The Best of HCCA’s Compliance Institute, 2021

The HCCA’s 25th Compliance Institute was recently held over April 19th through the 22nd. Unsurprisingly, it was a virtual conference this year. And while I can’t wait to get back to live conferences where we can all see each other in person, the information that was shared was wonderful. Because I know not everyone was able to attend, I thought I’d share highlights from some of my favorite sessions.

In case you missed it, last week I shared highlights from my favorite Government Enforcement Updates, which you can download here.

Addressing High-Risk Compliance Areas and Avoiding Common Pitfalls in Risk Assessment, Monitoring & Auditing

Presented by: Leslie Boles, Director of Compliance Audit, WCP Healthcare, Waud Capital Partners & Kelly J. Sauders, Partner, Deloitte

Many compliance professionals can feel overwhelmed with the amount of high-risk information generated from a risk assessment, or from continued monitoring and auditing. This session provided some great guidelines to avoid some of the more common pitfalls.

For example, the compliance risk assessment process should be used to identify and prioritize significant regulatory compliance risks using an efficient, structured approach. Steps shared by the speakers included:

    1. Planning and scoping
    2. Risk identification
    3. Risk prioritization
    4. Development of compliance work plan
    5. Obtain approval of assessment results and plan

Selling Effectiveness: Getting the Board On Board with Building an Effective Compliance Program

Presented by: Darrell W. Contreras, Chief Compliance Officer, Millennium Health

Demonstrating effectiveness to your board is an important activity for any compliance program. This session provided some sound advice on how to effectively approach your work with the board. Mr. Contreras’s approach was laid out with three major steps: Selling, Measuring, and Reporting.

    1. Selling: The governmental expectations were discussed to provide one form of selling the idea to the board. A second selling point includes the benefits for the organization including reduced liability, exposure and cost.
    2. Measuring: Two important tools to consider when measuring effectiveness include first “Measuring Compliance Program Effectiveness: A Resource Guide” which is an HCCA-OIG publication and second, the “Evaluation of Corporate Compliance Programs” published by the U.S. Department of Justice Criminal Division.
    3. Reporting: When it comes to reporting to the board, there are a few key questions to keep in mind:
      • What is valuable to the Board?
      • What information do you currently report to the Board?
      • How to make and show progress?

The Opioid Crisis a.k.a. Prescription Drug Abuse Epidemic: From the Provider’s Perspective

Presented by: Sonal J. Shah, Former Sr. Vice President, Compliance and Risk Officer

Before COVID-19 became a public health emergency, the opioid crisis was declared a public health emergency by HHS in 2017. Opioid overdoses accounted for more than 42,000 deaths in 2016, more than any previous year on record. An estimated 40% of opioid overdose deaths involved a prescription opioid. To combat these concerns, HHS announced a 5-Point Strategy to Combat the Opioid Crisis including:

    1. Better Addiction Prevention Treatment and Recovery Services – Improve Access to these Services
    2. Better Data – Strengthen Public Health Data Reporting and Collection
    3. Better Pain Management - Advance the Practice of Pain Management
    4. Better Targeting (Availability and Distribution) of Overdose Reversing Drugs
    5. Better Research - Support cutting-edge Research on Addiction and Pain

Physician Coding and Billing Cases Gone Badly

Ok, first, I wouldn’t necessarily say this was one of my favorite sessions, but it was the session I had the opportunity to present. I focused on sharing examples of physician settlements and cases resulting from poor coding and billing decisions. I picked three major areas of coding and billing mistakes.

First, I shared multiple examples of settlements that resulted from improper use of modifier 25. This modifier should only be used when there is a significant, and separately identifiable, evaluation and management (E/M) service that is above and beyond any normal pre-op or post-op care associated with a procedure on the same day. In one of the case studies I presented, a retinal practice was reporting E/M codes for almost all visits when the patients were presenting for scheduling eye injection procedures.

Second, we reviewed cases of incorrect usage of the “incident-to” rules. For example, multiple recent settlements were the result of physicians billing in their own name when services were provided by nurse practitioners and the physician was not present in the office suite as required by “incident-to” rules.

To conclude the session, I shared examples of physician upcoding. This included scenarios of physicians reporting E/M levels that were higher than warranted. It also included examples of procedure upcoding, such as excision of skin lesions where it was alleged the practice consistently chose codes representing excision of larger-sized lesions, when the lesions were actually smaller.

Core Elements of EMTALA for the Compliance Professional

Presented by: Frank Ruelas, Corporate Responsibility Officer, Hospital Setting

Most compliance professionals need to know how to properly handle EMTALA scenarios. This session focused on three key objectives:

    1. Review of the key EMTALA requirements
    2. Patient flow and meeting the Medical Screening Exam (MSE) process
    3. Key audits to support compliance

A helpful pattern was followed during practice scenarios where the inputs, processing, and outputs were logically followed to come to an appropriate way to handle various EMTALA scenarios. This was a helpful session for those who need a refresher on the nuts and bolts of EMTALA.

Two-Headed Beast: Compliance and Research Billing

Presented by: Ryan D. Meade, Fellow, University of Oxford & Kelly M. Willenberg, Manager, Kelly Willenberg and Associates

Research billing can be complex and unfortunately, often goes overlooked. This session covered many of the nuances and requirements when it comes to billing for services associated with clinical trials and research. Some of these unique topics include:

    • Coverage Analysis
    • Budgeting and Contracting
    • Charge Segregation
    • Invoicing to Sponsors
    • Reconciliation of Accounts Receivable
    • Payer Management Controls
    • Denial and Appeals Management
    • Write Offs or Research Off the Books

Compliance Data Mining and Benchmarking: How Data-Driven Decision Making Can Boost Your Compliance Program Success!

Presented by: Peiman Saadat, Vice President, Corporate Compliance Officer, AdvantageCare Physicians

Data mining is the new normal for compliance. This session shared a number of topic-specific areas to focus your data mining efforts on. For example, in the area of coding and billing, the following areas were recommended for data analysis:

    • Same provider – same day- two or more locations
    • Same patient – same day- two or more locations – same specialty
    • Providers daily visit count is more than 50 patients per day
    • Modifiers
    • Specialty specific reports
    • Top 25 codes in each specialty
    • Copy and pasting (cloning)

And in the area of opioid abuse, the following suggestions were provided:

    • Self-prescribing
    • Same Household
    • Monthly Quantities
    • MME (Morphine Milligram Equivalent)
    • Refills with no visits – no reassessment
    • CSs ordered with Benzodiazepines
    • Same patient – CSs received two or more in a month from different providers
    • Provider/Pharmacy


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As it is every year, there were more sessions and opportunities for learning than there was time. Above is just a quick summary of some of my favorite sessions I was able to attend. If you missed any of the above sessions, weren’t able to attend, or would like to learn more about them, you can either order the recordings of each session, or view the handouts online at HCCA’s website.

Questions or Comments?