Understanding the Healthcare Integrity and Protection Data Bank

Posted on January 4, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Healthcare Fraud and Abuse Data Collection Program

By Patricia Trites; MPA, CHBC, CPC

The Healthcare Integrity and Protection Data Bank (HIPDB) were created to coordinate information with the National Practitioner Data Bank (NPDB). Currently, health plans, health maintenance organizations, and federal and state agencies are required to report final adverse actions taken against healthcare providers on a monthly basis.

The NP Database

The database operates under the auspices of DHHS, the Health Resources and Services Administration, and the Bureau of Health Professions. The Secretary of DHHS is responsible for operating this data bank in the same fashion as the NPDB.

Adverse Actions

Five types of final adverse actions against a healthcare provider, supplier, or practitioner are reported into this data bank:

1. civil judgments in federal or state court related to the delivery of a healthcare item or service;

2. federal or state criminal convictions related to the delivery of a healthcare item or service;

3. actions by federal or state agencies responsible for licensing and certification;

4. exclusions from participation in a federal or state healthcare program; and

5. any other adjudicated actions or decisions that the secretary of DHHS establishes by regulations.

Assessment

These actions must be reported, regardless of whether the subject of the report is appealing the action. Federal and state agencies, hospitals, and health plans are permitted to query the HIPDB. This will also lead to increased activities by other federal agencies, including the Internal Revenue Service and the Federal Trade Commission, which can lead to civil and criminal penalties.

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Understanding the Healthcare Fraud and Abuse Control Program

Posted on December 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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A Joint Project Between the OIG and DOJ

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By Patricia Trites; MPA, CHBC, CPC

The Healthcare Fraud and Abuse Control (HCFAC) program is a joint project between the Office of Inspector General [OIG] and the Department of Justice (DOJ).

Functions

The primary functions are to coordinate federal, state, and local enforcement in controlling healthcare fraud, and to conduct investigations relating to delivery and payment of healthcare services, and oversee Medicare and Medicaid exclusions, civil money penalties, and the anti-kickback law. The program is also designed to provide opinions, alerts, and a means for reporting and disclosing final adverse actions against healthcare providers.

HIPAA Policies

HIPAA established the Health Care Fraud and Abuse Control Account within the Medicare Part A Trust Fund and funds DOJ and DHHS activities for operation of the HCFAC. In addition to federal appropriations, the fund receives a portion of funds collected from healthcare fraud and abuse penalties and fines. HIPAA also authorizes funds from general revenues for the Federal Bureau of Investigation (FBI) to combat healthcare fraud and abuse.

Assessment

Anti-fraud and abuse provisions were also included in the Balanced Budget Act of 1997 and the Deficit Reduction Act [DRA] of 2005, and annotated and

Conclusion

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Understanding Deviations in Medical Billing

Posted on August 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Appreciating Normative Comparisons

[By Patricia A. Trites; MPA, CHBC, CPC, CHCC, CHCO ]

tritesDeviation in medical billing can be detected through utilization data that insurance companies produce on all providers that submit a claim for payment of services.

Insurance companies track utilization through a variety of parameters, including CPT codes, ICD-9-CM, or number of referrals. Different programs utilize certain benchmarks to trigger a review.

Example

For example, a physician who sees patients in the office from 8:00 a.m. until 8:00 p.m., seven days a week and has the highest billing amounts in the region can be subjected to a review. This doctor’s activities would be scrutinized. The utilization review department would probably flag this doctor’s provider number and request more information on a sampling of his or her claims, based on the volume.

Utilization Review

Some utilization review activities may occur due to the type of services that a doctor may offer. For example, if a cardiologist should suddenly start billing for a large number of incision and drainages of abscesses, this might trigger a review, since that might not be a typical scope of service for this doctor in this locality. The same could be said for a pathologist, triggering a review due to the high volume of wound care or ulcer debridement.

Audit Trigger Thresholds Vary

Thresholds vary from locale to locale regarding what triggers an audit. There are consultants who have suggested querying the local carrier for provider specific information regarding utilization activity to compare against community performance. Some Carrier Advisory Committee (CAC) representatives have indicated that this may bring undesirable attention from the Medicare program and trigger an audit. Consult professional associations. and, if possible; local CAC representatives to obtain most current information in your area.

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OSHA and Sharp Medical Instruments

Posted on August 9, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding OSHA Requirements

By Patricia A. Trites; MPA, CHBC, CHCC, CMP™ (Hon)
Dr. Charles F. Fenton, III; JD, FACFAS
Hope Rachel Hetico; RN, MHA, CMP™

The OSHA Standard requires that contaminated needles and other contaminated sharp instruments (sharps) must not be bent, recapped, or removed.

Definition

Contaminated sharps are defined as any contaminated object that can penetrate the skin including, but not limited to: needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Contaminated needles and other contaminated sharps must not be recapped or removed from the syringes unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure. Also, shearing or breaking of contaminated needles is prohibited. This would include those instances, such as during surgery, where recapping was necessary due to the need to give multiple injections from the same syringe. If needles are recapped, it must be through the use of a one-handed technique.

Two-Handed Recapping

Two-handed needle recapping is strictly prohibited by the Standard. Recapping of needles can be a very dangerous procedure. It is during recapping that most skin punctures occur.

Immediately, or as soon as possible after use, contaminated reusable sharps must be discarded and placed in appropriate containers until properly reprocessed. The containers must be:

  • puncture resistant;
  • labeled or color-coded; and
  • leak proof on the sides and bottom.

Assessment

Finally, containers must be at the site as close as feasible to the use of the sharps. This will limit the risk of injury during the time the sharp would otherwise have been transported from the site of use to the site of disposal. During use, the sharps container must be maintained upright, not be allowed to be overfilled, and replaced routinely. When moving containers of contaminated sharps from the area of use, the containers must be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling. The container must be placed in a secondary container if leakage is possible. Reusable containers must not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of percutaneous injury. Physicians can purchase turn-key sharps containers that, when full, can be shipped back to the distributor for proper disposal.

Sharps

Conclusion

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OSHA and Workplace Pathogen Control

Posted on July 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Engineering and Medical Work Practice Controls

By Patricia A. Trites; MPA, CHBC, CHCC, CMP™ (Hon)
Dr. Charles F. Fenton, III; JD, FACFAS
Hope Rachel Hetico; RN, MHA, CMP™

Engineering and medical practice controls are methods used to isolate or remove bloodborne pathogen hazards from the workplace. These practices should be used to eliminate or minimize employee exposure by removing the hazard or isolating the employee from the exposure. However, where occupational exposure remains after institution of these controls, personal protective equipment [PPE] must be employed, as described below.

Engineering Controls

Engineering controls can be described as those an employer purchases and makes available to protect his or her employees. Examples are sharps containers, eye-wash stations, spill-kits, and safer needle systems. It is the employer’s responsibility to implement and maintain a system for ensuring engineering that controls are used. The engineering controls must be examined and maintained or replaced on a regular schedule to ensure their effectiveness. Conducting only an annual review of the engineering controls is inappropriate under the OSHA Standard.

Healthcare Work Practice Controls

Unlike engineering controls, healthcare work practice controls depend upon the behavior of the employee to reduce exposure. Examples are hand washing, utilizing universal precautions, and wearing appropriate PPE. Even with properly implemented work practice controls, exposure can still occur. Some of the engineering and work practice controls that must be addressed (if applicable to the specific healthcare organization) within the employee control plan [ECP] include:

  • hand washing facilities and practices,
  • treatment of sharp instruments,
  • separation of food from contamination,
  • certain procedures in the treatment of contamination,
  • sterilization, and
  • care of equipment.

Assessment

These engineering controls must be examined and maintained or replaced on a regular schedule to ensure their effectiveness. Conducting only an annual review of the engineering controls is inappropriate under the OSHA Standard.

Surgical prep

Conclusion

How has OSHA affected your practice? Or, is it so 1999?

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Understanding Periodic or New Employee Practice Compliance Audits

Posted on May 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Perform and Improve as Needed

By Patricia Trites MPA, CHBC; with Staff Reporters 

www.HealthcareFinancials.comho-journal12

There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point, discussed elsewhere on this ME-P, is to obtain a baseline audit. The next step is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Periodic Audits

Periodic audits are performed on an on-going basis. Depending on the volume of billing, these may occur weekly for a large multi-specialty ambulatory clinic to quarterly for a small medical practice. These periodic audits can be random or scheduled. Sometimes in the process of seeing how things run, a surprise review can be informative to staff and practitioners.

New Employee Audits

New employees require regular training and reviews until there is confidence in their capabilities. Background checks are often helpful to find out whether there are any potential conflicts. In hospitals, health plan offices, surgery centers, and other regulated facilities, background checks are a normal part of the credentialing process. This process typically includes Medicare violations, which would show up on the National Practitioner Data Bank report. However, independent medical practices do not have access to this type of information and may have to rely on other organizations to obtain the information. The OIG and the General Services Administration both maintain a database of excluded persons and entities that can be accessed through the Internet. As part of the organization’s initial and periodic audits, queries of these two databases should be performed for all employees and independent contractors (like locum tenens physicians). Failure to do so can put the practice at risk of large civil money penalties ($10,000 for each occurrence) and liability for refunds of all claims the excluded individual had part in providing or billing.

Assessment

Additional audits can be performed whenever new employees are added, or if there are complaints or issues that arise in the course of business; prn.

Conclusion

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