health care litigation – coding and documentation audits

Amper, Politziner & Mattia LLPCoders Day

September 2009

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Coding and Documentation AuditIndex

Overview of Coder’s role in HC litigationCase Study #1Case Study #2Case Study #3Conclusion

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Coding and Documentation AuditCoder’s role in HC litigation

Coding specialistGather evidence for HC attorneyExpert witness in Court

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Coding and Documentation AuditCase Study #1Situation

Medicare sends an audit letter to the practiceNo indication of the reason for nonpaymentPayment for all Medicare services stoppedPractice retains HC legal counselLegal counsel retains Amper

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Coding and Documentation AuditCase Study #1Results of Amper Review

All office visits billed at levels 4 or 5Numerous lab tests per patient per visitNumerous procedures at every visitNumerous high risk diagnosis at every visitMedicare nurse reviewers requested additional

documentation to complete their review

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Coding and Documentation AuditCase Study #1Results of Amper Review

Additional documentation supplied to MedicareMedical Director states he has a medical

necessity concern even though documentation is complete

Audit is disruptive to the practice’s cash flowImportance of a Compliance ProgramBilling Company role for documentation

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Coding and Documentation AuditCase Study #1Results of Amper Review

Managing partner to discuss clinical approach with Medicare’s Medical Director

Healthcare attorney involvement for all discussions with Medicare

Numerous coding and documentation corrections noted to the practice by Amper

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Coding and Documentation AuditCase Study #1Outcome of Efforts

Negotiated settlement with MedicareNo Fraud indictments issuedPractice no longer services Medicare patients

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Coding and Documentation AuditCase Study #2Situation

Private payor audit regarding consultationsPayor requested an overpayment request in

excess of $500,000 from the practicePayor threatened fraud indictmentPractice retained HC legal counselLegal counsel retained Amper

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Coding and Documentation AuditCase Study #2Results of Amper Review

Consults billed for all visits including new and established visits

Frequent and repetitive administration of testing procedures

High number of procedures performed on family members

Diagnosis did not support level of office visit or medical necessity

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Coding and Documentation AuditCase Study #2Results of Amper Review

Practice invested in an electronic medical records system – HC attorney suggested to use this investment as a defense against the payor Inadequate documentation for any visit Missing patient chart information Missing documentation of procedures

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Coding and Documentation AuditCase Study #2Outcome of Efforts

Overpayment request by payor reduced by 40%

Physician no longer serviced patients from payor

Fraud charges not brought against physicianPhysician sold practice

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Coding and Documentation AuditCase Study #3Situation

Physician sued by an imaging management company for overpayment of professional services

Portrayed as a contract dispute between management company and the physician

Physician retains HC legal counselLegal counsel retains Amper

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Coding and Documentation AuditCase Study #3Results of Amper Review

Management company billed global charges under the physician’s provider number

One owner of management company debarred from Medicare, but company continued to bill

Billings under the physician’s name after he retires

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Coding and Documentation AuditCase Study #3Results of Amper Review

The same series of ultrasounds and/or echocardiograms were performed on all patients

Numerous billings for family membersIncorrect reporting of diagnosis or procedures

to maximize paymentsBillings also submitted incorrectly to all private

payors

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Coding and Documentation AuditCase Study #3Outcome of Efforts

HC attorney turned over Amper findings to U.S. Attorney’s office

Criminal charges brought against owners of imaging management company

Physician was not required to return any overpayments requested by the management company

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Coding and Documentation AuditConclusion

Fraud and abuse is prevalent in healthcareCoder plays a key role in the proper billing of

servicesCoder assists legal counsel defend providers in

requests for overpaymentsEssential for all healthcare organizations to

have Compliance Programs

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Coding and Documentation AuditContact Information

Michael J. McLafferty CPA, MBA, FACMPE, CHFP

Partner, Healthcare Services GroupAmper, Politziner & Mattia LLPMcLafferty@Amper.comOffice – 732-287-1000 Extension 1284Cell - 732-598-8858

“The material contained in this presentation is for general information and should not be

acted upon without prior professional consultation.”