Why is the government ramping up RAC audits? Health care fraud costs US Taxpayers $60 Billion a year. Federal Agents charged close to 1,500 people last year alone.
Ever wonder why the government is spending more and more money on RAC audits and other fraud detection and deterrence initiatives? Each year it seems the Department of Justice and Office of Inspector General uncover more and more shocking examples of fraud and abuse. In the last year alone the feds have arrested con artists who steal Medicare numbers from the elderly in order to submit false claims, doctors that prescribe excessive amounts of controlled substances so they can sell them on the streets, even some who steal federal grant money intended for cancer or autism research. Not only are these acts deplorable and morally reprehensible because they steal money that is intended for the disadvantaged, the poor, and the sick - these criminals cost US Taxpayers $60 Billion (with a B) a year. Tom Costello contributed this report this morning on the Today Show. Be sure to assess your practice for any compliance risks, implement a strong compliance policy, and maintain it. If you uncover any concerns about fraud or abuse, be sure to contact a compliance expert and consider self-disclosure. With the amount of federal dollars being recouped each year (last year alone the federal government recouped $4.5 Billion in fines, penalties, and restitution) you can rest assured that the government will be ramping up its efforts.
Mike Enos, CPC, CPMA, CEMC and Nancy Enos FACMPE CPMA, CEMC, CPC-I, CPC have authored a series of articles published in MGMA's Connexion Magazine. The September issue featured the first part in the Code of Conduct Section, and Part 2 has now been published in the October edition.
In the September article EMR Risk- If it wasn't done, don't document it: Tackling E&M coding errors in the age of EHR's we explored the growing trend of overdocumentation made easier by EMR's. We discussed the causes and risks associated with overdocumentation, as well as proper ways of documenting lengthy visits to make sure you are reimbursed appropriately. In this article, we investigate the pitfalls and risks related to overdocumentation and cloned notes specifically.
Cloned notes (using the exact same verbage from patient to patient), copied notes, and automatically generated notes should be examined closely, and physicians should be trained on how to delete, correct, and authenticate the contents of their notes to ensure that the notes actually reflect the services provided, and nothing more. Often times in copy-and-paste notes, or other EMR notes where information from previous services are "pulled forward" into the note, we find information that is erroneous, superfluous, and sometimes directly contradictory with what is described in the history of present illness or the examination.
EHR's that have a "coding tool" can be especially risky, when the level is calculated based on data elements, and not medical necessity.
Annual Wellness Visit Tips
The Annual Wellness Visit (AWV) is exactly what it says it is... a Wellness Visit. It is a wellness visit during which the beneficiary's medical history, risk factors, functional ability and routine measurements are all captured in order to provide a Personalized Prevention Plan which the beneficiary may choose to follow to maintain good health. The AWV is NOT the same as a yearly (annual) physical exam.
Both the first AWV and subsequent AWVs have a checklist of elements which must be provided, or provided and referred, before submitting a claim for the AWV. These checklists can be found for your use on a quick reference factsheet at the following link: www.cms.gov/MLNProducts/downloads/AWV_Chart_ICN905706.pdf
A Medicare beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage and who has not received either an Initial Preventive Physical Examination (IPPE) or an AWV within the last 12 months is eligible for an AWV. Medicare Part B will pay for one initial AWV and a subsequent AWV yearly thereafter. There is no coinsurance or copayment on the part of the beneficiary for the AWV.
An AWV can be performed by the following health professionals:
· physician (doctor of medicine or osteopathy)
· qualified non-physician practitioner such as a physician assistant, nurse practitioner, or clinical nurse specialist
· health educator
· registered Dietitian
· nutrition professional
· other licensed practitioner
· team of such medical professionals working under the direct supervision of a physician
You can help your patients prepare for the AWV by advising them that this is NOT a physical exam or "check-up", and encouraging them to come prepared with the following:
Medical records, including immunization records
Family health history
A full list of current medications and supplements
A full list of current providers and suppliers involved in their care
The following resources are helpful in understanding the AWV in greater detail:
The Guide to Medicare Preventive Services - www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
Medicare Benefit Policy Manual - www.cms.gov/manuals/downloads/bp102c15.pdf
Change Request 7079 - Annual Wellness Visit - www.cms.gov/transmittals/downloads/R2159CP.pdf
Medicare Learning Network Preventive Services Educational Products Website - www.cms.gov/MLNProducts/35_PreventiveServices.asp
Mike and Nancy are independent consultants and coding educators. They are a mother/son team who are active in local and regional professional organizations.