Health Care Litigation – Coding and Documentation Audits

1. Health Care Litigation – Coding and Documentation Audits Amper, Politziner & Mattia LLP Coders Day September 2009

2. Coding and Documentation Audit • Index • Overview of Coder’s role in HC litigation • Case Study #1 • Case Study #2 • Case Study #3 • Conclusion

3. Coding and Documentation Audit • Coder’s role in HC litigation • Coding specialist • Gather evidence for HC attorney • Expert witness in Court

4. Coding and Documentation Audit • Case Study #1 • Situation • Medicare sends an audit letter to the practice • No indication of the reason for nonpayment • Payment for all Medicare services stopped • Practice retains HC legal counsel • Legal counsel retains Amper

5. Coding and Documentation Audit • Case Study #1 • Results of Amper Review • All office visits billed at levels 4 or 5 • Numerous lab tests per patient per visit • Numerous procedures at every visit • Numerous high risk diagnosis at every visit • Medicare nurse reviewers requested additional documentation to complete their review

6. Coding and Documentation Audit • Case Study #1 • Results of Amper Review • Additional documentation supplied to Medicare • Medical Director states he has a medical necessity concern even though documentation is complete • Audit is disruptive to the practice’s cash flow • Importance of a Compliance Program • Billing Company role for documentation

7. Coding and Documentation Audit • Case Study #1 • Results of Amper Review • Managing partner to discuss clinical approach with Medicare’s Medical Director • Healthcare attorney involvement for all discussions with Medicare • Numerous coding and documentation corrections noted to the practice by Amper

8. Coding and Documentation Audit • Case Study #1 • Outcome of Efforts • Negotiated settlement with Medicare • No Fraud indictments issued • Practice no longer services Medicare patients

9. Coding and Documentation Audit • Case Study #2 • Situation • Private payor audit regarding consultations • Payor requested an overpayment request in excess of $500,000 from the practice • Payor threatened fraud indictment • Practice retained HC legal counsel • Legal counsel retained Amper

10. Coding and Documentation Audit • Case Study #2 • Results of Amper Review • Consults billed for all visits including new and established visits • Frequent and repetitive administration of testing procedures • High number of procedures performed on family members • Diagnosis did not support level of office visit or medical necessity

11. Coding and Documentation Audit • Case Study #2 • Results of Amper Review • Practice invested in an electronic medical records system – HC attorney suggested to use this investment as a defense against the payor • Inadequate documentation for any visit • Missing patient chart information • Missing documentation of procedures

12. Coding and Documentation Audit • Case Study #2 • Outcome of Efforts • Overpayment request by payor reduced by 40% • Physician no longer serviced patients from payor • Fraud charges not brought against physician • Physician sold practice

13. Coding and Documentation Audit • Case Study #3 • Situation • Physician sued by an imaging management company for overpayment of professional services • Portrayed as a contract dispute between management company and the physician • Physician retains HC legal counsel • Legal counsel retains Amper

14. Coding and Documentation Audit • Case Study #3 • Results of Amper Review • Management company billed global charges under the physician’s provider number • One owner of management company debarred from Medicare, but company continued to bill • Billings under the physician’s name after he retires

15. Coding and Documentation Audit • Case Study #3 • Results of Amper Review • The same series of ultrasounds and/or echocardiograms were performed on all patients • Numerous billings for family members • Incorrect reporting of diagnosis or procedures to maximize payments • Billings also submitted incorrectly to all private payors

16. Coding and Documentation Audit • Case Study #3 • Outcome of Efforts • HC attorney turned over Amper findings to U.S. Attorney’s office • Criminal charges brought against owners of imaging management company • Physician was not required to return any overpayments requested by the management company

17. Coding and Documentation Audit • Conclusion • Fraud and abuse is prevalent in healthcare • Coder plays a key role in the proper billing of services • Coder assists legal counsel defend providers in requests for overpayments • Essential for all healthcare organizations to have Compliance Programs

18. Coding and Documentation Audit • Contact Information • Michael J. McLafferty CPA, MBA, FACMPE, CHFP • Partner, Healthcare Services Group • Amper, Politziner & Mattia LLP • McLafferty@Amper.com • Office – 732-287-1000 Extension 1284 • Cell - 732-598-8858 “The material contained in this presentation is for general information and should not be acted upon without prior professional consultation.”