New for 2016
New CMS Enrollment – NSV (National Site-visit Verification)
- There will be an increase of onsite visits for new enrollees to Medicare.
- Screening mechanism to prevent questionable providers and supplies from being accepted into the Medicare program.
- Announced and unannounced site visits.
- If found out of compliance, a revocation can last up to three years.
- The government is data mining and the first agencies to identify problems are likely to be MAC and ZPIC.
- MAC and ZPIC may believe they detect a possible pattern of fraudulent billing behavior from data mining.
- If a large enough amount of money involved, appearance of egregious behavior, lack of contractor resources, or a whistleblower could get you at the front of the line with the OIG.
Medical Record – First line of defense
- Indictments for incorrect use of "automatically inserted, into patient records, diseases and symptoms that the patient did not have" with services billed to Medicare.
- Danger Zone – Incorrect use of macros.
- Auditors will look for notes that are similar or exact between patients. This can be determined to be habitual behavior and can lead to cloned notes.
OIG 2016 Work Plan – Focus on physician practices
- Watch for referring and ordering physicians who are not eligible.
- Anesthesia paid by Medicare for non-eligible services.
- EHR (Electronic health records) used inappropriately to gain additional payment from Medicare.
- Lab test billing.
- – If you bill for UDT (Urine drug test), it is time you verified your processes.
When to Hire a Consultant
- There are many reasons when the best choice for your practice may be to hire a consultant. When an objective point of view is needed, if a situation requires special proficiency, the practice is facing a major crisis, or if management seems to be operating in crisis mode.
Terminating Reassignment Agreements
- Individual practitioners should notify Medicare within 30 days of any change in reassignment agreements, since failure to do so allows the previous entity to continue billing Medicare. Individual practitioners and/or suppliers can terminate a reassignment with the designated Medicare fee-for-service contractor.
Routine Waiver of Patient Responsibility
- "There are a few instances where a provider is allowed to write off the balance after Medicare has made payment. This is not allowed on a routine basis. The provider must make a reasonable effort to collect the coinsurance and/or deductible. Providers that routinely waive the collections of the coinsurance and/or deductible are in violation of the law pertaining to false claims and kickbacks." According to the Trailblazer Medicare Part B Newsletter No. 08-077, February 29, 2008.