Big Data: Implications of Data
Mining for Employed Physician
Compliance Management
Becker’s 2015 Annual CEO Roundtable
November 18-19, 2015
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 0
Big Data
“Big-data initiatives have the potential to transform
healthcare, as they have revolutionized other
industries. In addition to reducing costs, they could
save millions of lives and improve patient outcomes.
Healthcare stakeholders that take the lead in investing
in innovative data capabilities and promoting data
transparency will not only gain a competitive
advantage, but will lead the industry to a new era.”
(McKinsey)
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Agenda
• Public relations and litigation risk from the public
dissemination of data being harvested and aggregated by
the government (e.g. Physician payment data, Sunshine Act
regulations, discharge data)
• Internal use of Broad Spectrum Analytics in Employed
Physician Compliance Management
• Determination of Risk Tolerance and Customizing Analytics
that are “Outside the Box”
• Benchmarking, Monitoring, and Defining Physician/Focused
Risk Area Reviews
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 2
Big Data Trends
• Trends in the use and public dissemination of
healthcare financial, claims, and quality data
– Publicly Available & Third party data
• Federal Charge Data
• State-level Charge Data
• Physician and other Supplier Public use file
• Broad Disclosure of Physician Payment Information under
Sunshine Act
• Public Use Files of Part C and D Reporting Requirements
Data
• Other Public or For Purchase Data Sources
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Federal Charge Data
• CMS has released hospital-specific data from
2011 comparing the charges for the 100 most
common inpatient services and 30 common
outpatient services
• Inpatient DRG examples:
– Heart Failure & Shock w cc
– G.I. Obstruction w cc
– Transient Ischemia
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Federal Charge Data (con’t)
• Outpatient examples:
– Level III Endoscopy Upper Airway
– Level I Nerve Injections
– Level 1 Hospital Clinic Visits
See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Medicare-Provider-Charge-Data/index.html
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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3
State-Level Charge Data
• Numerous states also provide
state-level charge data
• The information and format varies
• Examples:
– Wisconsin, X Facility,
Cesarean Delivery: $12,881
– Tennessee, All Facilities, Rotator Cuff Repair,
Average Charge without another procedure: $23,483
– Oregon, X Facility, Esophagitis, gastroent & misc digest
disorders w/o MCC, Average Charge: $8,546
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Physician and Other
Supplier Public Use File
• Physician and Other Supplier Public Use File
released for the first time in April 2014
• Contains 100% of final-action
physician/supplier Part B non-institutional line
items for the Medicare fee-for-service
population for CY2012 paid through June 30,
2013
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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4
Physician and Other
Supplier Public Use File (con’t)
• Contains information on services and
procedures provided to Medicare
beneficiaries by physicians and other
healthcare professionals, including:
– Utilization
– Submitted charges
– Payment (allowed amount and Medicare
payment)
See http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Broad Disclosure of Physician
Payment Info under Sunshine Act
• Manufacturers of drugs, devices, biologicals, and medical
supplies, and some group purchasing organizations (GPOs),
must report payments and other transfers of value to
“covered recipients” which are defined as:
– Teaching hospitals
– Physicians (except physicians who are employees of the applicable
manufacturer)
• CMS must make information submitted
in transparency reports and physician
ownership reports publicly available
on a searchable website
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Public Use Files of Part C and D
Reporting Requirements Data
• Federal regulations require Medicare Advantage (MA) plans
and Part D sponsors to report to CMS information on (among
other things):
– Enrollment and Disenrollment (Part C and Part D)
– Grievances (Part C and Part D)
– Special Needs Plans Care Management (Part C)
– Organization Determinations/Reconsiderations (Part C)
– Coverage Determinations and Exceptions (Part D)
– Long-Term Care Utilization (Part D)
– Medication Therapy Management Programs (Part D)
– Redeterminations (Part D)
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Big Data Trends
• Other Government Data Sources
– Medicare Fraud Strike Force Team
– Data-Driven Quality Initiatives
– Other Non-Public Government Data Sources
• Government Uses of Data for Compliance
and Enforcement – Adventist results
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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What Providers and
Payers Can Expect
• Scenario 1: Increased Media Exposure
• Scenario 2: Linking Manufacturer Payments
Data to Anti-Kickback Allegations
• Scenario 3: Quality of Care FCA Litigation
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 1:
Increased Media Exposure
See http://time.com/#198/bitter-pill-why-medical-bills-are-killing-us/
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
• Expect qui tam relators to
attempt to bolster complaints
by “linking” physician payments
to “increased” drug or device
utilization in order to allege
an Anti-Kickback Statute (AKS)
violation
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
FRCP 9(b) & Big Data
• Interplay of Rule 9(b) Motions to Dismiss
and Big Data
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
Rule 9(b) Relator’s Counsel “In Their Own Words”
“Sunshine data instantly provides qui tam attorneys a
host of information that would have been impossible
or very difficult to find before the Act. [One relator’s
counsel] believes the information would, right off the
bat, add credibility to a relator's allegations. Attorneys
will be able to corroborate their client's allegations or
confirm suspicions of widespread conduct by running
a simply search.”
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 2: Linking Manufacturer
Payments Data to AK Allegations
“At the very least, Sunshine data will provide facts to
beef up a plaintiff's complaint. Rule 9(b) of the Federal
Rules of Civil Procedure requires that for ‘alleging
fraud or mistake, a party must state with particularity
the circumstances constituting fraud or mistake.’ [One
relator’s counsel] notes that the exact dates of
transactions and the precise amounts of payments will
add that required specificity.”
See http://www.policymed.com/2014/02/physician-payment-sunshine-act-will-sunshine-datahelp-qui-tam-whistleblowers-and-their-attorneys.html
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 3: Quality of
Care FCA Litigation
Linked To Data
• Expect qui tam relators and/or government to
contend payment structures and reporting
measures set forth in various new quality
programs materially affect payment and are
thereby conditions of payment—and that
violations triggers False Claims Act (FCA)
liability
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 3: Quality of
Care FCA Litigation
Data-Driven Quality Initiatives
• Programs resulting from the Patient Protection and
Affordable Care Act (PPACA), the American Recovery and
Reinvestment Act (ARRA) as well as those initiated by OIG
and CMS reflect an increased focus on quality
• Health Information Technology for Economic and Clinical
Health (HITECH) Act established the Electronic Health
Record (EHR) Meaningful Use Program to provide financial
incentives to providers to promote the adoption and
meaningful use of certified EHR technology to improve
patient care (ARRA, Public Law 111-5, Division A, Title XIII
and Division B, Title IV)
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Scenario 3: Quality of
Care FCA Litigation
Data-Driven Quality Initiatives (con’t)
• PPACA establishes numerous quality-related programs,
potentially exposing providers to increased liability for quality
shortfalls; these include, among others:
– Medicare Physician Quality Reporting Improvements: financial
incentives and penalties for reporting or failure to report Physician
Quality Reporting Initiative (PQRI) measures (PPACA §§ 3002,
3007)
– Value-Based Purchasing Program: pays hospitals based upon how
well they perform on specific quality measures (Id. § 3007)
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Potential Review Results
PQRS/QUALITY REPORTING DETAILED RESULTS
PQRS Results
Family Practice
Internal Medicine
Other
Specialties
Met
Not Met
PQRS code and/or ICD-9 code not documented
Supporting ICD-9 or additional PQRS code should be reported
A different PQRS code was documented
No documentation received
Corresponding CPT code not supported
Modifier deficiency1
757
545
144
99
107
0
195
6
247
145
56
26
29
2
32
0
103
68
50
6
7
4
1
0
Of note, Not Met is counted per transaction or claim line versus the deficiencies listed which include transaction-level
and component-level errors. Modifier deficiency is a component-level error; meaning that the error count in some
instances may also be captured in one of the other categories.
1
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Real World Examples of
Physician Compliance Risk
1. Overuse of -25 modifier
2. Overuse/exclusive use of high level E/M
codes
3. Extremely high levels of production
4. Psychiatry time based codes and use of E/M
codes with same
5. High utilization of specialty related services
(Oncology, Cardiac)
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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How Can We Mitigate Risk?
Think like a reporter, a qui tam relator, a MAC,
MIC, ZPIC, RAC, DOJ and the OIG, etc.
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Key Questions
• Are you incorporating data sets in your compliance
and internal audit activities?
• Is data analytics a key part of your monitoring and
auditing plan?
• Are you assessing data analytics capabilities (or lack
thereof) as part of your annual risk assessment?
• Are you evaluating where you are amongst your
peers?
• If you are an outlier, is there a legitimate reason why,
or do you need to mitigate an issue through corrective
action?
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Resources to Identify Most
Significant Areas of Potential Risk
• OIG Work Plan
• OIG Semi-Annual Report to Congress
• OIG Special Fraud Alerts
• OIG and DOJ Announcements
• Corporate Integrity and Deferred Prosecution Agreements
• RAC Audits
• RADV Audits
• Complaints, Investigations, and Audits
• . . . Your Gut!
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Using Data Effectively
• Considerations when designing an effective data
analytics function:
– Availability of data
– Accessibility to the data
– Timeliness to gain access to the data
– Quality of the data
– Expertise of those using the data
– Corporate support for the program
– Privacy and Privilege considerations
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 26
Making the information come to you…
Physician Compliance Monitoring
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Making Physician Compliance
Manageable AND Meaningful
Analytics Suite
on All Employed Physicians
Effective use of physician analytics
allows a physician compliance
program to be extremely detailed
while remaining efficient and
cost-effective.
Targeted
Physician Probes
Focused
Physician
Reviews
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 28
Typical Areas of Focus
Develop unique areas of focus, metrics to measure, and thresholds to assess
compliance and risk. This is an active, fluid initiative.
“CODING”
• Area/Metric
• Area/Metric
• Area/Metric
“PHYS ALIGN”
• Area/Metric
• Area/Metric
• Area/Metric
“REV $”
• Area/Metric
• Area/Metric
• Area/Metric
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Other Customized Analytics:
Getting “Outside Of The Box”
CODING
PHYS
ALIGN
In addition to a number of analytics to evaluate certain “expected” areas
of physician utilization (e.g., E/M bell curves), consider other topical ways
to assess physicians based upon a customized list of targeted service
areas to determine if “outlier” patterns exist. Some example focus areas
include:
• Critical Care Service Utilization
• 25-modified E/M Services
REV $
• Preventive Medicine Services (e.g., ratio of G-code to 9-code use)
• Extended Discharge Day Management Services
• Incident-to/Split Shared Services
• Time Studies/Work RVU Analysis
• EP Study Utilization
• Long-term Drug Use ICD-9 Code Utilization
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Physician Analytics Suite
Examples
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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E/M Distribution
(“Bell Curve”) Analysis
CODING
PHYS
ALIGN
REV $
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 32
Benchmark Specialty
Procedural Service Mix Analysis
CODING
PHYS
ALIGN
REV $
Specialty Benchmark Comparison
PHYSICIAN
Percent
CPT/HCPCS
Physician
Codes
Rank
Appended CPT/HCPCS Brief Description
1
23%
99232 Subsequent hospital care
2
15%
99222 Initial hospital care
3
14%
99231 Subsequent hospital care
4
7%
99223 Initial hospital care
5
5%
63047 Removal of spinal lamina
6
3%
99233 Subsequent hospital care
7
2%
63048 Remove spinal lamina add-on
8
2%
22851 Apply spine prosth device
9
2%
22551 Neck spine fuse&remov bel c2
10
2%
99221 Initial hospital care
11
2%
61781 Scan proc cranial intra
12
1%
22614 Spine fusion extra segment
13
1%
22552 Addl neck spine fusion
14
1%
61312 Open skull for drainage
15
1%
22845 Insert spine fixation device
Specialty Benchmark Comparison
NEUROSURGERY
Neurosurgery
Benchmark
Rank
8
16
7
13
28
21
12
14
37
24
17
46
33
Percent
Neurosurgery of Total
Benchmark Benchmark
Rank
Units
CPT/HCPCS Brief Description
1
14%
99213 Office/outpatient visit est
2
7%
99214 Office/outpatient visit est
3
6%
99212 Office/outpatient visit est
4
5%
99204 Office/outpatient visit new
5
5%
99203 Office/outpatient visit new
6
4%
J2323 Natalizumab injection
7
3%
99231 Subsequent hospital care
8
3%
99232 Subsequent hospital care
9
3%
J0585 Injection,onabotulinumtoxinA
10
2%
G8447 Pt vis doc use EHR cer ATCB
11
2%
99205 Office/outpatient visit new
12
2%
63048 Remove spinal lamina add-on
13
2%
99223 Initial hospital care
14
2%
22851 Apply spine prosth device
15
2%
99215 Office/outpatient visit est
Physician
Rank
63
55
3
1
7
4
8
-
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Special Data Analytics for High Risk Concerns
Targeted Physician Probes
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 34
New vs. Established
Patient E/M Services
Ratio
Est Patient E/M
to
New Patient E/M
PHYSICIAN
Ratio
Est Patient E/M
to
New Patient E/M
BENCHMARK
Percent
Variance
Physician A
1.3
3.6
177%
Physician E
0.9
2.4
176%
Physician I
1.7
3.6
112%
Physician C
1.2
2.4
100%
Physician B
3.2
4.0
25%
CODING
Physician
REV $
Dashboard
>=50%
>=35%
>=20%
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Focused Benchmark Analysis:
Modifier Use
CODING
PHYS
ALIGN
REV $
Modifier Use
> 30%
Above Benchmark
Physician
Modifier Use
> 25%
Above Benchmark
Physician A
25, 80
Physician B
51
Physician C
51
51
Physician D
80
59
Physician E
25
22
Physician F
22
Physician G
25
Physician H
59
25
Physician I
80
59
Modifier Use
> 20%
Above Benchmark
25
Significant separately identifiable E/M service
59
Distinct procedural service
80
Surgical assistant
22
Increased procedural service
59
22
51
25
80
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 36
Physician Productivity Analysis:
Addressing Work Relative Value
CODING
PHYS
ALIGN
REV $
th
Work RVUs
as a % of
Physician
Specialty
Work RVUs
Weighted
Average Work
RVU per Unit
90 Percentile
Work RVUs per
MGMA
Physician A
Geriatrics
20,658
1.43
6,194
90 Percentile
334%
Physician B
Hospitalist
21,666
1.03
6,901
314%
Physician C
Endocrinology
16,232
0.94
6,801
239%
Physician D
Geriatrics
14,163
1.58
6,194
229%
Physician E
General Surgery
18,179
2.63
10,730
169%
Physician F
Gynecology/Oncology
16,233
1.24
10,775
151%
Physician G
OB/GYN
16,022
1.88
10,432
154%
Physician H
Gastroenterology
15,609
1.75
12,604
124%
Physician I
Hospitalist
9,244
1.80
6,901
134%
Physician J
Family Medicine
7,790
0.35
7,082
110%
Physician K
Plastic/Reconstructive Surgery
6,551
1.87
11,411
57%
Physician L
Psychiatry
3,819
1.34
6,189
62%
th
Dashboard
>200%
>150%
>100%
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Physician Productivity Analysis:
Work RVUs
CODING
PHYS
ALIGN
REV $
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 38
Place Of Service Impact Analysis
The Office of Inspector General reports the following in its HHS OIG
Work Plan for Fiscal Year 2014:
CODING
REV $
“Federal regulations provide for different levels of payments to physicians
depending on where services are performed (42 CFR §414.32). Medicare
pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is
performed in a hospital outpatient department…”
SORTED BY
CLIENT Billed in
Non-Facility ($$) Setting
Benchmark Billed in
Facility ($) Setting
CLIENT | Benchmark
Place of Service
Match
Physician D
70%
30%
Physician A
61%
39%
Physician G
1%
76%
Physician C
0%
100%
Physician O
0%
77%
Physician K
0%
51%
Physician
Dashboard Reimbursement
Higher Based upon CLIENT
Compared to Benchmark
Place of Service
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Non-Physician Practitioner (“NPP”)
Collaboration “Probe” Analysis
CODING
Define physicians who may collaborate with NPPs to perform
incident-to, split/shared E/M visit and post-operative follow-up
services.
PHYS
ALIGN
Physician
REV $
SORTED BY
Percent
Billing Provider = MD
and
Rendering Provider = MLP
Physician B
55%
Physician A
47%
Physician C
35%
Physician D
33%
Physician G
20%
Physician K
15%
Physician O
0%
Dashboard
>=50%
>=35%
>=20%
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 40
Benchmark Physician
Time Study Analysis
CODING
PHYS
ALIGN
REV $
Physicians with “higher than expected” FTE-equivalent levels often
collaborate with NPPs, nursing and other ancillary staff to engage in the
work flow/practice patterns necessary to support high utilization levels.
Total
Professional
Service Time
(in Hours)
FTE-Equivalent
(Based upon 2,000
Annual Hours)
Physician B
9,702
4.85
Physician A
9,616
4.81
Physician C
6,803
3.40
Physician D
4,995
2.50
Physician G
4,306
2.15
Physician K
4,211
2.11
Physician N
2,683
1.34
Physician O
2,386
1.19
Physician
Dashboard
>=3.0
>=2.5
>=2.0
<2
Best calculated using the current Medicare Physician Time Study and 2,000
total annual hours per full-time equivalent.
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Gross And Net Revenue
“Pulse Check” Analysis
PHYS
ALIGN
Use data to gain a high level understanding of any potential areas of
revenue “vulnerability.”
REV $
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Outcome:
“At A Glance” Reporting
CODING
PHYS
ALIGN
REV $
Specialty
Physician
Physician A
Physician B
Electrophysiology
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Interventional Cardiology Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Total Work
RVU
Benchmark
Comparison
Total Work
RVUs by
Service Type
Weighted
Average Work
RVU per Unit Productivity
Total Days
by Service Stability Probe Worked by Day
Type
E/M Services of the Week
Average Daily
Billed Service
Hours by Day
of the Week
Benchmark
Physician
Time Study
Analytics
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Next Steps:
Focused Physician Reviews
Grading or Compliance Rate Considerations
Feedback During Review Process
Trending
Corrective Action Plans
No more annual 10 chart provider review
compliance plan commitments!!!
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 44
Coding and Documentation Review
Guidelines
VS.
Documentation
•
CPT
• Explanation of Benefits
•
ICD-9-CM
• CMS 1500
•
ICD-10-CM
•
HCPCS
•
1995/1997 Documentation
Guidelines for E/M Services
•
Medicare/Medicaid/Other Gov’t
•
State and Federal
• Medical Record
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Coding and Documentation Review
E/M Compliance Elements
General Compliance Elements
• Chief Complaint
• CPT Selection
• History of Present Illness
• Modifier Usage
• History Level
• ICD-9 Selection
• Review of Systems
• Signature Compliance
• Examination
• Time-based code support
• Past, Family and/or Social
History
• NPP/Midlevel Provider Compliance
• Medical Decision Making level
• Other agreed-upon regulatory or
facility-specific areas of interest
• Modifier Usage
• NCCI/Bundling Compliance
• ICD-10 Documentation Readiness
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 46
Potential Review Results
INTERNAL MEDICINE SNAPSHOT – PHYSICIAN CODING DEFICIENCY FINDINGS
(In Compliance Rate Order)
0.00%
10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
All Internal Medicine
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Physician S
Physician T
Physician U
Compliance
Missing Provider Signature
Not Documented
Missed Opportunity to Bill
Bundled
Insufficient Documentation to Bill
Overcoded
Undercoded
Inaccurate CPT/HCPCS Assigned
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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Potential Review Results
COMPLIANCE RATES PER PROVIDER
Fam ily Practice
Provider
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Physician S
Physician T
Physician U
Physician V
Physician W
Physician X
Physician Y
Physician Z
Physician AA
Physician AB
Physician AC
Physician AD
Physician AE
Physician AF
Physician AG
Physician AH
Physician AI
Physician AJ
Physician AK
Physician AL
Physician AM
Physician AN
Physician AO
Physician AP
Physician AQ
Physician AR
Physician AS
Physician AT
Physician AU
Physician AV
Internal Medicine
Compliance
90%
89%
88%
86%
76%
75%
75%
74%
74%
73%
71%
71%
69%
69%
68%
65%
65%
65%
64%
63%
62%
61%
59%
59%
58%
58%
58%
57%
57%
57%
55%
54%
54%
53%
52%
52%
48%
47%
45%
43%
40%
38%
37%
35%
34%
33%
31%
24%
Dashboard
<60%
61-89%
90-100%
Provider
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Physician S
Physician T
Physician U
Other Specialties
Com pliance
83%
80%
79%
75%
75%
75%
75%
72%
68%
67%
65%
62%
61%
53%
45%
43%
40%
40%
37%
36%
20%
Dashboard
<60%
61-89%
90-100%
Provider
Physician A
Physician B
Physician C
Physician D
Physician E
Physician F
Physician G
Physician H
Physician I
Physician J
Physician K
Physician L
Physician M
Physician N
Physician O
Physician P
Physician Q
Physician R
Physician S
Physician T
Physician U
Physician V
Com pliance
85%
75%
71%
68%
66%
65%
63%
60%
60%
58%
53%
52%
50%
50%
40%
36%
30%
27%
24%
18%
7%
5%
Dashboard
<60%
61-89%
90-100%
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 48
Potential Review Results
TOTAL AND SPECIALTY GROUPING ERROR COUNTS
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 49
25
Potential Review Results
E/M CODING DETAILED RESULTS
Family Practice
E/M Coding Detailed Results
Met
Not Met
Undercoded
Insufficient Documentation to Bill
Overcoded
Not Documented
Bundled
Inaccurate CPT/HCPCS Assigned
Missing Provider Signature
267
217
95
74
35
6
4
2
1
Internal Medicine
E/M Coding Detailed Results
55%
45%
20%
15%
7%
1%
1%
0.4%
0.2%
Met
Not Met
Inaccurate CPT/HCPCS Assigned
Insufficient Documentation to Bill
Missing Provider Signature
Not Documented
Overcoded
Undercoded
127
81
2
13
1
17
39
9
Other Specialties
E/M Coding Detailed Results
61%
39%
1%
6%
0.5%
8%
19%
4%
Met
Not Met
Inaccurate CPT/HCPCS Assigned
Insufficient Documentation to Bill
Missing Provider Signature
Not Documented
Overcoded
Undercoded
70
111
9
9
6
28
52
7
39%
61%
5%
5%
3%
15%
29%
4%
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 50
Potential Review Results
PROCEDURAL CODING DETAILED RESULTS
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 51
26
Identifying Overpayments
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 52
Medicare Parts A & B:
Identifying Overpayments
Medicare Parts A & B
• 60‐Day Overpayment Proposed Rule
– 10-year look‐back period
– Duty to take affirmative investigative action related to
potential overpayments
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 53
53
27
Medicare Parts C & D:
Identifying Overpayments
Medicare Parts C & D
• 60-Day Overpayment Final Rule
– Six-year look-back period
– “[I]f an MA organization or Part D sponsor has received
information that an overpayment may exist, the
organization must exercise reasonable diligence to
determine the accuracy of this information, that is, to
determine if there is an identified overpayment ... ‘‘day
one’’ of the 60-day period is the day after the date on
which organization has determined that it has identified
the existence of an overpayment.”
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 54
54
Questions
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
Page 55
28
Thank You!
Denise Hall, RN, BSN
Principal, Healthcare Consulting
Pershing Yoakley & Associates, P.C.
(404) 266-9876
dhall@pyapc.com
Prepared for Becker’s 2015 Annual CEO Strategy Roundtable
November 18-19, 2015
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