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Implementing an Effective Compliance Plan in Response to a Medicare Audit - PowerPoint PPT Presentation

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Implementing an Effective Compliance Plan in Response to a Medicare Audit webinar by SuperCoder explains in detail about government audits and what constitute a fool proof compliance plan. The webinar, which is presented by Candice Fenildo, CPC, CPMA, CPB, CENTC, CPC-I, is designed to help you jump over compliance potholes and ensure that your revenue is safe against financial setbacks. Some of the key points covered in the webinar include what is a Medicare audit and why is it undertaken, what is health care fraud and how to avoid it, how to leverage OIG compliance guidance, how to create an effective compliance program, how to identify risk areas, when and how to perform chart audit, who all are involved in an audit, how to respond correctly to an audit request, and more. The webinar also features critical advice on how to make your practice audit proof and avoid coming under the compliance hammer.

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Presentation Transcript


Implementing an Effective

Compliance Plan in Response to a

Compliance Plan in Response to a


Medicare Audit

an Effective


Presented by

Candice Fenildo, CPC, CPMA, CPB, CENTC, CPC-I

Date: May 25, 2016



• State of the Industry

• Why audits?

• Why a compliance program/plan?

• Determining what the Plan will encompass

• Where to start

• Identifying your risk areas

• Identifying who should be involved

• When & how to do chart audits

• How to respond to help ensure the best outcome


Why Audits?

The efforts to identify and eliminate healthcare waste, fraud and

abuse are on the rise.

Source: Healthcare analytics, Thomson Reuters


Why Audits?

• Health care costs continue to soar

• Investigations continue to find improper


• In 2014, the Government estimated a 12.7%

improper payment rate, equaling $45.8 billion.

• To combat these findings, the US Government

has employed a taskforce of agencies to

investigate and combat fraud and abuse


Who are these agencies?

Federal program enforcers include:

• Office of Inspector General (OIG)

• Department of Justice (DOJ)

• Federal Bureau of Investigations (FBI)

• Medicare Administrative Contractors (MAC)

• Quality Improvement Organizations (QIO)

• Program Safeguard contractors (PSC)

• Medicare Zone Program Integrity Contractors (ZPIC)


Who are these agencies?

Federal program enforcers include:

• Medicaid Fraud Control Units (MFCU)

• State Medicaid Inspector General

• State Attorney General

• Recovery Audit Program (RAC)

• Comprehensive Error Rate Testing (CERT) contractors

• Payment Error Rate Measurement (PERM)


2012 HCCA Survey

In 2012, the Health Care Compliance Association (HCCA)

launched a survey to assess the volume of audits. The

goal was to determine the level of audit activity and the

impact it is having on the compliance

profession and the

institutions they serve.


Percentage of Respondents Reporting at

Least One Audit

Auditing the Auditors

A survey by the Health Care Compliance Association (2012)


The Compliance



Health Care Fraud

is a Serious Problem


Fraud includes obtaining a benefit

through intentional

misrepresentation or concealment

of material facts

Waste includes incurring

unnecessary costs as a result of

deficient management, practices, or


Abuse includes excessively or

improperly using government



Medicaid Audit and Data Mining

• Some results from the NY OMIG:

• Women who had babies and then gave birth to another

baby 5 months later

• Children under 10 giving birth

• 50-year-old women who gave birth with no

corresponding fertility treatments – “we recovered

$500,000 on this alone.”


FBI Statistics

• Reports Estimate….

• Fraudulent health care billing accounts for between 3% and

10% of all health care expenditures.

• Most prevalent schemes identified are

• Billing for services not rendered

• Upcoding services or items to a more expensive version

• Filing duplicate claims

• Unbundling

• Billing for services in excess of a patient’s actual needs

• Medically unnecessary services

• Kickbacks


“We expect that every health care

provider will have an effective

compliance program.”

Daniel Levinson, Inspector General, Office of the Inspector

General, 2009 Compliance Institute, Las Vegas, NV


Why Should I Comply?

• It’s the right thing to do.

• Enhances correct billing

• Reduces denials

• Increases billing efficiency

• Minimizes the risk of a Government audit

• Minimizes the risk of a substantial overpayment.