Coders` Role in Anti-Fraud Investigations

Coders’ Role in Anti-Fraud
Investigations
Margaret Chambers, RN, CPC, CPC-P,
AHFI
Senior Investigator
Premera Blue Cross
Objectives
• Understand a coder’s role in fraud
investigations
• Obtain an understanding of the scope of
Health Care Fraud
• Recognize how a coder supports the
investigation team
• Understand the components of an
investigation
Disclaimer
This presentation is based on my experience in
my particular SIU.
These are my insights and observation.
HealthCare Fraud and Abuse
And the
Special Investigations Unit
SIU
What is Health Care Fraud?
“Fraud is an intentional act of
deception, misrepresentation or
concealment of a material fact or
information.”
=
Did you pay your 2012 Taxes?
How Big is the Problem
• United States spends more than $2.8 trillion
on health care every year.
• NHCAA estimates that:
3%; over $75 billion to $250 billion is lost to
health care fraud per year
• Patient harm is an unfortunate side effect of
health care fraud
(National Health Care Anti-Fraud Association )
February 11, 2013
LA Times
• Federal government recovered a record $4.2
billion in the last fiscal year from medical
providers and others who fraudulently billed
government healthcare programs
• The Justice Department also reported that 826
people were convicted of crimes related to
healthcare fraud last year
• That report drew stern criticism from members
of Congress from both parties. "This lack of
progress is deeply disappointing," said Sen.
Thomas R. Carper (D-Del.).
Our SIU 2012 Statistics
Cases > 100
4 -Convictions
Recovered $1,084,241 (hard $)
75 providers removed from our panel
Members: 1.7 million
Staffing:
3 investigators
3 Analysts
What Does an SIU Do?
• Detect health care fraud and abuse
 Referrals/complaints
• Assess

•
Investigate


•
Interviews
Coding and billing practice
Report

•
Substantiate allegations
Case summary for internal and external parties
Final resolution


Restitution
Law enforcement/conviction
Reactive (Pay and Chase)
• Investigative Sources
• Fraud Hot-line calls
– Hotline number is on our website and on the
explanation of benefits (EOB)
• Internal referrals
– Customer service
– Claims
• External referrals
– Ex-employees
– Practice partners
• Health Care Fraud Info Sharing Network
– Washington Medical Fraud quarterly meetings
– Other Plan peers
Proactive
Encourage our associates within the company to
be on the watch for questionable claims but
this is no longer adequate for successful prepayment detection.
Pre-payment analytics is essential in a SIU. The
money has to be stopped before it goes out.
“Pay and chase” has been the traditional
method of recouping dollars but it has many
drawbacks.
Proactive
The majority of SIUs use “anti-fraud” software:
• Identifies “outliers”
• Uses past claims data as a source
Pay and chase is necessary for certain cases but the
pre-payment model is now considered essential.
• Centers for Medicare and Medicaid Services
(CMS) is moving to this model.
• Predictive modeling techniques
SIU Strategies
• Prosecution Oriented SIU Staffing
– Former law enforcement; federal, state and local
– Goal is prosecution
• Team Oriented
– Teams organized around; geography, skill set,
specialty
– Investigators, analysts and coders
• Financial Recovery Oriented
– Pursue lost funds
– Auditors, investigators, coders, nurses
Team Member Requirements
• Education background
– Law enforcement, medicine, coding
• Experience
– Law enforcement, insurance, statistics, coding
• Required technical and investigative skills
– Interviewing, software proficiency, report writing,
curiosity.
• Communication skills
– Ability to interact with varying audiences
Coder’s Role
• Use suspect information to start looking for
billing issues or patterns
– Look for patterns/trending
» Do they bill an E/M code with every procedure
» Do they use an excess number of high end E/M
• On-Site Audits/Desk audits
– Investigators are CPC, CPC-P, CPMA
» Accredited Health Care Fraud Investigators
» Compare the chart notes with the documentation
» Determine if the correct codes are being used
Coder’s Role
• Review investigation findings with the
provider
– Investigators meet with the providers to review
the results and discuss the rationale
– Offer provider education and resources
• Prepare the referrals to other agencies
– Department of Health
– Medicare Medicaid
– Office of the Insurance Commissioner
Investigation
And
Information Gathering
Data Assessment
Investigation Process
• Use information to start looking for billing issues
or patterns
• Collect retrospective claims data
• On-Site Audits/Desk audits
• Interviews
• Review investigation findings with the provider
• Recovery
• Referral & Cooperation with Law Enforcement
(HHS, FBI, OIC, DOH)
Using Coding Skills
Patient intake form.
This provider did not signed the intakes which include a review of systems
Sometimes they make it easy
First page
The only
examination was
vital signs and ---Billing new patient
code 99204
(Detailed new
patient) with code
99402 (preventive
medicine
counseling)
Fraudulent and Abusive Billing
• Services/Procedures/Supplies not provided or
performed
– Bill for a procedure that “is sort of like” what was
performed
– Provider does a referral and bills for a consultation
– Dispenses a scooter and billed Medicare for a
wheelchair
– Bills for a septoplasty and performs a rhinoplasty
Example of “Cloaking”
Billed as code 93882 “duplex scan of extra-cranial arteries; unilateral or limited.”
The correct code is 0126T “common carotid intima-media thickness study”.
Considered investigational at our Company.
EarCheck Pro™
Tympanometry
This physician was using the EarCheck Pro™ on every patient at every visit.
He was billing code 92567, tympanometry and being paid $27.00 (2006).
In a 24 month period he had been paid $93,560.00.
Fraudulent and Abusive Billing
• Bills for services of a non-licensed person
– Billed for the services of a fitness trainer using
physical medicine codes
• Bill for more costly services than provided (upcoding)
– Higher level E/M than documented
– Bill for an adjacent tissue transfer when an
intermediate or complex closure was performed
Billing More Costly Services
Physician owned his ASC and professed to be an
“expert” on skin cancer.
He would excise the lesions with a laser, undermine the
wound edges and close.
He consistently billed adjacent tissue transfer codes
because they paid an ASC fee and he would also bill the
excision. In fact he was doing an intermediate closure.
He was investigated by our Company and eventually
ended up investigated by the Department of Health.
DOH Findings
Fraud does harm patients:
Other Issues
• Altering medical records
– While the investigation team was waiting for EMR,
the staff was altering the medical records
– White-out
• Members misrepresenting dependents
– Girlfriends as wives
– Unrelated children
• Altering member submitted claims
– Changing numbers on the claims
– Fabricating treatment records
White Out
White out
Coders Challenges
• Know something about everything
– Need to do research
– Need to have resources
•
•
•
•
•
CPT® Assistant
Anatomy book
Dental coding
PDR drug references
AAPC
– Time consuming but fascinating
– Company wide resource person
Coders Challenges
• Opportunities to educate on coding guidelines
and anti-fraud efforts
– Meet the providers on a common ground
– When it is abuse or ignorance assist the providers
in compliance.
– Don’t tell them how to bill but instead we help
them find the resources to bring them into
compliance
A
CASE OF
CLONING &
DOWN RIGHT BAD BEHAVIOR
Documentation
Neuromuscular reeducation, Code 97112
Examinations; being created especially for us
EMR “déjà vu”
How far will the SIU go to
investigate possible
fraud and/or abuse?
23 miles north of the
Arctic Circle!
Kotzebue Alaska at -31º
Laura Erickson,
Senior Analyst