and reimbursement specialist at onPoint Oncology in Sausalito, California. She discussed some of the key types of auditors and their roles.

Acronyms with a mission

Office of Inspector General auditors (OIGs) are responsible for ensuring appropriate use of Medicare funds. Their activities range from conducting basic audits to arranging arrests if a practice is deemed to have done something criminal.

OIGs will be scrutinizing a host of issues in 2011 and 2012, according to Ms. Buell. One is “place-of-service” errors, whereby a claim indicates a patient was treated in an office, where reimbursement is higher, but treatment actually took place in a hospital or ambulatory surgical center. This can be tricky for oncologists who sell their practices to a hospital but maintain a separate office. When physicians see patients in the office, “they’re…billing Part B. But if they walk across the hall to the infusion center and they see [patients] over there,…their place of service will be the hospital,” she said.

The OIGs will also be taking a close look at evaluation and management (E/M) codes to assess whether the codes accurately reflect the type, setting, and complexity of services provided as well as patient status—new or established. Also within the E/M category, auditors will be on the look out for identical (boilerplate) documentation across patients, sometimes a result of use of electronic medical records.

Error-prone providers, such as those with high numbers of duplicate claims, will catch the auditors’ attention as well. To avoid this, Ms. Buell recommended following up with a phone call when a claim goes unpaid, rather than resubmitting the claim. Medicare incentive payments for use of electronic medical records will also feature in the auditors’ work plan. “People are going to be randomly audited to make sure that they had 90 days of consecutive meaningful use—and it has to be for all patients, not just for Medicare patients,” Ms. Buell said.

Compliance with the Health Insurance Portability and Accountability Act will also be assessed. Some large fines have already been levied because of data-security breaches, so practices need to be especially vigilant about not leaving records around or losing laptops.

The OIGs will also scrutinize a variety of issues related to the Part D prescription drug program, such as inclusion of Part A and B claims with Part D claims. Ms. Buell cited billing practices for erythropoiesis-stimulating agents and pegfilgrastim (Neulasta) as an example: a practice might bill through Part D for Neulasta because it is “under water” on it, but “that is going to come back to haunt [you], because that’s not supposed to happen.”

A related aspect of Part D billing is the duplication of drug claims for hospice patients. “If somebody is in the hospice and is getting a drug through the hospice, but comes to your practice and gets it again, that’s going to be looked at,” she explained.

Zone Program Integrity Contractors (ZPICs) “are the [auditors] you really have to worry about. These are the folks who are looking for fraud.” Their data-analysis program is intended to identify provider billing practices and services that pose the greatest financial risk to the Medicare program, for example, high-volume and high-cost services that are being widely overused. But they also investigate credible whistle-blower (qui tam) complaints.

ZPICs can send a practice two types of letters. One is a request for records within 30 days, which usually means the practice was flagged by the screening program and the auditors want to take a closer look at the documentation. In this case, an attorney is not necessary. “But you have to have people look very hard at those records…[so] that everything that is done is justified in the record,” she said. The other type of letter usually arrives by fax and states that auditors will be on site within a few days. “That means that they have a complaint, either by a patient or more likely by a disgruntled physician or employee,” Ms. Buell noted. Here, the stakes are criminal penalties, and there should be an attorney on site during the visit.

Recovery Audit Contractors (RACs) “are bounty hunters,” she said. They are focused on recovering misspent Medicare funds and are paid a contingency fee of 9%–12% of the amount recovered. However, they are not active in practices because they have enjoyed such success in hospitals. At present, they do automated screening of practices’ Part B payments. “If you fall out of the screen, they ask for the money back and that’s the end,” Ms. Buell said. She cautioned, however, that RACs might start doing complex reviews later this year. And if they do, drugs are likely to be an early focus “because there is so much money involved and they have seen that [in the hospitals].”

Medicaid Integrity Contractors (MICs) review Medicaid claims for inappropriate payments and fraud, using a data-driven approach to identify aberrant billing practices. Unlike RACs, who receive a contingency fee, MICs are paid for their services and receive a quality-related bonus. Their look-back period for medical records varies by state. At present, they target mainly hospitals and, to a lesser extent, skilled nursing facilities, nursing homes, and hospices. Physicians are low on the list of priorities, “but…if you have a heavy Medicaid load, you do have to worry about [it],” Ms. Buell said.

Medicare Administrative Contractors (MACs) process claims for both Part A and Part B services and therefore can review discrepancies between the two sets of claims, revise payments, and increase denials. Some ongoing MAC activities include audits regarding usage of the 99204 and 99205 procedure codes for new patients.

Minimizing the risks

Given this environment, what can oncology practices do to minimize their risk? “Have a compliance [program] and make it a priority,” Ms. Buell recommended, adding that it is also a requirement of healthcare reform. Be sure to fix anything the program identifies, because auditors will take a much stiffer stance if they discover issues that were known but not resolved.

Practices can refer to a set of components that the OIG has set forth as the foundation of an effective compliance and ethics program (www.oig.hhs.gov/authorities/docs/physician.pdf). For example, there should be standard policies and procedures in the practice for things such as documentation, education and training, and updates on Medicare regulations. The enforcement of these policies is also a key element of an effective compliance program, as is a prevention component that anticipates mistakes and prevents them from occurring whenever possible.

The healthcare reform legislation requires that practices report and return Medicare and Medicaid overpayments. “If you find that you have been overpaid, for any reason, even if it’s their mistake, give the money back,” Ms. Buell said, because there is a good chance that auditors will eventually discover it.

Any practice that is concerned about being at risk for whistle-blower incidents should obtain legal help. “If you think there is…someone out there who can hurt you, you need to have your compliance program administered by an attorney.”

Finally, “educate, educate, educate,” she advised, to keep physicians and other practice members current on compliance issues.

What does an oncologist need to know about OIGs, RACs, and ZPICs? Plenty. They are some of the auditors who can make life difficult if a practice is not in compliance with Medicare and Medicaid billing and utilization procedures, Roberta L. Buell said at this journal’s annual Community Oncology Conference in Las Vegas.

The government is financing health¬care reform in part through audits to recover stolen and misused money, she explained. Thus far, it has recovered impressive sums, suggesting that the auditors are here to stay no matter how reform plays out. Anyone who runs a practice could be audited, cautioned Ms. Buell, a principal and coding and reimbursement specialist at onPoint Oncology in Sausalito, California. She discussed some of the key types of auditors and their roles.

Acronyms with a mission

Office of Inspector General auditors (OIGs) are responsible for ensuring appropriate use of Medicare funds. Their activities range from conducting basic audits to arranging arrests if a practice is deemed to have done something criminal.

OIGs will be scrutinizing a host of issues in 2011 and 2012, according to Ms. Buell. One is “place-of-service” errors, whereby a claim indicates a patient was treated in an office, where reimbursement is higher, but treatment actually took place in a hospital or ambulatory surgical center. This can be tricky for oncologists who sell their practices to a hospital but maintain a separate office. When physicians see patients in the office, “they’re…billing Part B. But if they walk across the hall to the infusion center and they see [patients] over there,…their place of service will be the hospital,” she said.

The OIGs will also be taking a close look at evaluation and management (E/M) codes to assess whether the codes accurately reflect the type, setting, and complexity of services provided as well as patient status—new or established. Also within the E/M category, auditors will be on the look out for identical (boilerplate) documentation across patients, sometimes a result of use of electronic medical records.

Error-prone providers, such as those with high numbers of duplicate claims, will catch the auditors’ attention as well. To avoid this, Ms. Buell recommended following up with a phone call when a claim goes unpaid, rather than resubmitting the claim. Medicare incentive payments for use of electronic medical records will also feature in the auditors’ work plan. “People are going to be randomly audited to make sure that they had 90 days of consecutive meaningful use—and it has to be for all patients, not just for Medicare patients,” Ms. Buell said.

Compliance with the Health Insurance Portability and Accountability Act will also be assessed. Some large fines have already been levied because of data-security breaches, so practices need to be especially vigilant about not leaving records around or losing laptops.

The OIGs will also scrutinize a variety of issues related to the Part D prescription drug program, such as inclusion of Part A and B claims with Part D claims. Ms. Buell cited billing practices for erythropoiesis-stimulating agents and pegfilgrastim (Neulasta) as an example: a practice might bill through Part D for Neulasta because it is “under water” on it, but “that is going to come back to haunt [you], because that’s not supposed to happen.”

A related aspect of Part D billing is the duplication of drug claims for hospice patients. “If somebody is in the hospice and is getting a drug through the hospice, but comes to your practice and gets it again, that’s going to be looked at,” she explained.

Zone Program Integrity Contractors (ZPICs) “are the [auditors] you really have to worry about. These are the folks who are looking for fraud.” Their data-analysis program is intended to identify provider billing practices and services that pose the greatest financial risk to the Medicare program, for example, high-volume and high-cost services that are being widely overused. But they also investigate credible whistle-blower (qui tam) complaints.

ZPICs can send a practice two types of letters. One is a request for records within 30 days, which usually means the practice was flagged by the screening program and the auditors want to take a closer look at the documentation. In this case, an attorney is not necessary. “But you have to have people look very hard at those records…[so] that everything that is done is justified in the record,” she said. The other type of letter usually arrives by fax and states that auditors will be on site within a few days. “That means that they have a complaint, either by a patient or more likely by a disgruntled physician or employee,” Ms. Buell noted. Here, the stakes are criminal penalties, and there should be an attorney on site during the visit.

Recovery Audit Contractors (RACs) “are bounty hunters,” she said. They are focused on recovering misspent Medicare funds and are paid a contingency fee of 9%–12% of the amount recovered. However, they are not active in practices because they have enjoyed such success in hospitals. At present, they do automated screening of practices’ Part B payments. “If you fall out of the screen, they ask for the money back and that’s the end,” Ms. Buell said. She cautioned, however, that RACs might start doing complex reviews later this year. And if they do, drugs are likely to be an early focus “because there is so much money involved and they have seen that [in the hospitals].”

Medicaid Integrity Contractors (MICs) review Medicaid claims for inappropriate payments and fraud, using a data-driven approach to identify aberrant billing practices. Unlike RACs, who receive a contingency fee, MICs are paid for their services and receive a quality-related bonus. Their look-back period for medical records varies by state. At present, they target mainly hospitals and, to a lesser extent, skilled nursing facilities, nursing homes, and hospices. Physicians are low on the list of priorities, “but…if you have a heavy Medicaid load, you do have to worry about [it],” Ms. Buell said.

Medicare Administrative Contractors (MACs) process claims for both Part A and Part B services and therefore can review discrepancies between the two sets of claims, revise payments, and increase denials. Some ongoing MAC activities include audits regarding usage of the 99204 and 99205 procedure codes for new patients.

Minimizing the risks

Given this environment, what can oncology practices do to minimize their risk? “Have a compliance [program] and make it a priority,” Ms. Buell recommended, adding that it is also a requirement of healthcare reform. Be sure to fix anything the program identifies, because auditors will take a much stiffer stance if they discover issues that were known but not resolved.

Practices can refer to a set of components that the OIG has set forth as the foundation of an effective compliance and ethics program (www.oig.hhs.gov/authorities/docs/physician.pdf). For example, there should be standard policies and procedures in the practice for things such as documentation, education and training, and updates on Medicare regulations. The enforcement of these policies is also a key element of an effective compliance program, as is a prevention component that anticipates mistakes and prevents them from occurring whenever possible.

The healthcare reform legislation requires that practices report and return Medicare and Medicaid overpayments. “If you find that you have been overpaid, for any reason, even if it’s their mistake, give the money back,” Ms. Buell said, because there is a good chance that auditors will eventually discover it.

Any practice that is concerned about being at risk for whistle-blower incidents should obtain legal help. “If you think there is…someone out there who can hurt you, you need to have your compliance program administered by an attorney.”

Finally, “educate, educate, educate,” she advised, to keep physicians and other practice members current on compliance issues.