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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.
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False Claims Act
• Regulated fraud associated with military contractors selling materials and gear to the Union Army.
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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.
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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
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Federal Anti-Kickback Law
• Protects patients from fraud and neglect by curtailing the corrupting influence of money on health care choices.
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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
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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
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McKinney Act
• Provides health care to the homeless
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11
Vaccines for Children Program
• Provides free immunizations to all children in low-income families
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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
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13
CCI
• Developed by CMS to trim down Medicare program expenditures by detecting out of place codes on claims and rejecting payment for them.
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HIPAA
• Mandated administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information.
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SCHIP
• Health insurance program for newborns, children, and youth – Covers health care services such as
physician visits, prescription medicines, and hospitalizations
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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
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Medicare Prescription Drug, Improvement, and Modernization Act
• Provides Medicare recipients with prescription drug savings and additional health care plan choices
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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.
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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
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• Long-term care services and coverage
• Unique identifiers for providers, health plans, employers and individuals
Health Insurance Portability and Accountability Act
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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
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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
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Common Forms of Medicare Fraud Includes
• Billing for services that were not performed
• Misrepresenting diagnosis to justify payment
• Unbundling codes
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Examples of Abuse
• Excessive charges for services
• Services not medically necessary
• Improper billing practices
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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
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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
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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
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Overpayments
• If reimbursed funds exceed the amount a provider or beneficiary were supposed to receive.
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Overpayments Include
• Payment based on a charge• Duplicate processing of charges• Payment made to the wrong payee• Payment made for a item not used
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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
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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
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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
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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
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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
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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
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National Correct Coding Initiative (NCCI)
• Local and national coverage determination
• Review of current coding practices