Copyright © 2008 Delmar Learning. All rights reserved. Chapter 5 Legal and Regulatory Issues

Copyright © 2008 Delmar Learning. All rights reserved. 2 Guidelines and Regulations The health insurance specialist must know about the different guidelines and regulations for maintaining patient records and processing health insurance claims.

Copyright © 2008 Delmar Learning. All rights reserved. 3 Regulations Federal laws and regulations affect health care in government programs like Medicare, Medicaid, TRICARE, and Federal Employees Health Benefit Plans. State laws regulate recordkeeping practices and provider licensing.

Copyright © 2008 Delmar Learning. All rights reserved. 4 False Claims Act Regulated fraud associated with military contractors selling materials and gear to the Union Army.

Copyright © 2008 Delmar Learning. All rights reserved. 5 False Claims Act Used by federal agencies –Regulates the behavior of any contractor that submits claims for expense to the federal government for any program.

Copyright © 2008 Delmar Learning. All rights reserved. 6 False Claims Act Amended in 1986 –Increase in civil monetary penalties to impose a maximum of $10,000 per false claim –Plus three times the amount of damages that the government sustains

Copyright © 2008 Delmar Learning. All rights reserved. 7 Federal Anti-Kickback Law Protects patients from fraud and neglect by curtailing the corrupting influence of money on health care choices.

Copyright © 2008 Delmar Learning. All rights reserved. 8 Federal Anti-Kickback Law Violation of this law could result in: –Five years in prison –Fines up to $25,000 –Administrative civil money penalties up to $50,000 –Exclusion from participation in federal health care programs

Copyright © 2008 Delmar Learning. All rights reserved. 9 Utilization Review Act Facilitated ongoing assessment and management of health care services Required hospitals to perform continued-stay reviews –To determine medical requirement and appropriateness of Medicare and Medicaid inpatient hospitalizations

Copyright © 2008 Delmar Learning. All rights reserved. 10 McKinney Act Provides health care to the homeless

Copyright © 2008 Delmar Learning. All rights reserved. 11 Vaccines for Children Program Provides free immunizations to all children in low-income families

Copyright © 2008 Delmar Learning. All rights reserved. 12 PATH Focus was on two issues: –Compliance with Medicare rules affecting payment for physician services provided by residents –If level of service was coded and billed properly

Copyright © 2008 Delmar Learning. All rights reserved. 13 CCI Developed by CMS to trim down Medicare program expenditures by detecting out of place codes on claims and rejecting payment for them.

Copyright © 2008 Delmar Learning. All rights reserved. 14 HIPAA Mandated administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information.

Copyright © 2008 Delmar Learning. All rights reserved. 15 SCHIP Health insurance program for newborns, children, and youth –Covers health care services such as physician visits, prescription medicines, and hospitalizations

Copyright © 2008 Delmar Learning. All rights reserved. 16 Centers for Medicare and Medicaid Services Department of Health and Human Services (DHHS) responded to the nation's first bioterrorism attack –Delivery of anthrax through the mail

Copyright © 2008 Delmar Learning. All rights reserved. 17 Medicare Prescription Drug, Improvement, and Modernization Act Provides Medicare recipients with prescription drug savings and additional health care plan choices

Copyright © 2008 Delmar Learning. All rights reserved. 18 Medicare Prescription Drug, Improvement, and Modernization Act Requires Medicare trustees to analyze the combined fiscal status and warn Congress and the president when the fund exceeds 45 percent.

Copyright © 2008 Delmar Learning. All rights reserved. 19 Health Insurance Portability and Accountability Act Improves portability and continuity of health insurance coverage in the group and individual markets Combats waste, fraud, and abuse Supports use of medical savings accounts

Copyright © 2008 Delmar Learning. All rights reserved. 20 Long-term care services and coverage Unique identifiers for providers, health plans, employers and individuals Health Insurance Portability and Accountability Act

Copyright © 2008 Delmar Learning. All rights reserved. 21

Copyright © 2008 Delmar Learning. All rights reserved. 22 Record Retention HIPAA mandates withholding patient records and health insurance claims for at least six years –Unless state law specifies longer Records are retained for two years after a patient’s death

Copyright © 2008 Delmar Learning. All rights reserved. 23 Preventing Health Care Fraud and Abuse HIPAA defines fraud as “an intentional deception or misrepresentation” The difference between fraud and abuse is individual’s intent

Copyright © 2008 Delmar Learning. All rights reserved. 24 Common Forms of Medicare Fraud Includes Billing for services that were not performed Misrepresenting diagnosis to justify payment Unbundling codes

Copyright © 2008 Delmar Learning. All rights reserved. 25 Examples of Abuse Excessive charges for services Services not medically necessary Improper billing practices

Copyright © 2008 Delmar Learning. All rights reserved. 26 Examples of Abuse A person found guilty of fraud can face: –Civil penalties of $5,000 to $10,000 per false claim –Imprisonment of up to 10 years –Administrative sanctions –Up to $10,000 civil monetary penalty per line item on a false claim

Copyright © 2008 Delmar Learning. All rights reserved. 27 Steps to Identifying Risk Areas 1.Perform periodic audits to monitor billing 2.Develop practice standards and procedures 3.Designate a compliance officer 4.Conduct training and education classes

Copyright © 2008 Delmar Learning. All rights reserved. 28 Steps to Identifying Risk Areas 5. Respond by investigating allegations and disclosing to appropriate entities 6. Develop open lines of communication –Have disciplinary standards and enforce them

Copyright © 2008 Delmar Learning. All rights reserved. 29 Overpayments If reimbursed funds exceed the amount a provider or beneficiary were supposed to receive.

Copyright © 2008 Delmar Learning. All rights reserved. 30 Overpayments Include Payment based on a charge Duplicate processing of charges Payment made to the wrong payee Payment made for a item not used

Copyright © 2008 Delmar Learning. All rights reserved. 31 Overpayments Include Payment during a period of nonentitlement Payment for another entity who is not the primary payer Payment made after the beneficiary’s date of death

Copyright © 2008 Delmar Learning. All rights reserved. 32 Provider Liability for Overpayments Providers are responsible for reimbursement of overpayment when: –Incorrect reasonable charge determination –Provider received duplicate payments –Receiving a payment after accepting a assignment

Copyright © 2008 Delmar Learning. All rights reserved. 33 Provider Liability for Overpayments Provider receives two payments: –One from Medicare and another from a workers’ compensation or automobile carrier Provider was paid and did not accept the assignment Provider furnished erroneous information

Copyright © 2008 Delmar Learning. All rights reserved. 34 Provider Liability for Overpayments Put in a claim for a services that were not medically necessary Put in a claim for something that is not qualified for Medicare reimbursement

Copyright © 2008 Delmar Learning. All rights reserved. 35 Provider Liability for Overpayments Overpayment was made because of a mathematical or clerical error Provider does not submit documentation Billed under the one-time authorization procedure

Copyright © 2008 Delmar Learning. All rights reserved. 36 National Correct Coding Initiative (NCCI) Analysis of standards medical and surgical practices Coding conventions included in CPT Coding guidelines made by national medical specialty societies

Copyright © 2008 Delmar Learning. All rights reserved. 37 National Correct Coding Initiative (NCCI) Local and national coverage determination Review of current coding practices

Copyright © 2008 Delmar Learning. All rights reserved. 38 Unbundling CPT Codes NCCI edits determine appropriateness of CPT code combinations NCCI edits are designed to detect unbundling