Fraud and Abuse Awareness Training for Healthcare Professionals

1. E & M CHART AUDITINGDepartment of Neurology – CORE Presentations and Fraud and Awareness TrainingNeurology Residency Program Presented by the MSU HealthTeam Compliance Office 427 West Fee Hall February 2019

2. Health care fraud is a serious problem

3. Definition of Fraud and Abuse • Fraud • When someone intentionally executes or attempts to execute a scheme to obtain money or property of any health care benefit program • Abuse • When health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program The primary difference between fraud and abuse is intention

4. Examples of Fraud • Medicare or Medicaid [or another health benefit plan] is billed for: • Services a beneficiary never received • Equipment a beneficiary never received • Documents are altered to gain a higher payment • Misrepresentations of dates, descriptions of furnished services, or the identity of the beneficiary • Someone uses a beneficiary insurance card without their permission [bills for services]

5. The CMS Program Integrity Contractors • Health Care Fraud Prevention and Enforcement Action(HEAT) Strike Force Teams • Zone Program Integrity Contractors • National Benefit Integrity (NBI) MEDIC • Recovery Audit Program • Medicaid Integrity Contractors

6. What Is Non-Compliance? Non-compliance is conduct that does not conform to the law, Federal health care program requirements, or an organization’s ethical and business policies. CMS has identified the following Medicare Parts C and D high risk areas: • Agent/broker misrepresentation; • Appeals and grievance review (for example, coverage and organization determinations); • Beneficiary notices; • Conflicts of interest; • Claims processing; • Credentialing and provider networks; • Documentation and Timeliness requirements; • Ethics; • FDR oversight and monitoring; • Health Insurance Portability and Accountability Act (HIPAA); • Marketing and enrollment; • Pharmacy, formulary, and benefit administration; and • Quality of care. For more information, refer to the Compliance Program Guidelines in the “Medicare Prescription Drug Benefit Manual” and “Medicare Managed Care Manual” on the CMS website.

7. Know the Consequences of Non-Compliance Failure to follow Medicare Program requirements and CMS guidance can lead to serious consequences including: • Contract termination; • Criminal penalties; • Exclusion from participation in all Federal health care programs; or • Civil monetary penalties. Additionally, your organization must have disciplinary standards for non-compliant behavior. Those who engage in non-compliant behavior may be subject to any of the following: • Mandatory training or re-training; • Disciplinary action; or • Termination

8. Fraud and Abuse Laws • False Claims Act • Anti-Kickback Statute • Physician Self- Referral Statute (Stark) • Exclusion Statute • Civil Monetary Penalties Law

9. False Claims Act Prohibits the submission of false or fraudulent claims to the Government

10. Causes of Improper Payments • Not all improper payments are fraud, but all payments made due to fraud schemes are improper • CMS is targeting all causes of improper payments • From honest mistakes to intentional deception • Most common error is insufficient documentation! Errors Waste Abuse Fraud Mistakes Inefficiencies Bending the rules Intentional deception

11. Third Detroit-area physician convicted in $17.1 million health care fraud scheme • Detroit, MI, May 9, 2017––A third Detroit–area physician was convicted Monday for his role in a $17 million Medicare fraud scheme involving medically unnecessary physician visits. • In connection with this case, Leonard Van Gelder, MD, 69, of Caledonia, Michigan, and Stephen Mason, MD, 46, of Indianapolis, each pleaded guilty to one count of conspiracy to commit health care fraud in March 2017 and December 2016, respectively. As part of their guilty pleas, Van Gelder and Mason admitted to seeing patients who did not need their services and for whom bills were submitted to Medicare at the highest billing codes. The evidence also showed the ordering of unnecessary tests.

12. Doctor Doesn’t Work Hard to Hide Symptoms of Medicare Fraud • Starting in 2002, Dr. Sheth’s inclination to spend lots of time with patients apparently melded with a desire to make tons of money. With privileges at Advocate South Suburban Medical Center, Ingalls Hospital and a third unidentified hospital, he was able to gain access to personal and insurance information about the patients. • He then prepared handwritten notes, which he faxed to outside billing firms, about bogus treatment of those individuals. Those firms sent formal billings to Medicare and about 30 private insurers. • When it came to Medicare, Dr. Sheth used two codes, each of which represents critical cardiac treatment and is reimbursed at a high rate. He sent 14,800 billings over five years to Medicare alone, billing for 24 hours or more of work every day of the year. His use of the codes represented a disproportionate use of them in the entire United States, and more than all the doctors in some states, according to the defense.

13. DocumentationTimeliness • Per CMS and reiterated by our Medicare Administrative Contractor (MAC): Documentation should be completed within 24 to 48 hours and the general interpretation for this is 1-2 business days. Additionally, it also describes that if documentation is not complete, services may not be billed. As well as if the signature is late, then do not just sign but enter a signed attestation. • Please see our MAC, WPS GHA Medicare Part B J8,response and information regarding documentation timeliness found at: http://www.wpsmedicare.com/j8macpartb/claims/submission/documentation-timelines.shtml

14. Documentation Timeliness, cont… • HealthTeam'spolicy on documentation is MRC-01 and mimics these guidelines (found at: https://healthteam.msu.edu/intranet/Policies/MRC%2001%20Medical%20Record%20Documentation.pdf), where the third paragraph excerpt reads: • "Documentation must support the level of coding for billing purposes (see CPT E&M requirements) and shall be completed and electronically signed no later than two business days after the ambulatory encounter. Billing transactions must not be transmitted until documentation in the medical record is complete and permanently signed."

15. Signature Attestations • If your signature isn’t completed within the two business days following each service, a signature attestation should be appended and should include, but is not limited to, the following information: • “I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]__when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.” • You’re allowed to change the format, but if you completely change the wording Compliance needs to review and approve

16. Signature Tips • The signature for each entry must be legible and should include the practitioner’s first and last name. • For clarification purposes, it is required by CMS to include applicable credentials, e.g., M.D, D.O., P.A, etc. (see MLN MM6698) • Residents/Fellows must sign the document when performing any key components of HPI, exam, or MDM.

17. E/M Services

18. Medical Necessity Chronic Problem Level 1 The patient presents today with a chronic problem Level 2 The problem is minimal in nature and questionable if the patient even if the patient truly needed to be seen on that given date of service Level 5 The chronic problem is severely exacerbated and posing threat to the patient Level 4 Management of 3 or more stable chronic problems or 2 or more problems where at least 1 is worsening Level 3 The problem is a chronic stable problem and not currently exacerbated

19. Medical Necessity Acute Problem Level 1 The patient presents today with an Acute Presenting Problem Level 2 The problem is minimal in nature and questionable if the patient even if the patient truly needed to be seen on that given date of service Level 5 The acute problem poses a threat to life or bodily function during today’s encounter Level 4 The problem is acute with complicating factors contributing to the complexity of caring for the patient on this date of service Level 3 The problem is acute and uncomplicated in presentation to the provider

20. History Exam Medical Decision Making Nature of Presenting Problem Counseling Coordination of Care Time COMPONENTS THAT DETERMINE AN E&M CODE KEY COMPONENTS Contributory Components

21. HISTORY • Chief Complaint • History of Present Illness • Review of Systems • Past, Family, and Social History

22. A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words. CHIEF COMPLAINT

23. Location (Where? Lowback pain) Quality(Sharp, dull, throbbing, etc…) Severity(Better/worse, mild, severe, 4/10, etc...) Duration(Pain for two days, first started three years ago, etc…) Timing(Hurts in the morning, happening 3x a week now, etc…) Context(Pain occurred after lifting bags, dropped weight on foot, etc…) Modifying factors(Aspirin does not help, recent cerumen removal helped, etc…) Associated signs and symptoms(i.e. vomiting, diarrhea, sweating, etc…) HISTORY OF PRESENT ILLNESSA chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes the following elements:

24. For use with both the 1995 and1997 Documentation Guidelines: 3 or more = Extended HPI Note: Document a brief comment about the status of the condition according to the patient, NOT the provider. This is part of the “history”, not the “assessment”. STATUS OF CHRONIC CONDITIONS

25. Problem Focused: (1-3 elements of HPI) 99212 Expanded Problem Focused: (same as PF) 99213 Detailed: (4+ elements of HPI or status of > 3 chronic/inactive conditions 99214 Comprehensive: (same as Detailed) 99215 Extent of HPI

26. An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. In a complete ROS (10 or more systems) positive or pertinent negatives responses must be individually documented with a statement that all other systems are reviewed and negative. The negative systems MUST be identified in the medical record documentation! REVIEW OF SYSTEMS (ROS)

27. Constitutional symptoms (fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 14 Systems for Review, Include:

28. Problem Focused: N/A [0] 99212 Expanded Focused: Problem Pertinent [1] 99213 Detailed: Extended [2-9] 99214 Comprehensive: Complete [10+] 99215 or pertinent positive and pertinent negative responses with notation that “all other systems reviewed and negative* The “all other systems” MUST have each system identified in the medical record documentation! Extent of ROS

29. PAST HISTORY Prior major illness and injuries, operations, hospitalization. Current medications. Allergies (food or drugs). FAMILY HISTORY Health status or cause of death of parents, siblings, and children. Specific diseases related to problems identified in the chief complaint or history of present illness. Diseases of family members which may be hereditary or place the patient at risk. SOCIAL HISTORY Marital status and/or living arrangements. Current employment. Occupational history, military history. Use of drugs, alcohol, tobacco. Level of education. Other relevant social factors. PAST, FAMILY, & SOCIAL HISTORY (PFSH)

30. Extent of PFSH • Problem Focused: • New pt/Initial care = 0 • Est pt/Subs care = 0 • 99201/99212/99231 • Expanded Problem Focused: • New pt/Initial care = 0 • Est pt/Subs care = 0 • 99202/99213/99232 • Detailed: • New pt/Initial care = 2 • Est. pt/subs care =1 • 99203/99214/99221/99233 • Complete: • New pt/Initial care = 3 • Est. pt/Subs care = At least 2 • 99204, 99205, 99215/99222/99223

31. Problem Focused Expanded PF Detailed Brief HPI; No ROS/PFSH Brief HPI; 1 pertinent ROS; No PFSH Extended HPI; Extended ROS (2-9 systems); PFSH Est Pt. = 1; PFSH New Pt./Consult = 1-2 Overall Level of History

32. Comprehensive Extended HPI; Complete ROS (> 10 Systems, or pertinent systems with “all others negative”); PFSH Est Pt. = 2, PFSH New Pt./Consults = 3 Overall Level of History (cont.)

33. CC, ROS, and PFSH may be listed as separate elements of history or included in the HPI Provider can review and receive credit for history elements obtained at another visit as long as they are relevant and referenced by datein this visit’s progress notes No date listed? Then does not count!! ROS, PFSH, or both, of the patient, may be recorded on a history form by ancillary staff as long as the provider documents confirmation of the information. History TIPS

34. History TIPS • Effective 2012:WPS GHA Medicare states credit can be given in the HPI for 2, or more, of each element stated ifthere are 2, or more, chief complaints (e.g., patient comes in for knee and arm pain). • If unable to obtain history from the patient or other source, document the patient’s condition which prevented you from gathering such history and the attempt to obtain such history. • Not automatically comprehensive history. • Note: WPS GHA has indicated (in 2012) that the provider MUST document that he/she was unable to obtain the history from any source!

35. HISTORY QUESTIONS

36. 1995 PHYSICAL EXAMINATION

37. PROBLEM FOCUSED (PF) - an exam limited to the affected body area or organ system 99201/99212/99231 EXPANDED PROBLEM FOCUSED (EPF) - an exam of the affected body area or organ system and other symptomatic or related organ systems 99202/99213/99232 DETAILED- an extended exam of the affected body areas and other symptomatic or related organ systems 99203/99214/99221/99233 COMPREHENSIVE- a general multi-system exam or a complete exam of a single organ system. The medical record for a general multi-system exam should include findings regarding 8 or more of the 12 organ system 99204/99205/99215/99222/99223 1995 EXAM GUIDELINES

38. Body Areas: Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Organ Systems: Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic BODY AREAS/ORGAN SYSTEMS

39. 1995 Physical Examination • Organ Systems and the audit tool:

40. 1997 PHYSICAL EXAMINATION General Multi-system Examination

41. Level of Exam Problem Focused Expanded Problem Focused Detailed Perform and Document 1-5 elements identified by a bullet At least 6 elements identified by a bullet At least 2 elements identified by a bullet from each of six areas/ systems OR at least 12 elements identified by a bullet in two or more areas/systems. Content and Documentation Requirements (General Multi-System Exam)

42. Level of Exam Comprehensive Perform and Document Perform all elements identified by a bullet in at least 9 organ systems or body areas and document at least two elements identified by a bullet from each of 9 areas/systems. Content & Documentation Requirements General Multi-System Exam (cont.)

43. General Multi-System Examination Cardiovascular Examination Ear, Nose and Throat Examination Eye Examination Genitourinary Examination Hematologic/Lymphatic/Immunologic Examination Musculoskeletal Examination Neurological Examination Psychiatric Examination Respiratory Examination Skin Examination 1997 Single Organ System Physical Examination Templates

44. EXAMINATION QUESTIONS

45. Part A - Number of Diagnoses or Treatment Options Part B - Amount and Complexity of Data Part C - Risk of Significant Complications, Morbidity, and Mortality MEDICAL DECISION MAKING INCLUDES:

46. 4 TYPES OF MEDICAL DECISION MAKING • Straightforward – minimal diagnoses/management options, minimal to none complexity of data, and minimal risk of complications and/or morbidity/mortality • 99201/99202/99212/99221/99231 • Low Complexity – limited diagnoses/management options, limited complexity of data, and low risk of complications and/or morbidity/mortality • 99203/99213/99221/99231 • Moderate Complexity – multiple diagnoses/management options, moderate complexity of data, and moderate risk of complications and/or morbidity/mortality • 99204/99214/99222/99232 • High Complexity – extensive diagnoses/management options, extensive complexity of data, and high risk of complications and/or morbidity/mortality • 99205/99215/99223/99233

47. Medical Decision Making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure, and/or the possible management options MEDICAL DECISION MAKING

48. Problems improving or resolving are less complex than those worsening or not improving as expected. Presenting problems with established diagnoses mean documentation mustsay if the problem is: Improving, well-controlled, resolving, or resolved Inadequately controlled, worsening, or failing to change as expected. This element is based on the number and type of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that must be made. The number and type of diagnostic tests may be an indicator of the number of possible diagnoses. The need to seek advice from others is another indicator of the complexity of diagnostic or management problems NUMBER OF DIAGNOSES OR TREATMENT OPTIONS

50. The amount and complexity of data to be reviewed depends on the types of diagnostic testing ordered and/or reviewed: Lab tests Radiology studies Non-invasive medicine studies Discussion with interpreting physician Independent visualization with interpretation Decision to obtain old records Review and summary of old medical records Obtaining history from someone other than the patient beyond what is normally obtained during the visit AMOUNT AND/OR COMPLEXITY OF DATA