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The Age of Audits Is this the Golden Age of audits? Joe W DeLoach, OD, FAAO CEO, Optometric Business Solutions.

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Presentation on theme: "The Age of Audits Is this the Golden Age of audits? Joe W DeLoach, OD, FAAO CEO, Optometric Business Solutions."— Presentation transcript:

1 The Age of Audits Is this the Golden Age of audits? Joe W DeLoach, OD, FAAO CEO, Optometric Business Solutions

2 DISCLAIMER I am CEO of Optometric Business Solutions. I have no financial interest in the company but this lecture does reference training products available from OBS.

3 The governments point of view Imagine you’re broke, you need money, your system is under scrutiny because it loses more and more money – And then you are presented with an investment opportunity with a historical 50:1 return on investment. What would you do???

4 The Age of Audits Optometry has never been “targeted” – has that changed? If you are filing claims, you are a target!

5 The Age of Audits What Has Changed? First and foremost – if you hadn’t heard, the government IS broke and looking for money! Health care reform – major emphasis on ABUSE and especialy FRAUD Change in False Claim Statute language from “knows or has reason to know” to “knows or should know” Qui Tam – The Whistleblower Act CMS new audit program – “Predictive Analysis”

6 Remeber the RACs? Ooooh they were mean. How did they do? July 2014 – RACs announce they recouped $2 BILLION in 2013 WOO-HOO!! And the OIG said…

7 And why??? $64 BILLION 96% Left on the table

8 What We Have All Done Wrong Too much CE on making money Too much CE on “turning medical” Too much CE on making sure you have an “allowable diagnosis” Not enough CE on medical necessity, reason for the visit, record documentation and coding ethics OUCH…but true!

9 And the result of our mis-guidance has been… Estimated 2012 audit repayments from optometry $28.5 MILLION Whether you know it or not, believe it or not – most of you in this room are next in line over the next three years!

10 HERE is the problem Improper Payment Rates Projected amount overpaid to optometry (examination services only) $57,875,452 THINK THEY MAY WANT IT BACK??? Per CERT 2013 Results

11 Improper Payment Rates Projected amount overpaid to optometrists for diagnostic testing $114,388,586 THINK THEY MAY WANT IT BACK??? Per CERT 2013 Results HERE is the problem

12 Improper Payment Rates Projected amount overpaid to optometry for DME $3,491,580 THINK THEY MAY WANT IT BACK??? Per CERT 2013 Results HERE is the problem

13 That’s $175 MILLION DOLLARS Medicare alone thinks they overpaid you! And you don’t think they are looking at your stuff??

14 Reasons for Overpayment #1 Insufficient documentation (65.5%) #2 Incorrect coding (25.7%) #3 NO documentation (4.3%) #4 Lack of medical necessity (3.6%) 70% Of denials are based on medical record documentation issues And CERT tells us why!

15 Still not worried??? 2104 Office of Inspector Work Plan Investigate inappropriate payment / abuse in the use of Evaluation and Management (99200) codes Investigate effective measures to evaluate and recoup Medicare overpayments Investigate methods to better evaluate physician medical records due to significant evidence that providers are not documenting adequate medical necessity

16 Still not worried? STILL??? 2104 Office of Inspector General Work Plan Investigate questionable billing practices by ophthalmologists Increase activities involving “predictive analysis” for reducing improper payments to physicians (more later!) Increase protection of fraud and abuse Whistleblowers Significant increase in resources to support the Health Care Fraud Prevention and Enforcement Action Team of 2009

17 2015 Plan Just Released 77…count them…77 health care items Fraud and abuse cited by the OIG as THE number one concern in health care today Listening? Not the uninsured, not the ACA, not Medicaid expansion – IT IS DOCTORS, INCLUDING OPTOMETRISTS, ABUSING HEALTH CARE REIMBURSEMENT!

18 2015 OIG Plan Excessive nursing home care services Non-compliance with CLIA Contractor performance issues Reducing costs for DME Recovering Medicaid overpayments Increasing Medicaid Fraud Control Units Increase Senior Medicare Patrol projects

19 AND…. Increase investigation of ophthalmologists for “inappropriate and questionable billing practices”

20 In order… the culprits 1. Medicare 2. Aetna 3. VSP 4. BCBS 5. EyeMed One of the biggest optometric “stings” in Auditing (term used loosely) medically necessary contact lens billings

21 What Did OBS Training Audits in 2013 Reveal After evaluating THOUSANDS of patient encounters: Average payback on “mini” audit (25 records) - $1, Average 5-year recoupment penalty - $397,650.00

22 Take home message… Auditing is VERY good business! “Auditing has become one of our most profitable lines of business” Medical Director, Aetna 2012

23 Why are our colleagues getting “violated” by vision and medical audits?

24 TRUTH!! (BLURRED TRUTH) THE HISTORICAL PROBLEM WITH CODING AND DOCUMENTATION INFORMATION

25 Biggest problems…. Too much “opinion” Too much “someone else said so” To little information based on regional payment policies “Experts” don’t do it “Experts” don’t audit

26 The Age of Audits What Triggers an Audit Specialization Success (The “Ladder Principle”) Repetition High utilization of single codes Billing codes not commonly used by the majority of your colleagues Billing codes at a higher percentage rate than the majority of your colleagues None inherently wrong, but…

27 Important point… Number 1 reason you will be audited BILLING AND CODING PRACTICES Number 1 reason you will LOSE an audit POOR MEDICAL RECORDS DOCUMENTATION

28 How Payers Conduct Audits The breadth of this topic is far too big for this course. WITHOUT A DOUBT, almost every payer has stepped up their audit/recovery game The bottom line is you need to familiarize yourself with the records documentation requirements and the audit procedures of every payer you do business with.

29 In General… Two Types of Audits Pre-Payment (“Guilty until proven innocent”) RAC (Recovery Audit Contractor) – contracted agent reviews claim based on statistical analysis of billing patterns (“predictive analysis”) Post-Payment (“Pay and chase”) Medical Review – review of medical record to evaluate if documentation justifies medical necessity

30 Circa 2014 and Forward The Pre-Payment Audit (“Predictive Analysis”) will rule the recapture reimbursement market Your money will be withheld and your only way to get it will be presenting a medical record that justifies what you did

31 A Bit More Complex In Medicare Claim Denied Doctor provides service to patient Doctor files claim to Medicare Prepayment payor review Prepayment RAC review 80% of pretty lousy fee paid to doctor Post -payment payor review Post-payment RAC review Payor focused audit CERT, ZPIC audit

32 Audit Defense The best defense is always a great offense! Keep exquisite medical records Know your payor rules and policies (remember they are REGIONAL!!) Keep updated by signing up for payer website listserves and newsletters

33 Audit Defense - Two New Tools “Training” audits (now Federal mandate under Fraud and Abuse Compliance) If you do not have exquisite expertise in billing, coding and payer rules, consider Outsourcing billing services to professionals or Find someone to train your staff how to do this correctly

34 What OBS has now… 1. Extensive, mean, ugly, leave no stone unturned training audits 2. Comprehensive billing services 3. Comprehensive program to train your staff to become experts

35 Thank you Sleep Well


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