Does your healthcare organization make proactive decisions about regulatory changes with time to adjust? Three steps to help make decisions farther upstream.Continue reading
Sharon Parsley covers five expert tips to investigate a known or suspected healthcare compliance issue for the YouCompli blog, Compliance Effectiveness Series.Continue reading
Healthcare Compliance delivers value through effectively managing regulatory changes. Patient care and financial returns can suffer without it.Continue reading
Metrics for healthcare compliance culture impact. OIG Supplemental Compliance Program Guidance 2005, and the Evaluation of Corporate Compliance Programs, 2020.Continue reading
Through 2019, telehealth was mainly for rural patients living far from healthcare providers. Then came COVID and the Public Health Emergency (PHE) declaration from the Department of Health and Human Services (HHS). Since 2020, a series of rolling 90-day waivers opened telehealth to everyone, temporarily.
Thanks to a recent surge in COVID cases, the current PHE extends to October 2022. When it ends, so does CMS’s authority to continue telehealth’s expended capabilities (unless there’s a further extension). That’s why Congress stepped in. The Consolidated Appropriations Act, which became law March 15, extends telehealth’s lifespan by five months (151 days, to be specific) after the PHE expires. (Related: Six key steps to reduce the impact of telehealth audits)
That means telehealth is alive and well at least through year’s end. So are many of the PHE-related coverage flexibilities. Here are some of the highlights:
- Telehealth from anywhere Before the PHE, Medicare covered only services delivered to patients at hospitals and other provider facilities. The Act redefines “originating site” to mean “any site in the United States at which the eligible telehealth individual is located at the time the service is furnished.” This could be patients’ homes, their cars – anywhere with phone or Wi-Fi connectivity.
- More practitioners In addition to physicians, nurse practitioners, physician assistants and other specialized providers, occupational and physical therapists’, speech language pathologists’ and audiologists’ services will be covered.
- Payment for audio-only services will continue for 151 days after the PHE ends.
- Relaxed in-person mental health services requirement The waivers ensure that the requirement that mental health patients have in-person visits of the first telehealth visit and every 12 months afterwards won’t take effect until the 152nd day after the PHE ends.
- Reinstated first-dollar coverage Until the end of 2021, telehealth services to High Deductible Health Plan and Health Savings Account patients were not subject to plan deductibles. The new law reinstated this relief through December 31 of this year.
- More data transparency The Medicare Payment Advisory Commission is required to analyze telehealth utilization, expenditures, payment policies, and implications on access to and quality of patient care. Starting July 1, the HHS Secretary must publicly post quarterly telehealth utilization data.
For more lasting, but not permanent, relief, the bipartisan Telehealth Extension and Evaluation Act, which would extend the telehealth waivers for two years, is inching its way through Congress.
If all the flux and uncertainty at the federal level weren’t enough, there’s also the state level. As I posted almost a year ago, the states have their own telehealth coverage, reimbursement, and privacy regulations. For now, patients and providers can continue on through at least the end of 2022 with access to telehealth. Beyond that, healthcare organizations are working hard to future proof their approach to telehealth. Stay tuned!
Read how one health system created a scalable repeatable process to address regulatory changes during the PHE. The hospital system is now fully prepared to revert those changes or update them to the new requirements.
Four ways to build a healthy culture of compliance. Help your clinical and operational colleagues see compliance as foundational to your healthcare organizationContinue reading
Avoid Nurse Licensure Compacts (NLC) compliance risks. Manage the changing healthcare regulations before they become enforcement actions.Continue reading
Healthcare compliance culture is strategic. Defining compliance culture in the context of overall healthcare priorities. Measure it.Continue reading
CJ Wolf, MD writes enforcement action summaries for the YouCompli blog. These summaries provide real-world examples of regulators’ response to practices that don’t fully comply with regulations.
This month’s article looks at physician coding and billing cases. It reflects remarks CJ made at HCCA’s 2022 Compliance Institute. (For more insights from the Compliance Institute, download our white paper on how compliance professionals can help healthcare institutions mitigate risk.)
Physicians are often seen as the drivers in healthcare. They examine patients, order labs and diagnostic testing. They perform procedures and surgeries, admit patients to hospitals, and document in the medical record.
If you ask physicians what they think about coding and billing, most of them will tell you this: The rules do not make sense, are hard to understand, and are constantly changing. Most of them are doing their best to apply the confusing rules as they care for patients. Some might even be billing improperly on purpose. Either way, these examples highlight the consequences of “getting it wrong.” They offer clues for compliance professionals to spot training opportunities before they become enforcement actions.
Billing for services not needed or received
In March of 2022, a New Jersey rheumatologist was convicted by a federal jury for defrauding Medicare and other health insurance programs. She had billed for services that were either unnecessary or were not provided. Court documents demonstrated the physician billed for expensive infusion medication that her practice never purchased. She also fraudulently billed millions of dollars for allergy services that patients never needed or received. The doctor will be sentenced in July for multiple counts of healthcare fraud. Each count carries a maximum penalty of 10 years.
Compliance officers should watch for:
Follow the money. If a practice is billing millions of dollars for allergies services, that code or set of codes is likely to stand out as an outlier to compliance programs monitoring all their billing data. Compliance officers should have a true sense of what their organization’s bread and butter services are. Then, they should perform regular audits of those high dollar, high volume services.
Billing for unnecessary urine drug testing
A Florida physician, serving as a medical director for a sober living facility, was found guilty of healthcare fraud. The federal jury found that he had ordered medically unnecessary urine drug tests. Court documents showed the physician unlawfully billed approximately $110 million of urinalysis (UA) drug testing services that were medically unnecessary for patients. Some of the evidence used at trial included inappropriate standing orders for UA drug tests in exchange for a monthly fee. As a condition of residency, patients had to submit to excessive and medically unnecessary urine drug testing three to four times per week.
Evidence also showed the medical director did not review the UA drug test results and did not use the UA drug tests to treat the patients. This lack of review called the necessity of the tests into question. In addition, the doctor had these same patients sent to his office so he could also fraudulently bill for services through his own practice. He faces up to 20 years in prison for healthcare fraud and wire fraud conspiracy. He faces another 10 years for each of eleven counts of healthcare fraud.
Compliance officers should watch for:
If your organization allows for standing orders, you should have a written policy that guides their use. The policy should outline the risks and benefits of the standing orders. It should describe when they are appropriate and when they are not appropriate. That policy should also outline the process for reviewing standing orders on a regular basis to determine if they are still appropriate. If it’s been more than a year since you’ve reviewed a standing order, you may want to schedule a review soon.
Modifier misuse: unbundling under modifier 25
Billing and coding modifiers can also be an area of risk for physicians. In general, most encounters are reported with one Healthcare Common Procedure Coding System / Current Procedural Terminology (HCPCS/CPT) code. Medicare generally prohibits healthcare providers from separately billing for E&M services provided on the same day as another medical procedure. The exception is if the E&M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the medical procedure.
When the E&M service meets this definition, modifier 25 can appropriately be appended to the E&M code. When that is done, a physician is, in essence, certifying that the procedure and E&M are separate enough to meet the definition of the modifier.
A urology practice learned an expensive lesson by allegedly using modifier 25 inappropriately. The practice agreed to pay $1.85 million to resolve allegations of modifier misuse. The case was initiated by a qui tam whistleblower. Allegedly the practice used modifier 25 to improperly unbundle routine E&M services that were not separately billable from other procedures performed on the same day. As a result, the practice improperly claimed compensation from Medicare for certain urological services. The whistleblower had performed audits that allegedly showed an overall error rate for the practice of 58% with some physicians showing a 100% error rate.
Compliance officers should watch for:
Any specialty could potentially run into problems with modifier 25. Consider common clinical scenarios such as a scheduled procedure. For example, in urology a physician might schedule a patient to return to the office another day for a scope procedure or a prostate biopsy. Frequently, upon return, the procedure is performed but a significant, separately identifiable evaluation and management service might not be performed. In those cases, it would not be appropriate to bill the procedure and an E&M service, but rather only the procedure. Automatically billing an E&M with modifier 25 just because the patient was in the office would be a red flag.
Physicians and their practices need to be aware of coding and billing risks. Enforcement agencies and potential whistleblowers may identify outliers or flat-out fraud. Common mistakes may include a lack of documentation or not performing a service but billing for it anyway. Other common mistakes are billing for procedures or services that were performed but were not medically necessary and misuse of medical codes and/or modifiers.