CJ Wolf
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The Medical Group Management Association (MGMA) is the premiere professional society for medical groups and those who work in medical practices. Their recent Financial and Operations Conference was held in Orlando. There was a tremendous amount of important information shared during the two-day conference, including compliance and regulatory information.
Here’s a summary of the most pertinent compliance and regulatory information shared at the conference:
Appropriate Billing for Advanced Practice Practitioners (APP)
Christopher Chandler from Intermountain Healthcare taught attendees about the dos and don’ts of APP billing.
In the facility setting (i.e., not the physician’s office), APPs and physicians can perform ‘shared services.’ According to Chandler, shared services only apply to evaluation and management (E&M) services, not procedures. The physician and APP must be in the same group and the APP cannot be on the hospital cost report. Finally, the provider who performs the substantive portion of the E&M service must be the billing provider.
Incident-to services, on the other hand, occur in the outpatient (non-facility) setting. Chandler explained the physician must establish a plan of care for new patients and incident-to applies for established patients and established problems only. Additionally, the physician must provide direct supervision when the APP delivers an incident-to service, which means the physician is on the physical premises and immediately available.
The presentation also includes examples of financial settlements with enforcement agencies for cases where APP billing, supervision and/or documentation practices went awry.
Navigating Today’s World of Audits
Diane Weiss and Sandy Giangreco Brown provided participants with a summary of the "world of audits” that medical practices face today. They shared auditing pressures from some of the following examples:
- Recovery Audit Contractors (RAC) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics)
- Medicare Administrative Contractors (MAC) medical reviews (https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review)
- Comprehensive Error Rate Testing (CERT) (https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsfast-facts/whats-comprehensive-error-rate-testing-cert-program)
- Supplemental Medical Review Contractors (SMRC) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/SMRC#:~:text=The%20SMRC%20conducts%20nationwide%20medical,%2C%20payment%2C%20and%20billing%20requirements.)
Washington, D.C. Outlook
Anders Gilberg from MGMA Government Affairs shared an update on what medical practices might expect from activity occurring from Washington, D.C. regarding legislation or federal rule-making.
Gilberg began the discussion with a review of MIPS (Merit-Based Incentive Payment System), MIPS Value Pathways (MVPs), and Medicare physician payment methodologies. Much of the subsequent discussion revolved around telehealth and its future. The COVID pandemic opened many telehealth doors and loosened many prior regulations (which were very stringent). Many medical practices are wondering if those prior restrictions will be reestablished or if there will be additional time for physicians to utilize telehealth in the way it has evolved due to the pandemic.
The public health emergency (PHE) is scheduled to end on May 11, 2023. While many regulations will return to pre-pandemic status, telehealth is getting a little reprieve through The Consolidated Appropriations Act of 2023, which extended many of the telehealth flexibilities authorized during the PHE through December 31, 2024.
Coding and Billing Compliance Enforcement Update
CJ Wolf had the honor of providing an update of medical practice enforcement cases relating to coding and billing.
In FY 2022, the government recovered over $2.2 billion related to the False Claims Act. $1.7 billion of that amount was related to the healthcare industry. Medical practices were not immune to the enforcement.
Some of the examples CJ shared included:
- A non-profit medical clinic paid back $1.8 million for reporting diagnosis codes that were not substantiated in the medical record. The practice used inaccurate diagnosis codes to ensure coverage of group psychotherapy services. In addition to the repayment, the government went after the CEO and COO. Both were sentenced to 82 and 14 months, respectively.
- A physician practice paid $4.2 million to settle allegations that it billed for E&M services on the same date of service as COVID tests when the E&M services were not warranted/medically necessary.
- New York physicians paid nearly $900,000 to settle allegations of billing for smoking cessation services that lacked the appropriate documentation in the medical record. In addition, the physician allegedly billed for higher levels of E&M codes than appropriate, a practice known as upcoding.
CJ also shared the important role that compliance programs play in preventing these type of missteps from happening in the first place. In a separate handout, CJ provided information about federal enforcement agencies’ expectations for effective compliance programs. Included in this handout was the U.S. Department of Justice’s compliance program evaluation document, the HHS OIG’s compliance guidance for medical practices, and an example of an OIG corporate integrity agreement.
Conclusion
Overall, the conference was well-attended and included timely information. Other sessions not described above included:
- A two-part session titled Compliance Planning by the Numbers, Part 1, and Part 2
- Optimize Your Revenue Cycle
- Payer Negotiations
- Aligning Financial and Clinical Data
- And many, many more
For those who missed it, some of the sessions will be repeated in a MGMA virtual summit in early June.
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