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News & Press: Annual Conference Speaker Spotlights

OIG and Orthopedic Audit Risks in 2020

Monday, February 3, 2020   (0 Comments)
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Written for AAOE by Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, Partner/ Vice President & Chief Compliance Officer of DoctorsManagement

Learn more by attending Sean Weiss' AAOE 2020 Annual Conference Session, "OIG and Orthopedic Audit Risks in 2020".

Orthopedic providers are a favorite of auditors at payors for a number or reasons including DME prescribing, minor procedures on the same day as EM Services, Imaging and complex surgical procedures. Since the MACs, UPICS, MICs, SIUs, etc., were not enough, CMS in 2017 created the Targeted, Probe and Educate Program to add to your love of billing to insurance companies. This program has only gained in momentum as an investigational tool for CMS with broad sweeping authority to subject you to three rounds of audits up to 40 encounters per round and make referrals to the MAC for further disciplinary action including but not limited to: pre-payment review, suspension of Medicare Payments and/or referral to the Office of Inspector General. This program should be considered a high-risk to all orthopedic practices and one that when you receive notice of audit, you handle it with the attention it requires out of the gate so you are not behind the 8-ball!

Join my session for the AAOE 2020 Annual Conference! The following is just a taste of what you’ll hear.

The Targeted Probe and Educate (TPE) Program:

According to CMS, “the program itself is designed to help providers and suppliers reduce claim denials and appeals. TPE is intended to increase accuracy in very specific areas and the Medicare Administrative Contractors (MACs) use data analysis to identify:

  • Providers and suppliers who have high claim error rates or unusual billing practices, and
  • Items and services that have high national error rates and are a financial risk to Medicare.”

If accuracy still does not improve after 3 rounds of education sessions, you will be referred to CMS for next steps. Thus far and in addition to those audit targets listed above, we have seen TPE focus on physician signatures and when notes were completed.

We have also been dealing with “Medical Necessity” for clients targeted under TPE. This is a bit more daunting to deal with because it is not something that is measured or quantified. “Medical Necessity” is something that must be qualified and can only be done so by a “qualified” licensed medical professional with the requisite skills in the specialty they are auditing.

Get Your Game Plan On!

  1. You have to be aware of your coding patterns;
  2. Once you have identified those services posing a moderate or high risk to the organization, create an audit sample;
  3. Ensure you have the audits performed under attorney/client privilege whether conducted by in-house staff or an external vendor;
  4. If overpayments are identified, depending on the amount and severity, your attorney will advise on the most effective process to follow for making refunds to Medicare following the 60-day rule.

Finally, work with your attorney or compliance consultant on developing a Corrective Action Plan and ensure there is proper auditing and monitoring going forward to ensure compliance.



About the Speaker

     Sean Weiss is a dynamic and engaging speaker who brings audiences alive while delivering critical, in-depth education on topics related to regulatory compliance, revenue cycle management, coding, and practice management. He covers a broad range of compliance topics including risk and mitigation, audit appeal, compliance program development, and management, as well as navigating today’s turbulent healthcare management arena. Weiss has presented courses for academia, management associations, pharmaceutical companies, and seminar companies around the globe. He is consistently one of the highest rated speakers at conferences and has been praised by Department of Justice Prosecutors for presenting timely, accurate information.


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